1 00:00:00,000 --> 00:00:02,654 Tracey: Yeah let's hope my poor guy with the urine cup tape to his face. 2 00:00:02,654 --> 00:00:03,464 It's so long. 3 00:00:04,164 --> 00:00:06,744 He's like, do I need to go out in public with this on my face? 4 00:00:06,744 --> 00:00:08,875 I'm like, yeah, just until you get to the emergency room. 5 00:00:16,882 --> 00:00:19,912 Joe: Hello, and welcome to the Evidence Based Urgent Care Urgentology Podcast. 6 00:00:20,877 --> 00:00:21,877 I'm Joe Toscano. 7 00:00:22,076 --> 00:00:26,666 I am on the editorial board of Evidence Based Urgent Care and also the Senior 8 00:00:26,676 --> 00:00:30,726 Research Editor for the sister EB Medicine publication, Emergency Medicine Practice. 9 00:00:31,379 --> 00:00:32,679 Tracey: And I'm Tracy Davidoff. 10 00:00:32,689 --> 00:00:35,619 I'm the editor in chief of Evidence Based Urgent Care. 11 00:00:35,748 --> 00:00:38,508 Joe and I have been involved in urgent care practice and education for many 12 00:00:38,508 --> 00:00:42,465 years, and we're really excited to bring to you This program from EB Medicine, the 13 00:00:42,475 --> 00:00:47,095 evidence based urgentology podcast, our goal for this podcast is to review one of 14 00:00:47,095 --> 00:00:51,128 the recent evidence based urgent care and highlight some of the important things 15 00:00:51,128 --> 00:00:54,208 that have come out of that issue, the learning points and potentially practice 16 00:00:54,208 --> 00:00:55,772 changing information from the piece 17 00:00:56,123 --> 00:00:59,033 Joe: We hope that the podcast will be valuable in and of itself, but it'll 18 00:00:59,043 --> 00:01:02,803 also whet your appetite to delve more deeply into the issue to hone your 19 00:01:02,803 --> 00:01:04,443 practice and even get some CME credit. 20 00:01:04,443 --> 00:01:06,613 Tracey: and, even if you've read the issue already, Joe and I hope 21 00:01:06,613 --> 00:01:09,903 to reinforce the important points and solidify important concepts to 22 00:01:09,903 --> 00:01:11,393 improve your learning as a result. 23 00:01:11,662 --> 00:01:13,192 Joe: If you create an account at ebmedicine. 24 00:01:13,802 --> 00:01:16,073 net, you can subscribe and purchase the issue. 25 00:01:16,543 --> 00:01:19,243 You can check out the interactive clinical pathways they have there. 26 00:01:19,643 --> 00:01:23,083 And you can get up to four hours of CME credit for completing this one issue. 27 00:01:23,673 --> 00:01:26,113 Hey, you've already started your CME journey by listening in. 28 00:01:26,518 --> 00:01:28,298 Tracey: And you can also subscribe for a full year. 29 00:01:28,298 --> 00:01:30,535 So you won't miss anything at the regular price. 30 00:01:30,535 --> 00:01:31,545 That's a great value. 31 00:01:31,652 --> 00:01:34,632 Be on the lookout for occasional promos, sales and special offers 32 00:01:34,632 --> 00:01:35,962 to make it that much easier. 33 00:01:36,697 --> 00:01:37,717 Joe: So, hi everyone. 34 00:01:37,897 --> 00:01:41,077 We are here for another month of the Urgentology podcast. 35 00:01:41,107 --> 00:01:41,947 How you doing, Tracy? 36 00:01:42,547 --> 00:01:43,237 Tracey: Good. 37 00:01:43,327 --> 00:01:46,475 We're gonna talk about a high anxiety topic today. 38 00:01:47,175 --> 00:01:48,915 Joe: Okay, I'm gonna start off with some promos. 39 00:01:49,285 --> 00:01:53,095 The new 2025 laceration course is here and it's new and improved. 40 00:01:53,095 --> 00:01:56,485 Make sure you check it out at the EB Medicine website. 41 00:01:56,965 --> 00:02:01,825 And another promo is between July 15th and August 15th, EB Medicine will be running 42 00:02:01,825 --> 00:02:04,405 a trial offer again for new subscribers. 43 00:02:05,005 --> 00:02:08,875 This time it will be $1 for seven days and new subscribers can try 44 00:02:08,875 --> 00:02:11,185 one, two, or all of our journals. 45 00:02:11,885 --> 00:02:12,995 Tracey: Oh, that's a lot of content. 46 00:02:13,455 --> 00:02:13,990 Joe: That's a lot. 47 00:02:14,690 --> 00:02:17,570 Tracey: So today we're gonna talk about ocular injuries, and this is 48 00:02:17,570 --> 00:02:20,585 an update from an article that was published in Emergency Medicine 49 00:02:20,585 --> 00:02:22,205 Practice in September of 22. 50 00:02:22,565 --> 00:02:23,765 And guess who did this? 51 00:02:23,765 --> 00:02:27,425 Joe Toscano, our very own Joe Toscano did this one, this update, and he 52 00:02:27,425 --> 00:02:29,975 reviewed the whole thing and came up with some really cool stuff. 53 00:02:30,391 --> 00:02:33,181 so since you wrote the article, we're gonna change the format 54 00:02:33,181 --> 00:02:35,611 just a little bit and we're gonna let you do most of the talking. 55 00:02:35,911 --> 00:02:38,611 And I'll just ask some questions and of course, , you know how I roll. 56 00:02:38,611 --> 00:02:40,051 I'm gonna give you my opinions too, 57 00:02:40,531 --> 00:02:41,431 Joe: And that's what we love. 58 00:02:41,518 --> 00:02:42,058 , Tracey: Yeah, thanks. 59 00:02:42,058 --> 00:02:45,808 My first opinion is that this is really a great review of the topic of eye injury. 60 00:02:45,808 --> 00:02:49,288 And I don't know about you, but I think everyone's a little scared about eyes. 61 00:02:49,288 --> 00:02:51,568 I see it on my schedule and I give it a little cringe. 62 00:02:51,568 --> 00:02:53,528 And I mean, these things are potentially serious. 63 00:02:53,528 --> 00:02:55,808 You mess this up and the patient can go blind in an eye. 64 00:02:55,808 --> 00:02:59,685 So, to me, this is one of the most dangerous things that we can see. 65 00:03:00,055 --> 00:03:00,895 And couple this with. 66 00:03:00,895 --> 00:03:03,625 We get what, one or two days of ophthalmology training in school. 67 00:03:03,645 --> 00:03:04,065 Joe: Mm-hmm. 68 00:03:04,405 --> 00:03:06,355 Tracey: Unless you are fortunate enough to do a rotation. 69 00:03:06,355 --> 00:03:08,035 So it makes some pretty high anxiety. 70 00:03:08,035 --> 00:03:11,075 And I think this article really sums up everything you need to know 71 00:03:11,075 --> 00:03:14,465 to competently evaluate the eye injury in the urgent care setting. 72 00:03:15,000 --> 00:03:16,639 So, let's start off with a couple questions. 73 00:03:16,639 --> 00:03:20,029 So after reading this article or after writing this article in your case, 74 00:03:20,179 --> 00:03:23,629 what are the absolute don't miss vision threatening injuries to the eye that we 75 00:03:23,629 --> 00:03:25,249 really need to be on the lookout for. 76 00:03:25,949 --> 00:03:28,859 Joe: Well, I wanna start off by saying that , I'm quote the author, 77 00:03:28,859 --> 00:03:32,399 but I really reworked an earlier article and it is very difficult. 78 00:03:32,591 --> 00:03:35,111 As hard as it is to write an article on your own when you have something 79 00:03:35,111 --> 00:03:38,531 in front of you that seems like it's pretty good, relatively recent 80 00:03:38,631 --> 00:03:39,861 it's hard to kind of spruce it up. 81 00:03:39,861 --> 00:03:43,581 It wasn't a matter necessarily of just distilling down an ER article to urgent 82 00:03:43,581 --> 00:03:45,741 care, but sort of adapting it quite a bit. 83 00:03:45,741 --> 00:03:47,331 It was a lot more of a challenge than I thought. 84 00:03:47,481 --> 00:03:47,771 Tracey: Yeah. 85 00:03:47,898 --> 00:03:51,988 Joe: To answer your question we'll talk about maybe the common things 86 00:03:51,988 --> 00:03:54,858 and identifying common things is important because if you can get 87 00:03:54,858 --> 00:03:57,628 those under your belt and feel really comfortable with them, you're done. 88 00:03:58,098 --> 00:04:01,788 We see a lot of corneal abrasions and corneal or conjunctival 89 00:04:01,788 --> 00:04:04,398 foreign bodies, and we really need to be really good at that. 90 00:04:04,398 --> 00:04:06,198 Those patients should come into our centers. 