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SmartPhone Diagnosis Cecelia Koetting OD FAAO Virginia Eye Consultants Norfolk VA

Disclosures � None

The Phone Call �  Be personable �  Give your name �  Project concern �  Documentation

�  Name �  Date of Birth �  Previous Patient? �  Date and Time �  Summary/Synopsis (gathered from TRIAGE) �  Actions taken

Active listening � Pay attention � Show that you’re listening � Provide feedback � Don’t interrupt � Respond appropriately

https://www.mindtools.com/CommSkll/ActiveListening.htm http://upliftconnect.com/six-habits-highly-empathic-people/

Why we avoid difficult interactions � Uncomfortable

� Fear caused by lack of knowledge or skills � Don’t want to make the situation worse

https://www.slideshare.net/abpascual/2013-dealing-with-difficult-patients

Well that escalated quickly. . . � When a situation becomes difficult:

�  Know your purpose and role within the situation �  Be assertive

� NOT loud, demanding, threatening

�  Use cooperative language � “Yes I agree that your situation is difficult”

�  Use active listening

What NOT To Do �  Ignore the problem � Accuse the patient of being problematic � Tell the patient there is nothing wrong or

nothing to be done for him/her

Emergencies �  Chemical burns �  Sudden Painless Loss of Vision �  Loss of Vision associated with scalp

tenderness/elderly �  Painful loss of vision with nausea �  Trauma from high velocity projectile/

possible laceration �  Trauma associated with persistent

pain �  Blunt trauma (fist or ball) �  Acute onset of pain �  Sudden onset of diplopia, ptosis,

pain, and dilated pupil �  Emergency referral from another

physician

Levels of Urgency �  Immediate

�  Should come to office to be seen immediately, or to nearest emergency eye care facility

�  Urgent �  24 hours

�  Semi-Urgent �  1 week

�  Routine �  Next available �  Does not pose immediate threat, may have

been present for more than a week

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Urgencies �  Persistent loss of vision with gradual evolution

over few days to weeks �  Sudden onset of diplopia �  Recent onset of flashes and floaters �  Acute red eye �  Blunt trauma with no pain or loss of vision �  Photophobia �  Increasing pain �  Acute swelling of eyelids with pain or

discharge

Routine � Discomfort after prolonged use of eyes � Difficulty with near work � Mild itching, burning, irritation � Tearing � Lid twitching � Mucous discharge � Mild redness without other symptoms � Unchanged floaters

The 5 W’s � Who � What � When � Where � Why

�  Assess and classify a patients signs and symptoms according to their severity and urgency

Lets Give This a Try! Patient Number 1

� “Hey so I started to notice these weird spots* in my vision, should I come in?” *insert squiggly lines, floaters, cobwebs, blobs, gnats, worms, etc.

Flashes and Floaters �  What are you noticing?

� Are there flashes? �  When? How often?

�  Is there a curtain or veil?

�  Which eye? �  When did they start? �  When was the most recent flash? �  Any recent head trauma or accident?

Doc I see spots!!!! Flashes and Floaters � Urgent � Same day if possible � Posterior Vitreous

Detachment (PVD)

� Establish if NEW

Image: https://www.asrs.org/patients/retinal-diseases/9/posterior-vitreous-detachment

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Flashes and Floaters � Retinal Detachment

Flashes or floaters

No Curtain/Veil

Should be seen within 24

hours

Yes Curtain/veil

Has been over a month

Should be seen that day

Started within the last few

weeks

Consider immediate

referral

Patient Number 2 � “I’m getting this weird stabby pain in my

eye every once in a while?” VS.

� “I have this really bad achy pain that won’t go away?”

VS.

� “My head hurts behind my eyes so bad I think I might vomit!”

picture from www.reedmigraine.com

Eye Pain � What are you feeling, describe the pain? � Which eye is it? � When do you notice it, how often? � When did this start? � Do you have glaucoma? Are you

currently taking any ocular medication? � Any recent trauma to the head or eye?

