1 in 4 Eye Emergency Referrals Are Non-Urgent, Study Finds

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Only a small percentage of patients referred to the ophthalmology clinic from the general emergency department had true ocular emergencies, with 27% of referrals being non-urgent. This over-referral is likely due to limited knowledge of ophthalmological conditions among emergency physicians, leading to unnecessary consultations and a strain on resources, which could otherwise be used for patients with genuine ocular emergencies.

“In previous studies, the criteria for ocular emergencies were defined as conditions and diseases that threaten vision and lead to functional impairment if not treated early,” wrote a team of investigators from Basaksehir Cam and Sakura City Hospital in Istanbul, Turkey. “The main causes are giant cell arteritis, open globe injuries, retinal artery occlusions, acute angle closure glaucoma, retinal detachment, keratitis, uveitis, orbital fractures, endophthalmitis, chemical injuries, burns due to chemical substances or direct caustic conditions such as fire and orbital fractures.”

True ocular emergencies require swift intervention to prevent vision loss or functional impairment. However, according to previous research, the proportion of patients presenting to general emergency departments with eye complaints who do not actually require emergency care ranges from 37% - 50%. Triage systems, implemented in hospitals across the globe, aim to distinguish true ocular emergencies from non-urgent complaints, which can allow providers to spend more time treating emergencies as well as reduce pre-examination waiting times.

To assess the proportion of true ocular emergencies among adult patients who arrived at the general emergency department of a tertiary hospital in Istanbul with ocular complaints who were referred to the Eye Emergency Clinic, investigators conduced a retrospective cross-sectional study. Eligible patients presented at the emergency department between January and December 2022. Patients were categorized into three groups: top eye emergencies (TEE), relative eye emergencies (REE) and non-emergency eyes (NEE).

A total of 652,224 patients presented at the emergency department seeking care. Of these, 9982 (1.5%) were referred to the Eye Emergency Clinic. These patients were mostly male (72.1% vs 27.9%, respectively). Although most (60%) cases were placed in the REE group, 27% were categorized as NEE and only 13% were considered true emergencies. The most common TEE were orbital fractures, chemical injuries and orbital-preseptal cellulitis. REEs included corneal erosion, conjunctivitis and corneal foreign bodies. Common NEEs were subconjunctival hemorrhage, eye redness and trauma without eye involvement.

Only 1.5% of patients arriving at the general emergency department complained of eye issues. However, one out of four patients who were ultimately referred to an ophthalmological clinic did not have an urgent eye condition.

Investigators believe this is due to the high proportion of patients who went to the emergency department coupled with a lack of knowledge of ophthalmological diseases by clinicians working in the emergency department, which could lead to unnecessary referrals to an ophthalmology clinic. This could, in turn, result in reduced time allocated to patients with actual ocular emergencies and a loss of workforce.

Diseases were not classified via a scoring system, which limited the study according to investigators. Additionally, distinctions between adult and pediatric conditions were not made.

“Although the prevalence of TEEs is not excessively high, a significant proportion of patients presenting to the emergency department with eye concerns are referred for eye consultation by doctors with limited expertise in ophthalmology,” investigators noted. “This burdens the Eye Clinic, leading to extended waiting times and compromising examination thoroughness. To address this issue, it is imperative to enhance the training of general emergency department staff, particularly in tertiary hospitals, in recognizing and managing eye emergencies. This will streamline patient care pathways, optimize resource allocation, and ensure timely intervention for TEE patients, minimizing adverse outcomes.”