treatment plan

What Do You Do When The Engine Stops?

BY BRUCE E. ONOFREY, OD, RPH, FAAO
September 2000

Airplane pilots constantly train for this unfortunate occurrence. Check the ignition, fuel mixture, carburetor heat, gas tank, fuel flow and auxiliary fuel pump. If the engine won't restart, then it's probably broken and we must engine won't restart, then it's probably broken and we must look for a place to land. Any delay in action can produce a fatal result. In spite of all the training, when the emergency actually occurs, the pilot can be so surprised that instant amnesia strikes and proper procedures are forgotten. To solve this problem, all pilots live by their checklists. There is a checklist to follow for everything. Most important are the emergency procedure checklists. These quick references prevent the exclusion of a critical procedure during an emergency.

In-Office Emergencies

Practitioners, too, face office emergencies. These may include patients with sudden vision loss, trauma, chemical injury, corneal ulceration, angle closure glaucoma attack or endophthalmitis. Like the pilot in training, practitioners know all the proper procedures for managing many of the emergent or urgent clinical situations. Unfortunately, like the pilot, when the actual event occurs in our office, our response may not be clinically appropriate. This can be a result of several factors, such as anxiety, attempting to see too many patients, lack of clinical experience, excessive fatigue or lack of proper diagnostic equipment or tests.

To avoid mistakes of exclusion, practitioners should also consider keeping procedural lists for clinical emergencies. Regular review of this material can dramatically reduce stress when a patient presents with a significant problem. Additionally, it is important to have lists of potential differential diagnoses for a given ocular complaint. For example, a complaint of light flashes can be caused by a posterior vitreous detachment, a retinal tear or a classic migraine headache. Bilateral flashes associated with a history of migraine-like headaches lasting 30 to 45 minutes certainly is more consistent with migraine than with retinal detachment.

Emergency Checklists

An excellent example of a clinical presentation that requires immediate and specific procedures is central retinal artery occlusion. Once the diagnosis is made, any delay in case management can rapidly result in unnecessary loss of vision. A typical procedure list for CRAO would include (before referral):

1. Massage the eye by anesthetizing with topical agent and apply on and off pressure with tonometer tip to attempt to dislodge embolus blocking artery.

2. Lower IOP with topical beta-blocker or clonidine derivative (Brimonidine or iopidine).

3. Try an oral carbonic anhydrase inhibitor.

4. Ask the patient to breathe into a paper bag. Increased carbon dioxide can induce arterial dilation.

5. Refer for anterior chamber paracentesis to further lower IOP if prior procedures fail.

Another commonly missed diagnosis is endophthalmitis. If you co-manage ocular surgical patients, particularly post-op cataract, commit to memory the following list of diagnostic signs and symptoms:

1. History of recent surgery within days of occurrence

2. Progressive eye pain

3. Progressive loss of vision

4. Redness

5. Intense cell and flare in anterior chamber and vitreous

6. Chemosis

7. Lid edema

8. Purulent conjunctivitis

As a clinical exercise, make diagnostic and treatment lists like these from memory. Then compare your lists to those found in a variety of clinical manuals. Try to avoid critical omissions that can affect the accuracy of your diagnosis or treatment. 

Dr. Onofrey, editor and author of various ophthalmic texts, practices in Albuquerque, N.M.