Corneal Abrasion � Symptoms

�  Intense pain �  Tearing � Redness �  Photophobia �  Lid edema �  Blurred Vision

Eye

pa

in

Single episode

Try using artificial tears every few hours

Appointment within a week

Constant

Photophobia

History of Trauma

Should be seen in office within a few days

Refer out?

History of Iritis

Insure using meds if on any

Seen in office within a few days

Fluctuating vision/FBS

Try using artificial tears every few hours

Appointment within a week

Glaucoma

Taking medication Be seen in office within 24 hours

Not taking medication Have patient take

medication and be seen

Nausea

Glaucoma Seen that day

Recent Surgery Seen that day

Recent Trauma Seen that day

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Patient Number 3 � “My dog scratched my eye!”

VS

�  “A dog bit my eye!”

Trauma � 5 Ws are critical in determining severity of

trauma � TRAUMA is always taken seriously! � What else would you want to ask?

Possible Complications! � Ecchymosis (bruising) � Orbital fractures

causing emphysema (air from sinus through orbit)-don’t blow your nose

� Penetrating Injury � Laceration � Traumatic hyphema

� Traumatic iritis � Traumatic iridoplegia � PVD � Berlins Edema � Retrobulbar HB

(proptosis) � Double vision from

swelling or orbital blowout fracture

Trauma �  Primary injury- Treat first!!!

�  Open globe �  Corneal abrasion �  Orbital/facial cuts �  Orbital bone breaks/fractures

�  Secondary ocular problems – Anticipate and treat once primary injuries are tended �  Iritis �  Hyphema �  Angle closure

Patient Number 4 � “So my vision, recently everything seems

more blurry!” VS

� “I’m concerned, I woke up this morning and everything was black!”

Blurred Vision � When did this start? � Which eye is it? � Do you notice it with your glasses on or

off? � Does it clear up or get worse with

blinking? � Any recent trauma to the head or eye?

Sudden Loss of Vision � Sudden LOV (Black or Shadow)=

�  EMERGENT

� Sudden Blurred Vision – Monocular/Binocular �  EMERGENT

� Gradual Blurred Vision – Binocular �  Next Available

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Sudden Loss of Vision � Monocular total field:

�  RD, ON, Vit Hb, CRAO, CRVO, Angle Closure, Endophthalmitis

� Monocular Partial Field �  ARMD, RD, ION, BRAO, BRVO

� Binocular Partial Field �  CVA

Gradual Loss/blurring of Vision �  Monocular:

�  IOP/K edema �  Macular edema �  Amaurosis �  ARMD �  Cataract �  KCN �  Dry Eye

�  Binocular �  Refractive Error �  Dry Eye �  Cataract �  Diabetic retinopathy, CME

Patient Number 5 � “I woke up this morning and it looks like

my eye is bleeding!” VS

� “I have blood in my tears!”

Hemorrhage �  What are you noticing?

�  Blood tinged tears vs bloody appearance to whites of eyes

�  When did you notice this? �  Which eye? �  What medications are you taking, are you on

blood thinners? �  Were you experiencing vomiting, diarrhea,

constipation? �  Have you had a recent increase in your blood

pressure? �  Has there been any recent trauma or surgery?

Bloody Eye

Blood tinged tears

Trauma

Should be seen that day May refer out/ER

No Trauma

Should be seen that day

Sub conj heme

Increased blood pressure

Should be seen within the next

few days

Normal blood pressure

Should be seen within a few

days to a week

Patient Number 6 � “My eyes are all red and watery.”

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Redness �  When did this start? �  Which eye is it? �  Do you have seasonal allergies? �  Who in your home or friends has had “pink

eye” recently? �  Did you get anything in your eye? �  Are you light sensitive? �  Have you tried putting any drops in it?

�  Was it helpful?

Who’s got pink eye? Bobs got pink eye!