91 00:04:06,198 --> 00:04:08,538 We make the diagnosis, we take care of it, and they can go home 92 00:04:08,538 --> 00:04:10,608 without the need for a referral. 93 00:04:10,608 --> 00:04:14,238 So being able to identify those things and feel comfortable with them is important. 94 00:04:14,688 --> 00:04:19,508 The don't miss things include mistaking a corneal ulcer for an abrasion. 95 00:04:19,908 --> 00:04:24,118 Certainly not very common, but missing a globe perforation or a rupture. 96 00:04:24,488 --> 00:04:28,488 Any kind of a situation where you may have an intraocular foreign body with 97 00:04:28,488 --> 00:04:33,281 an eye contusion, having a retrobulbar hematoma embedded in that really swollen 98 00:04:33,281 --> 00:04:35,321 contused eye and periorbital tissue. 99 00:04:35,741 --> 00:04:38,411 These are all rare, but really important that we don't miss. 100 00:04:38,411 --> 00:04:40,421 Those are patients that we shouldn't send home. 101 00:04:40,421 --> 00:04:43,828 We have to either r ule it in and refer them or be really 102 00:04:43,828 --> 00:04:46,828 suspicious , and send them on for further evaluation 'cause we're not 103 00:04:46,828 --> 00:04:48,353 able to do that in the urgent care. 104 00:04:49,053 --> 00:04:49,383 Tracey: Yeah. 105 00:04:49,383 --> 00:04:52,293 It's funny, I always say that whenever we review one of these, I always 106 00:04:52,293 --> 00:04:53,616 end up seeing something like that. 107 00:04:53,616 --> 00:04:55,926 And I think in the emergency medicine setting I saw a fair 108 00:04:55,926 --> 00:04:56,886 amount of ruptured globes, 109 00:04:56,986 --> 00:04:58,961 but I think in urgent care, I haven't seen that many. 110 00:04:58,961 --> 00:05:01,901 And the ones that I have seen, they're usually like a workman's comp kind 111 00:05:01,901 --> 00:05:05,021 of thing, where somebody was grinding with metal or, something was flying 112 00:05:05,021 --> 00:05:06,221 through the air or something like that. 113 00:05:06,551 --> 00:05:08,898 And I think I shared with you when I was doing one of the final 114 00:05:08,898 --> 00:05:12,808 reviews of this episode I actually, of course, it's a Saturday, right? 115 00:05:12,988 --> 00:05:16,238 When there's , no staff and no supplies around had a guy that came 116 00:05:16,238 --> 00:05:20,225 in that had a, a penetrating injury from a lawn mowing misadventure where 117 00:05:20,225 --> 00:05:21,708 something had flown into his eye. 118 00:05:22,058 --> 00:05:23,708 I'm like, oh, I just reviewed eyes. 119 00:05:23,708 --> 00:05:24,608 It's a good thing, you know? 120 00:05:24,608 --> 00:05:28,821 so we look at the eyes and we end up seeing the fluorescein flowing out of 121 00:05:28,821 --> 00:05:30,591 the edge of the ruptured globe there. 122 00:05:30,921 --> 00:05:33,081 So, I turned to my medical assistant, I'm like, Hey, do 123 00:05:33,081 --> 00:05:34,281 we have any hard eye shields? 124 00:05:34,281 --> 00:05:35,601 And she's like, what's that? 125 00:05:36,081 --> 00:05:37,815 I'm like, what do you mean no hard eye shield? 126 00:05:38,025 --> 00:05:39,015 How about a paper cup? 127 00:05:39,509 --> 00:05:43,348 She's like, well, I have really big foam cups so, we finally ended 128 00:05:43,348 --> 00:05:46,738 up taping a urine cup to the poor man's eye to protect his eye for his 129 00:05:46,805 --> 00:05:48,175 trip to the emergency department. 130 00:05:48,657 --> 00:05:49,672 Joe: There's your MacGyver moment. 131 00:05:49,977 --> 00:05:50,967 Tracey: Exactly, exactly. 132 00:05:50,967 --> 00:05:52,347 Which is, you know, one of my other things. 133 00:05:52,597 --> 00:05:55,897 so, sometimes you really have to be a, a jack of all trades 134 00:05:55,897 --> 00:05:57,119 and figure out things to do. 135 00:05:57,119 --> 00:05:57,409 Joe: Yeah. 136 00:05:57,434 --> 00:05:59,234 Tracey: every time we review one of these, I always end up 137 00:05:59,234 --> 00:06:00,354 seeing something like that. 138 00:06:00,354 --> 00:06:02,814 Joe: That's an absolute, absolute can't miss injury. 139 00:06:02,814 --> 00:06:05,814 I mean, you can save an eye if that patient gets surgery in time, and 140 00:06:05,814 --> 00:06:07,314 if not, that's just a bad scene. 141 00:06:07,319 --> 00:06:07,539 So 142 00:06:07,764 --> 00:06:08,124 Tracey: Yeah. 143 00:06:08,124 --> 00:06:08,844 Absolutely. 144 00:06:09,324 --> 00:06:10,914 So, let's talk about history too. 145 00:06:10,969 --> 00:06:11,309 Joe: Mm-hmm. 146 00:06:11,309 --> 00:06:14,094 Tracey: I think getting a really good description of how the injury occurred, 147 00:06:14,484 --> 00:06:17,284 and this occurs with orthopedic stuff too, that we always talk about. 148 00:06:17,284 --> 00:06:19,844 If you really know the mechanism of injury, you can kind of predict 149 00:06:19,844 --> 00:06:22,210 what you're gonna be looking for when you do your physical exam. 150 00:06:22,664 --> 00:06:25,364 So can you comment on some of those historical elements that we think 151 00:06:25,394 --> 00:06:26,624 might be the most important here? 152 00:06:27,314 --> 00:06:30,500 Joe: Sure , there's a nice table in the issue that summarizes all the 153 00:06:30,500 --> 00:06:33,177 questions you can ask , and there are times where asking all of them 154 00:06:33,177 --> 00:06:36,257 is gonna be important , if you got a root down to what the cause is. 155 00:06:36,287 --> 00:06:38,807 If somebody doesn't have a lot of insight and their eye just all of a sudden started 156 00:06:38,807 --> 00:06:40,097 to hurt and there could be some trauma. 157 00:06:40,617 --> 00:06:44,157 But drilling down to some of the more important ones in my opinion, 158 00:06:44,157 --> 00:06:47,222 kind of that when they hit the door kind of thing would be the questions 159 00:06:47,222 --> 00:06:48,872 that go along with chemical exposure. 160 00:06:49,322 --> 00:06:51,812 At the time, you're starting to irrigate them immediately. 161 00:06:51,812 --> 00:06:54,272 You wanna try and get some sense of what the chemical was. 162 00:06:54,632 --> 00:06:57,032 We really don't measure pH right from the beginning. 163 00:06:57,032 --> 00:07:01,802 So knowing at the beginning if it's alkali or acid, can kind of guide your treatment. 164 00:07:02,112 --> 00:07:05,722 If the patient or somebody who accompanies them has an MSDS that can help you 165 00:07:05,722 --> 00:07:09,650 kind of identify the toxicity of the substance that's in the eyes a s well. 166 00:07:10,230 --> 00:07:15,130 Other high risk historical features are kinda sudden pain or foreign body 167 00:07:15,130 --> 00:07:19,570 sensation in the eye when there's metal on metal contact or other projectile 168 00:07:19,570 --> 00:07:23,120 type activities like you talked about the lawnmower a lawnmower blade kicking 169 00:07:23,120 --> 00:07:24,614 something out from underneath it. 170 00:07:24,704 --> 00:07:27,864 And sometimes people don't tell the truth, but I'm always a little bit more 171 00:07:27,864 --> 00:07:30,894 careful when somebody says they're not wearing eye protection and they had 172 00:07:30,894 --> 00:07:34,694 one of those type of situations, so t hose things perk up your ears for sure. 173 00:07:35,024 --> 00:07:38,174 I think true diplopia in the setting of trauma can lead you 174 00:07:38,174 --> 00:07:41,384 to some pretty specific diagnoses and entrapment of an intraocular 175 00:07:41,384 --> 00:07:43,870 muscle or retrobulbar hematoma. 