Eye exam — anterior chamber

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Angry Birds

Angry Birds

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I confess I don’t really know how to examine the anterior chamber. I “learned” it in residency and just never did it thereafter. Do you all know how to do this? Is this a must know skill in reality? I have the ability to refer patients to next day ophthalmology.

I just don’t think I have enough comfort and familiarity to reliably do this exam.

It’s not like we give the steroids ourselves. Ophthalmology does that. So next day appointment is ok right?
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I can't do the in-depth eye exam I could in residency but I don't think it's that important (even though every specialty probably has things they think it's important we should do that we don't). You rule out the emergent stuff and then get them next day ophtho follow up is pretty good in my book. Besides, I don't think any ophthalmologist believes anything we say about our eye exam.
 
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Angry Birds said:
Can you explain?
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Angle closure glaucoma is the only anterior chamber pathology I’m not allowed to miss. Everything else can wait until tomorrow.

(Yes there are some other OBVIOUS anterior chamber pathologies that are important too, but the secretary at the front desk would be able to pick them out.)
 
I can and do anterior chamber exams. I have picked up cells and also seen flare before. That said, I would not consider it standard of care for an ED doc to be able to perform effective slit lamp exams. I once spoke w/ an ophtho resident who said their attendings don't even trust their anterior chamber exams until they've been doing it for at least a year because it's simply not reliable without extensive experience.

The best use for a slit lamp for an ED doc isjust FB removal with a needle if you are comfortable doing it. Anything else is above and beyond standard of care. Just at least look at the eye, check pressures and fluorescein stain, check visual acuity, and tell them to follow-up with ophthalmology the next day. I promise you the follow-up with ophtho instructions will help you avoid potential lawsuits (true story)
 
My current ER doesn’t even have a slit lamp.

It’s been 3 years since my last slit lamp exam. I don’t think i was honestly ever that good at it
 
I just diagnosed someone with likely anterior uveitis. I just used process of elimination to arrive at it (vs scleritis). I had to make a grid to narrow it down to that but better than learning how to use the damn slit lamp.
 
cyanide12345678 said:
My current ER doesn’t even have a slit lamp.

It’s been 3 years since my last slit lamp exam. I don’t think i was honestly ever that good at it
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You have no idea how much better that makes me feel.
 
The expectation level on our end is low. A decent penlight exam where you actually take the time to look at things and reasonable fluorescein proficiency counts for a lot. I can count on one hand the number of things that can’t wait until the morning (and outside of academic institutions, more often than not everything does).

Acute angle closure gets a lot of talk, but it’s pretty darn rare and isn’t a subtle finding. I’d prefer you not miss a ruptured globe. Not to pick on him, but I once got called by a resident for angle closure. True, the angle was closed, but it was because half of the anterior segment was hanging outside the eye.
 
Angry Birds said:
I just diagnosed someone with likely anterior uveitis. I just used process of elimination to arrive at it (vs scleritis). I had to make a grid to narrow it down to that but better than learning how to use the damn slit lamp.
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1: nicely done.
2: Even if you had literally ZERO clue which one it was, you're safe just giving that person an ophtho referral. Don't sweat the lack of slit lamp skills. They really don't matter in the ED. I haven't done one in maybe 5 years and just defer to the professionals on that one.

Tonopen, fluorescein, tetracaine, woods lamp, pH paper, eyewash station, eye shield. That's pretty much all the equipment that I think you really need to know how to use in the ED when it comes to eyes (barring scissors/hemostat/foreceps for a lateral canthotomy).
 
True story: patient had a massive corneal ulcer. Initially misdiagnosed by a family doctor a couple days before, and misdiagnosed the same by an ED doc. ED doc said to go straight to the eye hospital however. Family doc said come back to me in a couple days if not better. Let’s just say one of those potential defendants did not even end up getting named.
 
There's not a ton that needs to be diagnosed Emergently these days.

I'm pretty good with the slit lamp and I'm happy finding corneal abrasions/ulcers, going between scleritis and episcleritis and conjunctivitis etc., but IOP and VA are usually enough to triage patients in conversation with ophtho on-call.