Photo courtesy of The Today show and http://www.thedailybeast.com/articles/2014/02/12/everything-you-wanted-to-know-about-bob-costas-s-olympic-pink-eye.html

Red Eye � Semi-Urgent

�  Allergies � Usually itchy � Seasonal allergies � Should see w/in 1

week �  Bacterial

Conjunctivitis � Yellow/green

discharge � Crusting � May itch

�  Viral Conjunctivitis �  Weepy watery �  Crust �  Lid edema

�  Iritis �  Light sensitivity �  Pain �  Should be seen within

1-2 days �  Foreign Body

�  Light sensitivity �  Recent trauma �  Actual foreign body

Red Eye � Not urgent

�  Irritation/Dryness � Try to use AT Q2H

and call if worsens � Should see w/in

1-2 weeks

VIRAL CONJUNCTIVITIS �  Adenovirus: 2 common types affect the eye

�  20 strains �  Epidemic KeratoConjunctivitis (EKC)

�  Highly Contagious �  Wash Hands �  Change Pillows/Linens �  Clean Surfaces �  KEEP QUARANTINED

�  3 weeks contagious/10 day incubation �  Pharyngoconjunctival Fever

�  More common children �  Fever, sore throat, bilateral red irritated eyes

Patient Number 7 � My eyes feel super irritated like I have

sand in my eye. vs.

�  I actually think I got sand in my eye!

Foreign Body Sensation � What are you feeling? � Which eye is it? � When do you notice it, how often? � When did this start? � Have you possibly gotten anything in your

eye? � Any recent trauma to the head or eye?

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Foreign Body � Urgent

�  Same Day if Possible

� Triage: �  Environment? �  Metal/Metal? �  Protective Eyewear? �  Grinding?

Image courtesy of W Whitley OD

Foreign Body �  Ok to flush

�  Don’t try to remove if visible

�  Removal �  Bent 25 G needle �  Alger brush for

Rust ring

�  Bandage CL/AB drops

Image courtesy of W Whitley OD

Foreign Body

Sensation

Actual foreign body

Seen that day

No chance for foreign

body

Increased artificial

tears

Seen within a week or 2

Patient number 8 � “I was cleaning and I splashed a

chemical in my eye.”

Chemical burn �  Immediate appointment � When did this happen? � Which eye? �  Is there an eye wash station where you

are or do you have contact lens solution/water? �  Flush eye for 15 min before leaving

Chemical Splash � Alkali 7.1 or greater

�  Lye (oven cleaner) �  Lime (concrete) �  Ammonia (fertilizer/cleaners)

� Acid 7.0 or less �  Car Batteries �  Household Bleach

Chemical Splash �  Severe damage rapidly �  Bring agent splashed �  When patient arrives, irrigate with sterile

saline �  Check ph until between 7-8 �  ALKALI BURN-30 minutes of irrigation

� Most severe/Penetrate causing deep tissue death

Irrigate!!

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Irrigation � Guide Patient to a chair which reclines � Anesthetize with topical drop � Lid speculum may be used � Flush with sterile eye wash or saline � Everting lid may be necessary for cement

or particles

Chemical Splash Treatment

� Always irrigate first � Topical Antibiotic � Topical Steroid � Cycloplegic � More Severe:

�  Amniotic membranes, grafts, doxycycline, Vit C

Patient Number 9 � “I’ve noticed over the last few days I keep

seeing double.”

Double Vision � When did you start to notice this? � Has there been any recent trauma? � When do you notice the double vision, is it

constant? � When you cover one eye is it still double

or does it go away?

Astigmatism � Produces shadows � Not 2 fully separate

images � Will still be present if

closes one eye �  Improves with

refraction

True Diplopia � 2 separate images

that can be side to side, up and down, or at an angle

� Usually goes away when one eye is covered

�  Improves and measured with prisms

Double Vision

Monocular

Treatment for macular problems

New onset see within a few days or have return to Retina specialist

No macular problem

Artificial tears See within a week

Binocular

Trauma

See that day

No Trauma

See within a few days