176 00:07:44,270 --> 00:07:48,900 I really wish visual acuity, in terms of the patient's sense was a sensitive and 177 00:07:48,900 --> 00:07:51,390 specific indicator of what might be wrong. 178 00:07:51,510 --> 00:07:55,680 But in my experience, many people complain of blurriness and it doesn't end up 179 00:07:55,680 --> 00:07:58,850 being anything that's too significant, so you have to ask that question. 180 00:07:58,850 --> 00:08:01,330 But at the same time if somebody has a little bit of blurry 181 00:08:01,330 --> 00:08:02,650 vision, it's not necessarily bad. 182 00:08:02,860 --> 00:08:04,090 It's more of a magnitude thing. 183 00:08:04,090 --> 00:08:07,030 And I think when you get big changes from baseline, it can 184 00:08:07,030 --> 00:08:07,990 be a little bit more important. 185 00:08:08,380 --> 00:08:11,590 And then certainly objectifying that measuring visual acuity gives 186 00:08:11,590 --> 00:08:14,750 you a little bit better information than just the patient saying, oh 187 00:08:14,750 --> 00:08:16,070 yeah, my vision's a little blurry. 188 00:08:16,550 --> 00:08:20,175 Tracey: Yeah, one of my pain points with the chemical exposures is, I 189 00:08:20,175 --> 00:08:23,814 don't think the front desk always appreciates the severity of that. 190 00:08:24,234 --> 00:08:26,874 And frequently I'll see somebody, their worker's comp, so by the 191 00:08:26,874 --> 00:08:29,664 time they get approval and all the paperwork gets done and whatever, 192 00:08:29,854 --> 00:08:32,944 now the patient sat out there in the waiting room for heaven knows how long, 193 00:08:33,254 --> 00:08:36,201 or their employer took an hour to decide whether or not they needed to 194 00:08:36,201 --> 00:08:40,044 come to the urgent care center, so I always like to keep the board scanned. 195 00:08:40,044 --> 00:08:42,894 I always like to look at that tracking board, and if I see something out there 196 00:08:42,894 --> 00:08:47,074 that looks like it's some sort of eye or exposure, I'll go up to the front desk and 197 00:08:47,224 --> 00:08:50,404 kind of scope it out and make sure that it's not something that needs emergent 198 00:08:50,404 --> 00:08:54,198 irrigation, because this is not something you wanna wait for the paperwork for. 199 00:08:54,441 --> 00:08:57,461 You wanna get the fluids going right away to help flush out that eye. 200 00:08:57,896 --> 00:09:01,079 So I encourage you to scan the tracking boards for these sorts of things, 201 00:09:01,419 --> 00:09:01,982 squadcaster-h174_1_07-02-2025_173538: You're so 202 00:09:01,982 --> 00:09:02,822 Joe: Good, Tracy. 203 00:09:02,972 --> 00:09:03,932 Tracey: oh, I know, I know. 204 00:09:03,932 --> 00:09:04,382 Thanks. 205 00:09:04,589 --> 00:09:07,124 Alright, so physical, what's the important p hysical things. 206 00:09:07,124 --> 00:09:10,544 I mean, I always say that a visual acuity exam is the most important vital sign 207 00:09:10,544 --> 00:09:13,304 for the eye, and it absolutely kills me when it's not already done and on 208 00:09:13,304 --> 00:09:14,714 the chart before I walk in the room. 209 00:09:15,084 --> 00:09:18,384 It is really one of the first things that the MA or nurse, depending upon 210 00:09:18,384 --> 00:09:20,964 what you have, should really do and make sure it's available on the chart. 211 00:09:21,414 --> 00:09:24,987 And one thing that I didn't even realize until recently is in my d 212 00:09:25,104 --> 00:09:29,837 ocumentation, when the MAs put it in, it goes into some nebulous form somewhere 213 00:09:29,837 --> 00:09:31,217 and it doesn't pull into my note. 214 00:09:31,517 --> 00:09:35,167 So, people would have the impression that maybe I didn't check visual acuity 215 00:09:35,167 --> 00:09:36,967 because it's not physically in my note. 216 00:09:37,267 --> 00:09:39,947 So you really wanna make sure that visual acuity pulls, into your 217 00:09:39,947 --> 00:09:41,524 note and look at it, you know. 218 00:09:41,639 --> 00:09:42,389 Don't just look at it. 219 00:09:42,389 --> 00:09:45,879 I was reviewing a chart of another provider not too long ago, and it was 220 00:09:45,879 --> 00:09:49,419 a patient was like their third visit for an workman's comp eye injury. 221 00:09:49,599 --> 00:09:53,979 And on the second visit, their right eye had gone from 2040 to 2070. 222 00:09:54,639 --> 00:09:55,034 Joe: Oh, wow. 223 00:09:55,344 --> 00:09:58,324 Tracey: And the comment was patient's feeling better 224 00:09:58,324 --> 00:10:00,004 improving follow up one week. 225 00:10:00,004 --> 00:10:03,640 And I'm thinking you just missed that huge drop in visual acuity. 226 00:10:03,720 --> 00:10:04,140 Joe: Mm-hmm. 227 00:10:04,400 --> 00:10:06,680 Tracey: Definitely make sure that you look at 'em and one reading is 228 00:10:06,680 --> 00:10:08,380 not always what you're looking for. 229 00:10:08,410 --> 00:10:10,810 Maybe you wanna do multiple readings before and after treatment, 230 00:10:10,810 --> 00:10:13,790 especially if you're doing some sort of procedure like removing a 231 00:10:13,790 --> 00:10:14,770 foreign body or something like that 232 00:10:14,785 --> 00:10:15,205 Joe: Mm-hmm. 233 00:10:15,780 --> 00:10:16,770 Tracey: Or those sorts of things. 234 00:10:16,770 --> 00:10:19,020 So visual acuity is super, super important. 235 00:10:19,020 --> 00:10:21,840 Make sure not only do you do it, but it's documented and it 236 00:10:21,840 --> 00:10:23,280 shows up in your notes somewhere. 237 00:10:23,910 --> 00:10:27,660 So, like I said, it's very important for medical legal purposes, but also 238 00:10:27,720 --> 00:10:29,460 helpful for your medical decision making. 239 00:10:29,460 --> 00:10:32,220 It's gonna be a lot different for you if they have normal vision versus 240 00:10:32,220 --> 00:10:33,900 they clearly have abnormal vision. 241 00:10:34,540 --> 00:10:38,507 If visual acuity is normal and the patient subsequently has vision loss 242 00:10:38,507 --> 00:10:41,957 later, then you know, you can say that it wasn't there when I saw the patient. 243 00:10:42,307 --> 00:10:46,094 Do you have any tips that make visual acuity testing easier or, 244 00:10:46,094 --> 00:10:48,884 say somebody's having a significant difficulty with pain in their eye 245 00:10:48,884 --> 00:10:50,174 or say they forgot their glasses. 246 00:10:50,174 --> 00:10:50,924 Any ideas? 247 00:10:51,624 --> 00:10:54,335 Joe: Yeah, so well, I'll start by agreeing with everything you said. 248 00:10:54,335 --> 00:10:56,405 Visual acuity objectifies the situation. 249 00:10:56,405 --> 00:10:57,995 It absolutely needs to be done. 250 00:10:58,305 --> 00:11:00,430 If the patient's uncomfortable, has some blepharospasm. 251 00:11:00,975 --> 00:11:02,745 It might not be the first thing that you're able to do. 252 00:11:02,745 --> 00:11:04,945 So get a topical anesthetic in the eye. 253 00:11:05,155 --> 00:11:07,855 Have them gradually feel a little more comfortable opening it. 254 00:11:08,195 --> 00:11:11,795 You wanna do it close to the beginning of your exam 'cause it does give 255 00:11:11,795 --> 00:11:15,395 you some information, but sometimes it can't be done immediately. 256 00:11:15,395 --> 00:11:19,105 And so, I think anesthesia or analgesia and then, taking a little 257 00:11:19,105 --> 00:11:22,015 bit of time so that the patient feels comfortable doing it's important. 258 00:11:22,225 --> 00:11:23,725 It's really important to have good lighting. 259 00:11:23,725 --> 00:11:26,385 I've worked at a couple places where the Snellen chart was at 260 00:11:26,385 --> 00:11:28,425 the end of a dark kind of hallway. 261 00:11:28,935 --> 00:11:31,189 And it's hard to read when there's not good light. 262 00:11:31,499 --> 00:11:34,559 You wanna make sure that there's good light on the chart itself, otherwise 263 00:11:34,559 --> 00:11:36,289 you won't get an accurate reading. 