If you’ve listened to our podcast, you may have heard Will use the term “pants patient”.
When he says this, he means a call about a patient that would cause him, a noted internet-comedian ophthalmologist with copious work-life balance, to immediately put on his pants and head to the hospital to see a patient.
Basically, someone having a really bad time with their eyeballs.
So for this month's deep dive, Will explains four kinds of cases that fit the bill, and how emergency physicians can best prepare these patients for the on-call ophthalmologist when they arrive. (Wearing pants. We promise.)
Enjoy!
The Glaucomfleckens
Pants Patient #1: Open Globe Injuries
If you think these sound bad, you’re right. Open globe injuries occur when trauma to the eye (aka, the “globe”) is severe enough to cause a full-thickness rupture or laceration.
The most challenging thing about an open globe injury for the non-ophthalmologist is making the diagnosis. Sometimes, this is easy – say there’s a foreign body sticking out of the eye. The patient I saw in residency with an unfortunate fish hook injury comes to mind.
Sometimes it’s harder to make out the anatomic structures, because of excessive bleeding and eyelid lacerations – think firework injury. Fortunately, all an emergency physician has to do is SUSPECT an open globe injury. Then, it’s up to the on-call ophthalmologist to put the pieces together.
Your first clue is the vision assessment. Open globe is a common cause of light perception (LP) or no light perception (NLP) vision. That means the patient cannot see (or barely see) a bright light directly in front of their eye. A patient with a traumatic injury who is LP or NLP is an open globe UNTIL PROVEN OTHERWISE. Us medicine folks love any clinical pearl that ends with “UNTIL PROVEN OTHERWISE.”
Also, get a CT scan. Although an open globe is a clinical diagnosis, when you see a flattened eyeball on a scan (what we call “smushed grape sign”) it heightens our suspicion for an open globe. An orbital CT scan also helps us find any metallic foreign bodies and orbital fractures.
Ok, so far we have a patient who has no light perception and a smushed grape on CT scan. What do you do next?
First, put a shield on the eye. We have to protect that eyeball. If the patient tries to rub their eye, the contents that are normally inside the eye could end up outside the eye. Not ideal.
If I come in (with pants on), and see the patient does not have a shield, I’ll make a frowny face and say something like, “come on, buddy!”
After the shield is on, call the ophthalmologist. We might be sleepy, so you probably have to tell us things 2 or 3 times. While you wait, give the patient some Zofran, pain medicine, and IV moxifloxacin. Moxi has excellent intraocular penetration, and these wounds are dirty.
Ok, that’s it, you’re done. I’ll take the patient to the OR, which should happen within four hours of the injury to give us the best chance of success.
Pants Patient #2: Chemical Burns
These are some of the most dreaded cases in ophthalmology as they're difficult to evaluate, manage, and treat. Each different chemical can mess your eye up in unique and special ways.
When I get a call about a chemical injury, I immediately start reaching for my pants, but the speed at which I put them on is determined by whether it’s been caused by an acid or a base.
- Acids denature the proteins on the surface of the eye. This is painful as hell, but the denatured proteins can act as a barrier that prevents deeper penetration. Worst case scenario is a total corneal abrasion – painful, but it'll heal. The only exception is hydrofluoric acid, an acid so strong it’s basically blood from the Alien movie franchise.
- Bases are a bigger problem. They saponify the fatty acids in your cell membranes, burning through the cornea and into the globe. Think, the worst soapmaking class ever.
I also want to know how red the eye is. An angry, red eye is actually a relief, since it tells us the blood supply is still intact. Eyes that have gone completely white indicate ischemia. An ischemic eye means the eye has no ability to heal itself. These eyes almost always have a poor outcome.
Either way, the first thing to do is check a baseline tear film pH and start constant irrigation with a balanced saline solution, if you have it. Normal saline will work as well. Run a few liters of fluid then check pH again. Repeat until physiologic.
Most emergency departments and burn units have a Morgan lens to help deliver irrigation fluid. Make sure to sedate the patient because this kind of irrigation is borderline torture.
Once I arrive, I will sweep under the eyelids as gently as I can with a Q-tip to make sure we’ve cleared all debris. After that, we can prescribe specialty drops depending on the compound involved and the severity of the injury. There will be many follow-up appointments and potentially surgery, as these injuries can require a lengthy recovery.
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Pants Patient #3: Extraocular Muscle Entrapment
These are a little lesser-known, but boy, do they need immediate attention.
Our eyes sit inside the orbit – the little bone cave of the skull. When there’s a blunt force injury to the eye, the force can increase the intraorbital pressure enough to cause a blow out fracture in the medial and inferior orbital wall.
Sometimes, especially in young people with pliable bones, the fractured bone will pop right back to where it was initially. And sometimes, muscles around the eye (usually the inferior rectus) can become trapped in the fracture line.
Here’s what to watch for in patients like these:
- Pain moving the eye (usually looking up is quite painful)
- Nausea, syncope, or even bradycardia with upgaze
- Double vision
- If left untreated, ischemia and eventually necrosis of the extraocular muscle
To confirm an entrapped extraocular muscle, I go in with forceps to perform forced duction testing, which is horrifying to watch, but painless, because I numb up the surface of the eye REAL good. This helps me confirm whether or not the muscle is entrapped.
If it is, we move into surgery to pull the muscle out of the fracture before necrosis sets in. An oculoplastics specialist or a tertiary care center can often do this type of surgery ASAP. Once this is done, the prognosis is fairly good.
Pants Patient #4: Acute Angle Closure Glaucoma
We’ve all heard of glaucoma. It’s in my name. It’s a leading cause of blindness in the world. There are several types of glaucoma, but angle closure glaucoma is the scariest because of how quickly it can blind you.
The eye has an internal pressure. Let's think about it as a bathtub.
Say you have the faucet on, but the drain is open. The water level would stay the same. This is how a healthy eye should function – producing fluid, but also draining it to maintain a steady pressure.
When the drain is closed or blocked, the water level starts to rise. And eventually, it overflows. Except the eye is a closed system. There is nowhere for the overflow to go, so the pressure just keeps rising.
In angle closure glaucoma, the drainage system of the eye (the trabecular meshwork) is totally closed. The sudden increase in pressure puts a lot of stress on the optic nerve, and causes pain, nausea, vomiting, and if we don’t act fast enough, blindness.
First, I need their “ocular vital signs” – vision and eye pressure. If I hear from the ED that the pressure is over 40 mmHg… I’m putting on my pants. Often, the pressure in angle closure glaucoma reaches 50 or 60. Normal is 11-20mmHg, by the way.
The first thing to do is start frequent eyedrops. Timolol, dorazolamide, brimonidine, and oral acetazolamide can help decrease aqueous fluid production. We apply these every 20-30 minutes to bring the pressure down. From there, treatment will be a combination of laser and incisional surgery, depending on the underlying reason why the drain became blocked in the first place. There are LOTS of possible reasons.
When these patients come through, there may be regular follow-up appointments for months, or even years to come. I make a lot of jokes about being an ophthalmologist, but these conditions just suck. If they’re scary for clinicians, they’re even scarier for patients.
Thorough care and a hearty dose of empathy can do them a whole lot of good. Also, a nod from your Jonathan. That can cure anything, probably.
In Last Month's Issue
While Kristin describes most of her experience with Will’s health journey as co-survival, she’s also been a caregiver at times, too.
In last month’s deep dive, she took a closer look at what it’s like to give and receive care as a younger person; and how diverse the caregiving experience can actually be.
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