I'd probably say it might be useful to be able to find hyphema and hypopion in the AC – hyphema sometimes needs admission with drops around-the-clock to prevent post-traumatic glaucoma and clogging of the trabecular meshwork. Hypopion would be a lot rarer – and the eye would probably be post-surgical, and the cornea might be hazy and gross – there's no way you'd be sending that one home based on just a basic end-of-the-bed history/exam, anyway.
 
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Angry Birds said:
I confess I don’t really know how to examine the anterior chamber. I “learned” it in residency and just never did it thereafter. Do you all know how to do this? Is this a must know skill in reality? I have the ability to refer patients to next day ophthalmology.

I just don’t think I have enough comfort and familiarity to reliably do this exam.

It’s not like we give the steroids ourselves. Ophthalmology does that. So next day appointment is ok right?
Click to expand...

I'm not particularly good at it, sometimes I try to angle the light to the side to see cells/flare but I really don't know what I'm doing.

Rx'ing maxitrol QID is probably safe over 1-2 days, whether it's a suspected infection or iritis or something like that, while they wait for ophtho.
 
eyeeye_captain said:
The expectation level on our end is low. A decent penlight exam where you actually take the time to look at things and reasonable fluorescein proficiency counts for a lot. I can count on one hand the number of things that can’t wait until the morning (and outside of academic institutions, more often than not everything does).

Acute angle closure gets a lot of talk, but it’s pretty darn rare and isn’t a subtle finding. I’d prefer you not miss a ruptured globe. Not to pick on him, but I once got called by a resident for angle closure. True, the angle was closed, but it was because half of the anterior segment was hanging outside the eye.
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Thanks for the feedback! We don't hear from our eye colleagues here too often.
 
Rendar5 said:
I can and do anterior chamber exams. I have picked up cells and also seen flare before. That said, I would not consider it standard of care for an ED doc to be able to perform effective slit lamp exams. I once spoke w/ an ophtho resident who said their attendings don't even trust their anterior chamber exams until they've been doing it for at least a year because it's simply not reliable without extensive experience.

The best use for a slit lamp for an ED doc isjust FB removal with a needle if you are comfortable doing it. Anything else is above and beyond standard of care. Just at least look at the eye, check pressures and fluorescein stain, check visual acuity, and tell them to follow-up with ophthalmology the next day. I promise you the follow-up with ophtho instructions will help you avoid potential lawsuits (true story)
Click to expand...
I remember spending a few days with ophthalmology in clinic during residency (?does that make sense... it's been awhile). The doc, perhaps jokingly, told me he's not sure he's actually seen cell and flare on slit lamp exam and perhaps just thinks he sees it after he decides the patient has uveitis.
 
How often are you all seeing ocular complaints? Maybe I just don't get many due to a strong ophthalmology presence in my area. Outside of conjunctivitis, a smattering of FB removals and corneal abrasions I maybe deal with a small handful of other eye complaints over the course of a year. Almost all just followup with ophthalmology in the next 1-2 days. Outside of the rare globe rupture (often admitted in the setting of polytrauma), that once in ~10 years bad hyphema, very rare lateral canthotomy, and seemly equally rare acute angle closure glaucoma, I'm not sure what else needs emergent ophthalmology consultation. Most things with eyes, just like most things in EM can wait. Ophthalmologists picked eyes for a reason, so they could close theirs at night while some of us foolishly work.
 
I came here to feel better about my eye incompetence and I was not disappointed. Thank you!
 
I’m an ophthalmologist 10 years out of fellowship. I’ve seen acute angle closure glaucoma 5-6 times. It’s very rare. You are not expected to do a slit lamp exam. In fact, I think it is a waste of your time to do one. I would take vision and pressure (with a tonopen) and then refer to ophtho. I’d also use a fluorescein strip with a blue light if you suspect an ulcer or abrasion.

I would also recommend NOT looking at the nerve or retina. Quite frankly you have no idea what you’re looking at. An ophthalmologist is not going to trust what you’re seeing. It’s the equivalent of an ophthalmologist performing an echo. (Don’t worry, I had a cardiology rotation during my intern year 14 years ago.)
 
We don’t even dilate the eye so how would our slitlamp exams even be worth jack?
 