264 00:11:36,699 --> 00:11:40,329 When patients wear corrective lenses and don't have them with them at the 265 00:11:40,329 --> 00:11:43,805 time they're having their visual acuity measured in the clinic, you're gonna 266 00:11:43,805 --> 00:11:46,355 have a lower value than would be ideal. 267 00:11:46,595 --> 00:11:48,515 And that's where they talk about this pinhole. 268 00:11:48,575 --> 00:11:52,375 And I find that that really works a lot of people who measure visual acuities, like 269 00:11:52,375 --> 00:11:56,425 even our ER nurses or medical assistants in the clinics don't necessarily 270 00:11:56,425 --> 00:11:57,865 think about that automatically. 271 00:11:58,115 --> 00:12:01,715 Or they may not quote, have a pinhole, that basic plastic thing 272 00:12:01,715 --> 00:12:02,975 that has the hole poked in it. 273 00:12:02,975 --> 00:12:05,693 And you can just do this with poking a hole in a piece of paper. 274 00:12:05,973 --> 00:12:07,923 People ask, how big does the hole need to be? 275 00:12:07,923 --> 00:12:09,813 And it is literally a pinhole. 276 00:12:10,053 --> 00:12:12,093 It's the smallest hole through which they can see. 277 00:12:12,093 --> 00:12:14,823 And the principle is that you're restricting their vision to the 278 00:12:14,823 --> 00:12:18,213 central visual axis where they're gonna have their best vision. 279 00:12:18,513 --> 00:12:22,553 Most people who have refractive problems are because as you expand that visual 280 00:12:22,553 --> 00:12:26,033 axis, irregularities in the cornea or the shape of the eye or the distances 281 00:12:26,033 --> 00:12:30,727 between the cornea and the lens in the back of the eye all come out of focal 282 00:12:30,727 --> 00:12:34,019 alignment . And that's why people need corrective lenses in the first place. 283 00:12:34,019 --> 00:12:39,266 So, definitely the pinhole helps to get an accurate visual acuity in situations 284 00:12:39,266 --> 00:12:43,406 where a patient wears corrective lenses and doesn't have them with them. 285 00:12:43,806 --> 00:12:48,066 The gold standard is to look at a Snellen chart from a 20 foot distance. 286 00:12:48,116 --> 00:12:51,476 But there are hand cards or even people have apps on their phones 287 00:12:51,476 --> 00:12:54,806 that you can hold in front of a patient to measure visual acuity. 288 00:12:54,806 --> 00:12:56,876 Just make sure you're holding at the proper distance for 289 00:12:56,876 --> 00:12:58,106 whatever tool you're using. 290 00:12:58,106 --> 00:13:02,326 That's important 'cause that is h ow you make the calculation and it translates 291 00:13:02,326 --> 00:13:04,846 that into the 20 20, 20 40 for you. 292 00:13:05,296 --> 00:13:09,960 You had mentioned pediatrics and sometimes if people potentially can't read, or kids 293 00:13:09,960 --> 00:13:13,724 haven't learned all their letters , there are picture Snellen charts or picture 294 00:13:13,724 --> 00:13:18,594 eye charts that can be used where there's a dog or a cat or a boat or a sun or 295 00:13:18,594 --> 00:13:23,604 even, something that looks like the letter E where the prongs of the E are 296 00:13:23,604 --> 00:13:27,894 pointing to the left, to the right or up or down, and there are different sizes 297 00:13:27,894 --> 00:13:31,464 that correlate with the visual acuity and people can tell you, oh yeah, up, down, 298 00:13:31,464 --> 00:13:33,324 right, left, or something like that. 299 00:13:33,324 --> 00:13:37,078 So all of those things make it so you can adapt the exam to situations where 300 00:13:37,078 --> 00:13:40,193 it's not incredibly straightforward and all of those are helpful. 301 00:13:40,553 --> 00:13:42,293 And the main thing is you just gotta do it. 302 00:13:42,293 --> 00:13:43,313 Gotta get it on the chart. 303 00:13:43,758 --> 00:13:44,178 Tracey: Yep. 304 00:13:44,268 --> 00:13:44,928 Absolutely. 305 00:13:45,278 --> 00:13:47,613 So you mentioned a little earlier that you know those bread and butter 306 00:13:47,613 --> 00:13:50,733 things, the things that you really need to know how to do, the things 307 00:13:50,733 --> 00:13:52,233 that we see the most of with eyes. 308 00:13:52,263 --> 00:13:54,460 Can we talk about maybe treatment for those things? 309 00:13:55,060 --> 00:13:55,600 Joe: Yeah, sure. 310 00:13:55,850 --> 00:14:00,140 Foreign bodies I think are pretty common just in experience and statistically 311 00:14:00,420 --> 00:14:01,830 and they need to be removed. 312 00:14:01,880 --> 00:14:03,770 So you need to feel comfortable removing 'em. 313 00:14:03,770 --> 00:14:06,113 There's a, variety of ways to do it. 314 00:14:06,113 --> 00:14:09,523 Sometimes you can with a moist sterile cotton tip applicator, 315 00:14:09,523 --> 00:14:10,813 just swipe it off the cornea. 316 00:14:10,813 --> 00:14:13,753 The more embedded it is, the more difficult it may be. 317 00:14:13,783 --> 00:14:16,843 If it's just loosely on there or on the conjunctiva, you might be 318 00:14:16,843 --> 00:14:18,373 able to get it off with irrigation. 319 00:14:18,713 --> 00:14:21,083 You just need to make sure that you can kind of catch it 320 00:14:21,083 --> 00:14:22,223 as it moves around the eye. 321 00:14:22,473 --> 00:14:25,233 Occasionally can get under the lid when you do that, so just be careful. 322 00:14:25,573 --> 00:14:29,863 And in situations where you can't remove the foreign body, that's one 323 00:14:29,863 --> 00:14:31,163 of those things that's time sensitive. 324 00:14:31,163 --> 00:14:34,183 You wouldn't necessarily leave a foreign body in the eye and have 325 00:14:34,183 --> 00:14:35,593 somebody follow up the next day. 326 00:14:35,593 --> 00:14:39,223 Those are people you would have to send to the ED or to an ophthalmologist. 327 00:14:39,223 --> 00:14:42,463 If you have a good relationship with somebody who will see somebody 328 00:14:42,463 --> 00:14:44,060 from the urgent care center. 329 00:14:44,440 --> 00:14:47,950 Most metallic foreign bodies will start to rust fairly quickly. 330 00:14:47,950 --> 00:14:48,970 It's pretty surprising. 331 00:14:49,300 --> 00:14:52,900 And that rust can either form a ring around the outside of the foreign body 332 00:14:52,900 --> 00:14:57,040 or even stain the cornea in the divot that it makes once it's embedded. 333 00:14:57,380 --> 00:15:00,620 I know years ago we used to try to get those out and we had burrs 334 00:15:00,620 --> 00:15:04,157 and we would use 31 gauge needles and kind of try to scrape away the 335 00:15:04,157 --> 00:15:05,747 layers of the corneal epithelium. 336 00:15:06,197 --> 00:15:09,167 Honestly, you don't wanna do that unless you feel really comfortable doing it and 337 00:15:09,167 --> 00:15:13,367 have some experience, and it does not need to be done at urgent care or even r 338 00:15:13,387 --> 00:15:15,307 eferring to the ED to do it immediately. 339 00:15:15,307 --> 00:15:18,727 If the patient could get in to see an ophthalmologist within a day or so, 340 00:15:18,727 --> 00:15:20,977 24 hours or so, then they can do that. 341 00:15:20,977 --> 00:15:23,617 And I've even seen them do it on a delayed basis. 342 00:15:23,717 --> 00:15:25,937 The corneal epithelium can grow over the stain and then 343 00:15:25,937 --> 00:15:27,993 they'll just expose it later. 344 00:15:28,393 --> 00:15:33,663 For abrasions or other kind of traumatic corneal defects, whether it's either the 345 00:15:33,663 --> 00:15:38,193 primary injury from getting scratched by like a tree branch or a fingernail 346 00:15:38,193 --> 00:15:41,513 or something like that, or c reated by that foreign body being embedded. 