Neuro-imaging in the Emergency Room (ER) setting in patients with Vitreo-retinal symptoms.
Adnan Mallick, M.D. 1 Jules Winokur, M.D. 1 Vincent Deramo, M.D. 1 David Fastenberg, M.D. 1
1Hofstra Northwell School of Medicine, Department of Ophthalmology. Great Neck, New York.
To investigate ER management of patients presenting with retinal disease.
In this retrospective review, charts of 96 consecutive patients monocular flashes, floaters, or changes in visual field were evaluated. Ophthalmology consults were called on these patients by ER physicians from 3 hospitals in the Northwell Health system between 1/2014 to 1/2017. Patient demographics, past medical and ocular history, subjective complaints, ER physician exams, testing ordered prior to ophthalmology consultation, and ophthalmology exams were documented. Outpatient retinal photocoagulation and surgical procedures were also reviewed for patients requiring intervention by retinal specialists. Patients with binocular symptoms, or patients in whom workup was required for other systemic complaints were excluded.
96 patients were included with 45 females and 51 males, mean age of 58.4.
Subjective complaints included floaters in 47 patients (49%), changes in visual field in 39 patients (41%), and flashes in 28 patients (29%). Among the 24 patients who had documented eye exams by ER physicians, 10 included confrontational visual field exams (42% of total ED exams). Prior to consultation by an ophthalmologist, tests ordered by the ER included routine blood work in 29 patients (30%), computerized axial tomography (CT) of the head with or without orbits in 33 patients (34%), ultrasound of orbit by the ER physician in 2 patients (2%), magnetic resonance imaging (MRI head) in 1 patient (1%), and serum ESR/CRP in 1 patient (1%).
Final diagnosis after examination by an ophthalmologist was found to be posterior vitreous detachment in 44 patients (46%), vitreous hemorrhage in 31 patients (32%), retinal detachment in 12 patients (13%), central retinal artery occlusion in 6 patients (6%), and central or branch retinal vein occlusions in 3 patients (3%).
Of the 12 patients with retinal detachments, 3 patients (25%) underwent surgical repair within 1 week of examination.
In patients presenting to the ER with monocular flashes, floaters and visual field changes, over 30% underwent imaging studies and blood work prior to ophthalmology consultation. Signs and symptoms of retinal pathology should be recognized promptly. Proper triaging may lead to fewer imaging studies and more judicious management of time sensitive diagnoses.
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