Angry Birds said:
You have no idea how much better that makes me feel.
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I use the slit lamp all the time. Once you get the basics down, it is pretty quick and gives a really good view of the cornea of the eye. I find it also makes removing foreign bodies much easier.
 
Speaking of eye exams, have any of you ever used the bluminator? They look like a really nice way to perform a quick eye exam.

www.slitlamp.com

Eidolon Bluminator Ophthalmic Illuminator

Ergonomic, battery-powered, and durable, the BLUMINATOR® is suited to all examination venues
www.slitlamp.com www.slitlamp.com
 
Rendar5 said:
Dilation isn’t for the slit lamp exam. It’s for fundoscopic exam.
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Speaking of, what about fundoscopic exam? Is that an absolutely essential skill? I am not good at that either.
 
Angry Birds said:
Speaking of, what about fundoscopic exam? Is that an absolutely essential skill? I am not good at that either.
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I check it for show. Just like doing a complete neuro exam in some patients who don’t need it.

The only time it’s probably doable for us is in CRAO vs other causes of acute blindness since the eye is already naturally dilated in a dark room and won’t constrict in response to light. In which case you’d be consulting ophtho anyway because they’re blind in that eye.

CRAO is the only time I’ve actually trusted my fundiscopic exam. I’ve seen a couple.

As above the only parts of an eye exam that I consider part of standard of care is visual acuity, pupil exam, extraocular movements, tonometry, fluorescein staining, peripheral field exam when appropriate, and very close referral to ophtho. Retinal detachments are nice to dx but Im pretty sure current standards are that it can wait for ophtho within 24 hours
 
we have a fancy fundoscopic camera that is friggin' dope. the retina images are uploaded to the computer, we call ophtho and they look at it and help with dispo.
 
Angry Birds said:
Ultrasound for retinal detachment ?
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Ultrasound to differentiate retinal vs vitreous detatchment is hugely useful. It’s the difference between an optho consult/transfer and a discharge.

Also helps triage primary ocular vs CVA problem. Painless vision loss with NO sign of detachment on ultrasound? Houston, we have a problem.
 
skougess said:
Also helps triage primary ocular vs CVA problem. Painless vision loss with NO sign of detachment on ultrasound? Houston, we have a problem.
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Not quite as dichotomous as one would think. Still requires both ophtho and neuro consultation for the differential which includes hypertensive optic nerve ischemia and GCA (ophtho presentations are not as well taught in residency) Unless you happen to be in an ivory tower with a neuro-ophthalmologist on hand.
 
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Rendar5 said:
Not quite as dichotomous as one would think. Still requires both ophtho and neuro consultation for the differential which includes hypertensive optic nerve ischemia and GCA (ophtho presentations are not as well taught in residency) Unless you happen to be in an ivory tower with a neuro-ophthalmologist on hand.
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Well of course it’s not completely dichotomous, but like I said it’s a great triage tool. Painless vision loss gets an ultrasound up front. A good chunk of the time you see a flap on the vitreous or retina and then you know what to do. If you don’t, then you’re looking at admission/specialist consultation because regardless of pathology, you have a blind patient and you don’t know why.
 
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Rendar5 said:
Not quite as dichotomous as one would think. Still requires both ophtho and neuro consultation for the differential which includes hypertensive optic nerve ischemia and GCA (ophtho presentations are not as well taught in residency) Unless you happen to be in an ivory tower with a neuro-ophthalmologist on hand
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lol ophtho routinely sends in CRAO/AION for neuro stroke workup.

Any visual field impairment will obviously have a dilated fundo exam, but that can be done inpatient. The reality is that if your center does dedicated ophtho US imaging you definitely don’t need to bother pretending to do a fundoscopic exam. Obviously you won’t be diagnosing retinal toxo and other uncommon diagnoses, but those will be caught downstream by ophtho in 24 hours.
 
Jabbed said:
The reality is that if your center does dedicated ophtho US imaging you definitely don’t need to bother pretending to do a fundoscopic exam
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That's every ED with an ultrasound machine. I have no idea if radiology will do an ophtho US at my shop, but I also don't know why I'd bother to order one. It's arguably one of the simplest and easiest to interpret US's that we do at the bedside.
 
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