347 00:15:42,013 --> 00:15:43,723 Those will heal on their own. 348 00:15:43,773 --> 00:15:45,663 So we don't necessarily have to do much. 349 00:15:45,723 --> 00:15:49,783 And unfortunately there's not a lot of data about whether we need to do 350 00:15:49,783 --> 00:15:53,053 the main thing that we do in these situations, which is use antibiotics. 351 00:15:53,083 --> 00:15:56,443 Some studies show that it decreases the chance of infection. 352 00:15:56,443 --> 00:15:57,163 Some don't. 353 00:15:57,253 --> 00:16:00,687 And in the end, the initial authors of the article said you know, there's 354 00:16:00,687 --> 00:16:04,167 no convincing evidence so you can feel comfortable going ahead and using 355 00:16:04,197 --> 00:16:09,247 erythromycin and I think that probably the chance of harm with that is pretty low. 356 00:16:09,527 --> 00:16:12,377 It tends to be somewhat soothing, whether it really changes the 357 00:16:12,377 --> 00:16:15,347 chance of an infection, which is kind of uncommon anyway. 358 00:16:15,347 --> 00:16:16,187 It's hard to know. 359 00:16:16,577 --> 00:16:20,277 But the ointment sometimes kind of soothes the eye and helps take the patient's mind 360 00:16:20,277 --> 00:16:22,227 off of it, I think in, my experience. 361 00:16:22,617 --> 00:16:25,347 The main take home point from that is that you don't need to use 362 00:16:25,347 --> 00:16:30,597 moxifloxacin or big gun broad spectrum antibiotic eyedrops in these patients. 363 00:16:30,907 --> 00:16:34,087 I'm not sure whether it leads to antimicrobial resistance on the 364 00:16:34,087 --> 00:16:35,467 surface of the eye, let's say. 365 00:16:35,687 --> 00:16:37,187 But they tend to be a lot more expensive. 366 00:16:37,237 --> 00:16:40,327 And, we wanna save those for the times when they're really necessary. 367 00:16:40,787 --> 00:16:45,017 For contact lens wearers who have corneal abrasions, they do recommend 368 00:16:45,017 --> 00:16:49,153 broader coverage just because they have some kind of baseline ischemia 369 00:16:49,153 --> 00:16:51,643 of their cornea, regardless of the type of contact lens they wear. 370 00:16:51,643 --> 00:16:56,098 So they're a little more likely to have issues that r elate to any 371 00:16:56,098 --> 00:16:59,338 kind of damage, either primarily an ulcer, which is an infection itself 372 00:16:59,578 --> 00:17:00,868 or an abrasion that's healing. 373 00:17:00,868 --> 00:17:03,248 It takes a little bit longer and they're a little bit more 374 00:17:03,248 --> 00:17:04,298 likely to have complications. 375 00:17:04,298 --> 00:17:07,638 So that's when you would use a little broader spectrum antibiotic eye drop. 376 00:17:07,978 --> 00:17:11,098 But whether you know exactly how much of a difference it makes , there's 377 00:17:11,098 --> 00:17:13,678 not really good research, which probably have somebody to do a study. 378 00:17:14,378 --> 00:17:15,398 Tracey: Ooh, good idea. 379 00:17:15,778 --> 00:17:16,235 Joe: Yeah. 380 00:17:16,295 --> 00:17:19,458 Tracey: Alright, so, we kind of touched on chemical exposures a little bit. 381 00:17:19,458 --> 00:17:21,952 Is there anything that we should really talk about? 382 00:17:21,952 --> 00:17:23,512 I mean, I guess irrigation, right? 383 00:17:23,782 --> 00:17:25,252 Joe: Yeah, probably a couple high points here. 384 00:17:25,252 --> 00:17:28,162 You know, the solution to pollution is dilution, right? 385 00:17:28,212 --> 00:17:29,286 And that means irrigation. 386 00:17:29,416 --> 00:17:34,093 so regardless of what the chemical is, acid base or something in between 387 00:17:34,093 --> 00:17:38,003 if it's just kind of corrosive , and some corrosive materials don't have 388 00:17:38,003 --> 00:17:41,363 to be acid or based, they will degrade tissue on a different basis, an 389 00:17:41,363 --> 00:17:43,373 oxidative basis or a reactive basis. 390 00:17:43,673 --> 00:17:46,343 So any kind of chemical in the eye, you want to get started 391 00:17:46,343 --> 00:17:47,633 with irrigation right away. 392 00:17:47,843 --> 00:17:49,533 And there's a number of ways to do that. 393 00:17:49,533 --> 00:17:53,110 There's the quote c ommercially available contact lens type thing 394 00:17:53,110 --> 00:17:57,400 with a tubing system that puts the irrigant directly on the eye. 395 00:17:57,710 --> 00:18:02,480 You can use an eyewash station, you can use a nasal cannula and direct 396 00:18:02,580 --> 00:18:06,510 by basically plugging it into your IV bag, direct IV fluid into either 397 00:18:06,510 --> 00:18:08,040 or both eyes at the same time. 398 00:18:08,430 --> 00:18:10,350 Just wanna make sure you're kind of catching the water 399 00:18:10,350 --> 00:18:11,460 and not making a total mess. 400 00:18:11,460 --> 00:18:13,860 That's more of a challenge sometimes in the irrigation. 401 00:18:13,993 --> 00:18:19,503 Maybe except for hF or hydrofluoric acid, there should be no attempt to 402 00:18:19,503 --> 00:18:21,123 neutralize whatever's in the eye. 403 00:18:21,123 --> 00:18:23,823 So it's not the sort of thing where if there's an acid, you wanna try 404 00:18:23,823 --> 00:18:26,073 and put some base in the eye, or if there's a base, you wanna put some 405 00:18:26,073 --> 00:18:29,583 acid, you just want to irrigate like crazy, at least a liter or so. 406 00:18:29,913 --> 00:18:34,113 After a liter and or 30 minutes, you can go ahead and check the pH at that point. 407 00:18:34,593 --> 00:18:39,013 You really don't even delay irrigation to do any sort of an in-depth exam. 408 00:18:39,013 --> 00:18:42,678 Maybe get a real gross look at the eye to begin with to make sure it's not something 409 00:18:42,678 --> 00:18:44,328 worse than just the chemical exposure. 410 00:18:44,758 --> 00:18:47,828 And then after you've done your irrigation you can check a pH. 411 00:18:47,828 --> 00:18:51,128 If they're still symptomatic or the pH is abnormal, you irrigate more. 412 00:18:51,308 --> 00:18:54,468 If they're feeling okay and the pH is neutral, you're okay to stop at that 413 00:18:54,468 --> 00:18:56,208 point and do the rest of your exam. 414 00:18:56,548 --> 00:19:00,128 And then, there's been some research in terms of what the quote, best 415 00:19:00,128 --> 00:19:04,148 irrigant to use, and there's really not a lot of big difference between normal 416 00:19:04,148 --> 00:19:07,628 saline or lactated ringers or other sorts of solutions or even tap water. 417 00:19:07,988 --> 00:19:11,062 So, you can use whatever is a clean solution. 418 00:19:11,062 --> 00:19:14,225 It doesn't even really have to be sterile to get this job done in tap 419 00:19:14,225 --> 00:19:16,355 water is fine if that's all you have. 420 00:19:16,945 --> 00:19:18,072 Tracey: Yeah, actually that's what we use. 421 00:19:18,082 --> 00:19:20,062 We don't do IV fluids in my center. 422 00:19:20,442 --> 00:19:24,108 So we generally have, we have an emergency eyewash station and we put 423 00:19:24,108 --> 00:19:27,398 some tetracaine drops in there and let 'em hold open their eyes and have at 424 00:19:27,398 --> 00:19:29,058 it over the emergency eyewash station. 425 00:19:29,308 --> 00:19:31,020 The beauty of that is it doesn't make a mess. 426 00:19:31,050 --> 00:19:33,120 I mean, it makes a little bit of a mess, but certainly not as 427 00:19:33,120 --> 00:19:36,572 much as if you're using the other irrigation devices that are available. 428 00:19:36,572 --> 00:19:37,592 Joe: You made an important point too. 429 00:19:37,592 --> 00:19:39,465 I didn't mention it, but you really want to get some 430 00:19:39,465 --> 00:19:40,650 anesthetic eye drops in the eye. 431 00:19:40,650 --> 00:19:43,586 This is really impossible to do if the eye's not numb. 432 00:19:43,776 --> 00:19:47,044 And if you're Irrigating for about 30 minutes, you might need to even put 433 00:19:47,044 --> 00:19:50,854 another dose in either or both eyes that you're irrigating in the course 434 00:19:50,854 --> 00:19:53,824 of your first irrigation, just because it can wear off during that time. 435 00:19:54,004 --> 00:19:56,394 Tracey: Yeah, I mean, I think you're kind of washing the drops outta their eyes, so. 436 00:19:57,094 --> 00:19:57,814 Joe: Exactly. 437 00:19:57,979 --> 00:19:58,909 Tracey: so yeah, definitely. 438 00:19:59,279 --> 00:20:01,769 So I just wanna mention, you know, we're really not gonna go over , the 439 00:20:01,769 --> 00:20:04,699 really traumatic eye injuries that we see because they're so 440 00:20:04,699 --> 00:20:06,679 much less common in urgent care. 441 00:20:06,679 --> 00:20:10,099 I mean, I think a lot of people sort of self-select for the ED if they have 442 00:20:10,099 --> 00:20:13,519 some gaping, bulging, nasty eye injury. 443 00:20:13,809 --> 00:20:15,489 But you know, you do need to know about these. 444 00:20:15,489 --> 00:20:19,229 So I would strongly advise you to dive into the issue a little more in 445 00:20:19,229 --> 00:20:22,633 depth i f you're a subscriber and if you're not a subscriber, hey, why not? 446 00:20:22,929 --> 00:20:23,259 Joe: Yeah, 447 00:20:23,399 --> 00:20:25,659 Tracey: So I Firmly encourage you , to look at these things. 448 00:20:25,709 --> 00:20:26,702 It's what's the term? 449 00:20:26,702 --> 00:20:27,722 Oh, it's a halo thing. 450 00:20:27,722 --> 00:20:29,582 It's a high acuity, low occurrence. 451 00:20:29,887 --> 00:20:32,767 Definitely something you need to familiarize yourself about a bit. 452 00:20:32,767 --> 00:20:33,427 oh, yes. 453 00:20:33,427 --> 00:20:34,961 I'm dying to ask you this question. 454 00:20:35,161 --> 00:20:38,037 Patients always ask me, you know, not providers so much, but the 455 00:20:38,037 --> 00:20:40,707 patients always say, Hey, doc, you put those drops in my eye. 456 00:20:40,707 --> 00:20:41,757 They feel so great. 457 00:20:41,757 --> 00:20:42,717 Can I take them home? 458 00:20:42,862 --> 00:20:45,828 I think one out of every three or four patients will ask me that. 459 00:20:46,018 --> 00:20:48,208 I was always taught that that is a terrible idea. 460 00:20:48,208 --> 00:20:50,973 That if your eye is numb, you can cause yourself more trauma 461 00:20:50,973 --> 00:20:53,733 by accidentally poking yourself in the eye and not realizing it. 462 00:20:54,007 --> 00:20:57,560 or that the overuse of the stuff is toxic to the corneal epithelium. 463 00:20:57,900 --> 00:20:59,400 But I think thoughts on that are changing. 464 00:20:59,400 --> 00:21:00,450 What does the evidence say? 465 00:21:01,150 --> 00:21:01,330 Joe: Yeah, 466 00:21:01,330 --> 00:21:01,540 squadcaster-h174_1_07-02-2025_173538: you know, 467 00:21:01,540 --> 00:21:02,350 Joe: I was taught that way too. 468 00:21:02,350 --> 00:21:05,410 I think we were both taught at around the same time and, went through, went 469 00:21:05,410 --> 00:21:08,840 through practice and it was probably eight or 10 years ago that somebody 470 00:21:08,840 --> 00:21:10,220 thought, well, why don't we test this? 471 00:21:10,320 --> 00:21:11,640 Same two reasons. 472 00:21:11,700 --> 00:21:15,390 When the eye is numb, somebody's likely to injure it more, or maybe there's something 473 00:21:15,630 --> 00:21:17,707 toxic about the drops themselves. 474 00:21:17,707 --> 00:21:21,165 And I think there is some evidence that they might slow c orneal healing. 475 00:21:21,555 --> 00:21:26,335 The initial studies that were done actually used dilute alcaine or tetracaine 476 00:21:26,335 --> 00:21:28,555 drops rather than the full strength. 477 00:21:28,605 --> 00:21:32,025 People could put it into periodic intervals for up to 24 or 48 hours. 478 00:21:32,385 --> 00:21:37,225 And, this is one of those things where our acute care literature and 479 00:21:37,225 --> 00:21:39,385 the specialty literature diverge. 480 00:21:39,915 --> 00:21:42,045 And there's just plain difference of opinion. 481 00:21:42,045 --> 00:21:43,905 And most of these studies were done in the ED. 482 00:21:44,160 --> 00:21:48,540 and they showed that people did okay, that there was a really low likelihood of harm. 483 00:21:48,880 --> 00:21:52,390 Even placebo controlled studies, their pain was lower and they 484 00:21:52,390 --> 00:21:56,680 didn't rub their eye and incur more injury or have any toxic effects. 485 00:21:56,680 --> 00:22:01,767 So it was the basis for a while for there to be kind of a, standard practice of 486 00:22:01,943 --> 00:22:04,673 letting patients not necessarily take the whole bottle with them, but giving 487 00:22:04,673 --> 00:22:08,777 them a kind of a dilute amount that they could use for analgesia over time. 488 00:22:08,967 --> 00:22:13,110 But in the ED literature, there are pro con things and it's almost 489 00:22:13,110 --> 00:22:15,960 always an ophthalmologist on the other side who basically says, our 490 00:22:15,960 --> 00:22:17,780 literature shows you can't do this. 491 00:22:17,990 --> 00:22:21,530 And I think that was basically the basis of what we learned because it was only 492 00:22:21,530 --> 00:22:24,764 ophthalmologists who were studying it before that E D literature came out. 493 00:22:25,073 --> 00:22:28,583 So, it's not something that I regularly do. 494 00:22:28,943 --> 00:22:32,993 I would say occasionally you have that person that just has blepharospasm 495 00:22:32,993 --> 00:22:35,270 and they're so uncomfortable. 496 00:22:35,640 --> 00:22:39,820 And I found, the issue talks about topical NSAIDs, which I would have to say even 497 00:22:39,820 --> 00:22:44,830 for myself when I've used them, they don't really seem like they help that much. 498 00:22:45,010 --> 00:22:47,140 And systemic analgesia doesn't seem to help. 499 00:22:47,420 --> 00:22:51,343 Ibuprofen, acetaminophen and then when you talk about doing an opioid for just 500 00:22:51,343 --> 00:22:53,713 a corneal abrasion, that's kind of a lot. 501 00:22:53,983 --> 00:22:56,773 So how are you gonna help make this person more comfortable? 502 00:22:57,213 --> 00:23:02,733 I will rarely do it and I haven't heard anything bad about those for my n of four, 503 00:23:03,273 --> 00:23:05,163 but it's not something to do routinely. 504 00:23:05,563 --> 00:23:08,023 I think until our ophthalmologists tell us it's okay, and they 505 00:23:08,023 --> 00:23:09,013 may never tell us that. 506 00:23:09,463 --> 00:23:09,853 Tracey: Yeah. 507 00:23:09,943 --> 00:23:10,363 Yeah. 508 00:23:10,363 --> 00:23:11,353 Entirely true. 509 00:23:11,930 --> 00:23:13,880 Lastly, let's talk about some specialty referral. 510 00:23:13,880 --> 00:23:19,783 How do you decide who needs to go now versus, in a day or two versus whenever 511 00:23:20,183 --> 00:23:22,283 Joe: Yeah, you gotta kind of know what you're dealing with. 512 00:23:22,283 --> 00:23:27,713 It's really based on the diagnosis or if you can't make a diagnosis, 513 00:23:27,713 --> 00:23:29,003 how bad is the situation. 514 00:23:29,003 --> 00:23:33,002 So, if you can either make the diagnosis with your side L sign, like you talked 515 00:23:33,002 --> 00:23:36,827 about, of a rupture or a perf of the globe, that person needs to go right away. 516 00:23:36,877 --> 00:23:38,827 They're pretty much gonna go to the operating room. 517 00:23:38,827 --> 00:23:42,367 So sending 'em to the ophthalmologist's office is not necessarily gonna be the 518 00:23:42,367 --> 00:23:43,447 right thing, but send 'em to the ED. 519 00:23:44,184 --> 00:23:46,374 Retrobulbar hematoma, again, rare. 520 00:23:46,684 --> 00:23:49,264 But if you have a patient with that, they need to go to the 521 00:23:49,264 --> 00:23:50,404 ER to have a decompression. 522 00:23:50,714 --> 00:23:55,854 Any suspicion or positive diagnosis of an intraocular foreign body or foreign body 523 00:23:55,854 --> 00:24:01,679 that you can't remove, those patients need to go immediately to the ED and then you 524 00:24:01,679 --> 00:24:05,159 may not know that you're dealing with any one of those, but I would say anytime the 525 00:24:05,159 --> 00:24:09,239 patient has severe pain or any kind of visual loss, even if they don't have any 526 00:24:09,239 --> 00:24:10,889 of those, I would send those patients. 527 00:24:11,199 --> 00:24:14,079 We talked about the fact that rust staining doesn't need to be an 528 00:24:14,079 --> 00:24:16,029 immediate referral, but within 24 hours. 529 00:24:16,029 --> 00:24:19,089 So that person, you could make a referral to an ophthalmologist and 530 00:24:19,089 --> 00:24:22,809 then maybe say if the ophthalmologist that was supposed to see them didn't 531 00:24:22,809 --> 00:24:25,509 see them, then they could go to the ED where they have some ophthalmology 532 00:24:25,509 --> 00:24:26,919 backup to take care of that for them. 533 00:24:27,429 --> 00:24:33,869 For things like hyphema, corneal ulcer and traumatic iritis if you can't get 534 00:24:33,869 --> 00:24:37,199 in touch with an ophthalmologist to guide you and to let you know that 535 00:24:37,199 --> 00:24:40,959 they're going to see the patient the next day or so then those patients 536 00:24:40,959 --> 00:24:43,289 should be referred promptly to the ED. 537 00:24:43,799 --> 00:24:46,649 If you can talk to a consulting ophthalmologist who will do the follow 538 00:24:46,649 --> 00:24:48,379 up, they don't even need to go to the ED. 539 00:24:48,439 --> 00:24:52,079 You can be managed definitely ulcers or traumatic iritis at home. 540 00:24:52,409 --> 00:24:56,849 And then small hyphemas in patients without a high risk for re-bleeding. 541 00:24:57,209 --> 00:24:59,999 There's actually a move toward managing them at home also. 542 00:25:00,419 --> 00:25:03,916 And then our biggest group of patients where we've removed a foreign body 543 00:25:03,946 --> 00:25:05,626 or they have a corneal abrasion. 544 00:25:05,876 --> 00:25:09,226 If those patients are doing well they don't need to be referred at all. 545 00:25:09,656 --> 00:25:12,416 You can either give them kind of anticipatory guidance or have 546 00:25:12,416 --> 00:25:16,046 them follow up with us if it's not getting better at a particular rate. 547 00:25:16,256 --> 00:25:18,806 If they have any immediate worsening, obviously they should 548 00:25:18,856 --> 00:25:20,656 seek care in that situation. 549 00:25:21,356 --> 00:25:22,696 Tracey: Yeah, definitely makes sense. 550 00:25:23,069 --> 00:25:24,499 I've said this on many of the other 551 00:25:24,499 --> 00:25:25,029 squadcaster-0826_1_07-02-2025_203538: episodes, 552 00:25:25,049 --> 00:25:27,119 Tracey: but, make friends with your local ophthalmologist. 553 00:25:27,164 --> 00:25:30,394 I find many of them are very willing to see people, either 554 00:25:30,394 --> 00:25:31,714 the same day or the next day. 555 00:25:31,714 --> 00:25:35,164 And I know none of us really wanna make a phone call in the middle of our busy 556 00:25:35,164 --> 00:25:36,694 day when you've got 10 patients waiting. 557 00:25:36,694 --> 00:25:40,514 But you could save the patient some time and potentially an ED visit because 558 00:25:40,514 --> 00:25:43,694 they may do the same thing at the ED and just call the ophthalmologist 559 00:25:43,694 --> 00:25:44,744 and send the patient there. 560 00:25:45,044 --> 00:25:48,101 So, save them an extra bill . Make friends with your ophthalmologist. 561 00:25:48,211 --> 00:25:48,841 You know, fine. 562 00:25:48,841 --> 00:25:51,164 It's only Monday through Friday, nine to five, but, at least if you 563 00:25:51,164 --> 00:25:54,164 have somebody to talk to, to give you some guidance, you may avoid that ED 564 00:25:54,164 --> 00:25:57,794 visit or they may tell you something insightful that's helpful to you. 565 00:25:58,274 --> 00:25:58,814 Joe: Yep, for sure. 566 00:25:59,504 --> 00:26:02,384 Tracey: So listen, we splint ortho injuries prior to referral. 567 00:26:02,384 --> 00:26:04,904 If we send somebody to the ED with an eye injury, what do we do with 'em? 568 00:26:04,904 --> 00:26:06,611 Should we patch them? 569 00:26:07,311 --> 00:26:09,351 Joe: Well, hey, I was gonna kind of mention this back 570 00:26:09,351 --> 00:26:10,701 when we talked about pain. 571 00:26:11,181 --> 00:26:16,592 And this is one of those things also where the research may not exactly 572 00:26:16,592 --> 00:26:21,272 agree with your experience, or it's not a one size fits all thing. 573 00:26:21,272 --> 00:26:23,229 It's like, bronchodilators for bronchiolitis. 574 00:26:23,419 --> 00:26:24,859 The guidelines say don't give 'em to anybody. 575 00:26:25,039 --> 00:26:26,509 It's like don't give 'em to anybody. 576 00:26:27,009 --> 00:26:31,389 And I think my experience with patching is it's not the thing you should be doing 577 00:26:31,389 --> 00:26:33,189 to every patient with a corneal abrasion. 578 00:26:33,189 --> 00:26:36,039 It's not a standard treatment, but some people are actually 579 00:26:36,039 --> 00:26:38,559 more comfortable with their eye closed when they have an abrasion. 580 00:26:38,559 --> 00:26:43,081 And if you're having that patient who just is so uncomfortable with their eye 581 00:26:43,081 --> 00:26:46,741 open, you're trying to figure out what to do to make them more comfortable, 582 00:26:47,161 --> 00:26:50,971 and you put some erythromycin ointment in their eye if you have it and you 583 00:26:51,001 --> 00:26:54,601 have them close it and it's soothing and they feel better, that might be 584 00:26:54,661 --> 00:26:56,491 that rare patient that you would patch. 585 00:26:56,491 --> 00:26:59,161 Again, it's not gonna help them get better any faster. 586 00:26:59,161 --> 00:27:03,481 May be some evidence obviously if they open their eye under the 587 00:27:03,481 --> 00:27:04,921 patch, it's gonna scratch it more. 588 00:27:05,311 --> 00:27:08,251 Again, not something you can do for everybody, but if you individualize the 589 00:27:08,251 --> 00:27:12,091 care that little splint for the eye, if you wanna think of it that way might be 590 00:27:12,091 --> 00:27:13,651 the right thing to do in that one case. 591 00:27:13,651 --> 00:27:14,761 But not standard treatment. 592 00:27:14,761 --> 00:27:19,181 Again, years ago we used to do it for just about every eye problem, 593 00:27:19,241 --> 00:27:20,561 gosh, for just about everything. 594 00:27:21,081 --> 00:27:24,581 And it's not necessary except maybe in those rare cases. 595 00:27:24,956 --> 00:27:25,646 Tracey: just keep in mind, 596 00:27:25,646 --> 00:27:25,886 squadcaster-0826_1_07-02-2025_203538: you know, 597 00:27:25,886 --> 00:27:28,556 Tracey: for it to work properly, it really has to be kind of tight, 598 00:27:28,811 --> 00:27:29,231 Joe: Mm-hmm. 599 00:27:29,246 --> 00:27:31,816 Tracey: the whole purpose of it is to keep the eyelid shut. 600 00:27:32,086 --> 00:27:35,896 So if you just throw one little soft patch on there and you tape it loosely, 601 00:27:35,896 --> 00:27:37,246 that's not really gonna do the job. 602 00:27:37,246 --> 00:27:39,229 And it's kinda like C collars in my mind. 603 00:27:39,279 --> 00:27:42,612 It has to be tight enough that it's actually uncomfortable to have it on. 604 00:27:42,956 --> 00:27:46,166 And most patients will not tolerate that with an eye patch. 605 00:27:46,466 --> 00:27:49,346 Now, on the other hand, when we're talking about significant trauma, you 606 00:27:49,346 --> 00:27:53,116 want to use one of those metal eye shields or the paper cup routine to 607 00:27:53,116 --> 00:27:55,036 protect the eye from any future trauma. 608 00:27:55,086 --> 00:27:58,206 That would be the indication of when you would definitely wanna patch an eye 609 00:27:58,206 --> 00:28:00,096 because you don't want any further trauma. 610 00:28:00,096 --> 00:28:02,596 You don't want them pressing on their globe and squirting out 611 00:28:02,596 --> 00:28:03,916 through all their vitreous fluid. 612 00:28:03,916 --> 00:28:05,906 You want to kind of preserve that as much as you can. 613 00:28:05,906 --> 00:28:07,959 So definitely that's the place for the eye patch. 614 00:28:07,959 --> 00:28:09,069 But you know you're right. 615 00:28:09,139 --> 00:28:11,149 It's case by case basis for everybody else. 616 00:28:11,389 --> 00:28:11,719 Joe: Yeah. 617 00:28:11,769 --> 00:28:16,359 And that's just getting them safely to their next kind of definitive care really. 618 00:28:16,359 --> 00:28:17,224 It's not part of the treatment. 619 00:28:17,224 --> 00:28:18,334 You're just sort of protecting it. 620 00:28:18,334 --> 00:28:19,144 So you're absolutely right. 621 00:28:19,144 --> 00:28:21,799 Tracey: Yeah let's hope my poor guy with the urine cup tape to his face. 622 00:28:21,799 --> 00:28:22,609 It's so long. 623 00:28:23,309 --> 00:28:25,889 He's like, do I need to go out in public with this on my face? 624 00:28:25,889 --> 00:28:28,019 I'm like, yeah, just until you get to the emergency room. 625 00:28:28,719 --> 00:28:29,779 Joe: Yes, oh gosh, 626 00:28:29,779 --> 00:28:30,809 Tracey: He also said, oh, 627 00:28:30,864 --> 00:28:32,424 Joe: I feel so much better with the tetracaine. 628 00:28:32,424 --> 00:28:33,444 Do I really have to go? 629 00:28:33,444 --> 00:28:34,524 I'm like, yes, yes. 630 00:28:34,629 --> 00:28:35,319 yes. 631 00:28:35,709 --> 00:28:36,039 Yep. 632 00:28:36,159 --> 00:28:37,239 If you wanna have an eye. 633 00:28:37,939 --> 00:28:40,279 Tracey: All right, so I think we've done a nice review of the article. 634 00:28:40,279 --> 00:28:41,239 Can we wrap it up? 635 00:28:41,239 --> 00:28:44,389 Are there any final tips that we wanna do about eye trauma? 636 00:28:45,089 --> 00:28:49,779 Joe: Yeah, I can, maybe just summarize I guess we as urgent care clinicians need 637 00:28:49,779 --> 00:28:54,879 to know how to identify those rare, super time sensitive conditions or know when 638 00:28:54,879 --> 00:28:56,649 to suspect them, even if we can't tell. 639 00:28:57,039 --> 00:28:59,379 If we suspect, those patients get referred. 640 00:28:59,769 --> 00:29:02,889 We need to feel really comfortable characterizing those common, 641 00:29:02,919 --> 00:29:06,219 uncomplicated, low risk conditions and feel comfortable with the treatment. 642 00:29:06,649 --> 00:29:08,329 We didn't talk too much about POCUS. 643 00:29:08,534 --> 00:29:09,644 The article does a little bit. 644 00:29:09,644 --> 00:29:12,494 It's kind of a cutting edge thing, and I use it in the ED. 645 00:29:13,074 --> 00:29:16,884 We don't have one in urgent care, but it's actually changed my approach to 646 00:29:16,884 --> 00:29:19,044 patients with possible retinal detachment. 647 00:29:19,294 --> 00:29:20,764 Those can happen spontaneously. 648 00:29:20,764 --> 00:29:23,947 Probably more of 'em are, but they can also happen with a globe contusion. 649 00:29:23,947 --> 00:29:25,806 So, it's actually catching on. 650 00:29:25,806 --> 00:29:28,386 People are really interested at the conferences, so if you can get your hands 651 00:29:29,056 --> 00:29:32,716 on an ultrasound and learn how to use it not only on the eye, but elsewhere. 652 00:29:33,106 --> 00:29:35,146 That's sort of a, kind of a nice tip. 653 00:29:35,446 --> 00:29:39,176 And then finally no pun intended, keep your eyes open for some of the 654 00:29:39,176 --> 00:29:41,186 resolution to some of these controversies. 655 00:29:41,186 --> 00:29:45,056 Like, can we give people tetracaine to go home and do we really need 656 00:29:45,056 --> 00:29:47,876 to use antibiotics and those sorts of things 'cause our knowledge 657 00:29:47,876 --> 00:29:49,646 is always growing and changing. 658 00:29:50,331 --> 00:29:51,441 Tracey: You said keep your eyes open. 659 00:29:51,441 --> 00:29:52,791 I was gonna say be on the lookout. 660 00:29:52,791 --> 00:29:53,761 But both of them work 661 00:29:53,826 --> 00:29:55,986 Joe: There you go, that's why the eyes are so important. 662 00:29:56,091 --> 00:29:56,811 Tracey: There you go. 663 00:29:56,911 --> 00:29:58,021 Fortunately we have two of them. 664 00:29:58,221 --> 00:30:00,531 Alright, so I let Joe do all the work here and I'm sure he'll get 665 00:30:00,531 --> 00:30:03,172 me back when we do low back pain in a few months 'cause that's the 666 00:30:03,172 --> 00:30:04,642 one that I'm working on right now. 667 00:30:04,952 --> 00:30:08,402 We really gave a brief overview and there's lots of useful tidbits and 668 00:30:08,402 --> 00:30:11,049 really extensive discussion in the issue. 669 00:30:11,049 --> 00:30:15,234 So be sure to check that out and make sure that you claim and pick up your CME. 670 00:30:15,264 --> 00:30:17,124 You pay for it, so you might as well grab it, right? 671 00:30:17,484 --> 00:30:19,224 So I encourage you to really go through it. 672 00:30:19,224 --> 00:30:22,404 There's also some really cool free content on FOAMEd as well. 673 00:30:22,404 --> 00:30:26,247 So if you're not familiar with that, go to the EB medicine site and check out FOAMEd. 674 00:30:26,397 --> 00:30:28,887 There's some questions and there's all sorts of freebies on there, 675 00:30:28,887 --> 00:30:32,060 which are useful some of which will follow this issue as well. 676 00:30:32,495 --> 00:30:36,192 And as always we recommend that you stay up to date on the latest evidence-based 677 00:30:36,192 --> 00:30:39,552 practices so you can really hone your skills and practice the safest most 678 00:30:39,552 --> 00:30:41,322 effective urgent care medicine possible. 679 00:30:41,904 --> 00:30:45,405 I was gonna say, not sure what next month is, but I can now reveal to 680 00:30:45,405 --> 00:30:49,495 the masses that next month is acute diverticulitis which we've really 681 00:30:49,495 --> 00:30:52,492 worked on well, and there's a lot of new evidence and a lot of changes 682 00:30:52,547 --> 00:30:52,967 Joe: Mm-hmm. 683 00:30:53,122 --> 00:30:56,445 Tracey: So, we look forward to that and we will talk about that next month. 684 00:30:57,132 --> 00:30:57,432 Joe: Sounds great. 685 00:30:57,717 --> 00:30:58,107 Tracey: All right. 686 00:30:58,107 --> 00:30:58,827 Take care everybody. 687 00:30:58,827 --> 00:30:59,577 See you in a month. 688 00:31:00,042 --> 00:31:00,647 squadcaster-h174_1_07-02-2025_173538: Take care everyone. 689 00:31:00,647 --> 00:31:01,047 Bye-bye. 690 00:31:01,711 --> 00:31:04,871 Tracey: I want to thank everybody to listening to this month's evidence based 691 00:31:04,871 --> 00:31:09,301 urgentology podcast . Just a reminder that subscribers can go to ebmedicine. 692 00:31:09,311 --> 00:31:13,111 net and read the full issue if you want more information, if you haven't already, 693 00:31:14,010 --> 00:31:15,900 Joe: And if you're not a subscriber head to the site. 694 00:31:16,070 --> 00:31:17,030 That's ebmedicine. 695 00:31:17,260 --> 00:31:18,840 net to check out what they have. 696 00:31:19,163 --> 00:31:22,773 If you subscribe you'll get access to the article as well as future articles 697 00:31:22,793 --> 00:31:25,393 and the whole archive of all past issues. 698 00:31:25,847 --> 00:31:26,997 Tracey: Look forward to seeing you there.