Tracey: Yeah let's hope my poor guy with the urine cup tape to his face.
It's so long.
He's like, do I need to go out in public with this on my face?
I'm like, yeah, just until you get to the emergency room.
Joe: Hello, and welcome to the Evidence Based Urgent Care Urgentology Podcast.
I'm Joe Toscano.
I am on the editorial board of Evidence Based Urgent Care and also the Senior
Research Editor for the sister EB Medicine publication, Emergency Medicine Practice.
Tracey: And I'm Tracy Davidoff.
I'm the editor in chief of Evidence Based Urgent Care.
Joe and I have been involved in urgent care practice and education for many
years, and we're really excited to bring to you This program from EB Medicine, the
evidence based urgentology podcast, our goal for this podcast is to review one of
the recent evidence based urgent care and highlight some of the important things
that have come out of that issue, the learning points and potentially practice
changing information from the piece
Joe: We hope that the podcast will be valuable in and of itself, but it'll
also whet your appetite to delve more deeply into the issue to hone your
practice and even get some CME credit.
Tracey: and, even if you've read the issue already, Joe and I hope
to reinforce the important points and solidify important concepts to
improve your learning as a result.
Joe: If you create an account at ebmedicine.
net, you can subscribe and purchase the issue.
You can check out the interactive clinical pathways they have there.
And you can get up to four hours of CME credit for completing this one issue.
Hey, you've already started your CME journey by listening in.
Tracey: And you can also subscribe for a full year.
So you won't miss anything at the regular price.
That's a great value.
Be on the lookout for occasional promos, sales and special offers
to make it that much easier.
Joe: So, hi everyone.
We are here for another month of the Urgentology podcast.
How you doing, Tracy?
Tracey: Good.
We're gonna talk about a high anxiety topic today.
Joe: Okay, I'm gonna start off with some promos.
The new 2025 laceration course is here and it's new and improved.
Make sure you check it out at the EB Medicine website.
And another promo is between July 15th and August 15th, EB Medicine will be running
a trial offer again for new subscribers.
This time it will be $1 for seven days and new subscribers can try
one, two, or all of our journals.
Tracey: Oh, that's a lot of content.
Joe: That's a lot.
Tracey: So today we're gonna talk about ocular injuries, and this is
an update from an article that was published in Emergency Medicine
Practice in September of 22.
And guess who did this?
Joe Toscano, our very own Joe Toscano did this one, this update, and he
reviewed the whole thing and came up with some really cool stuff.
so since you wrote the article, we're gonna change the format
just a little bit and we're gonna let you do most of the talking.
And I'll just ask some questions and of course, , you know how I roll.
I'm gonna give you my opinions too,
Joe: And that's what we love.
, Tracey: Yeah, thanks.
My first opinion is that this is really a great review of the topic of eye injury.
And I don't know about you, but I think everyone's a little scared about eyes.
I see it on my schedule and I give it a little cringe.
And I mean, these things are potentially serious.
You mess this up and the patient can go blind in an eye.
So, to me, this is one of the most dangerous things that we can see.
And couple this with.
We get what, one or two days of ophthalmology training in school.
Joe: Mm-hmm.
Tracey: Unless you are fortunate enough to do a rotation.
So it makes some pretty high anxiety.
And I think this article really sums up everything you need to know
to competently evaluate the eye injury in the urgent care setting.
So, let's start off with a couple questions.
So after reading this article or after writing this article in your case,
what are the absolute don't miss vision threatening injuries to the eye that we
really need to be on the lookout for.
Joe: Well, I wanna start off by saying that , I'm quote the author,
but I really reworked an earlier article and it is very difficult.
As hard as it is to write an article on your own when you have something
in front of you that seems like it's pretty good, relatively recent
it's hard to kind of spruce it up.
It wasn't a matter necessarily of just distilling down an ER article to urgent
care, but sort of adapting it quite a bit.
It was a lot more of a challenge than I thought.
Tracey: Yeah.
Joe: To answer your question we'll talk about maybe the common things
and identifying common things is important because if you can get
those under your belt and feel really comfortable with them, you're done.
We see a lot of corneal abrasions and corneal or conjunctival
foreign bodies, and we really need to be really good at that.
Those patients should come into our centers.
We make the diagnosis, we take care of it, and they can go home
without the need for a referral.
So being able to identify those things and feel comfortable with them is important.
The don't miss things include mistaking a corneal ulcer for an abrasion.
Certainly not very common, but missing a globe perforation or a rupture.
Any kind of a situation where you may have an intraocular foreign body with
an eye contusion, having a retrobulbar hematoma embedded in that really swollen
contused eye and periorbital tissue.
These are all rare, but really important that we don't miss.
Those are patients that we shouldn't send home.
We have to either r ule it in and refer them or be really
suspicious , and send them on for further evaluation 'cause we're not
able to do that in the urgent care.
Tracey: Yeah.
It's funny, I always say that whenever we review one of these, I always
end up seeing something like that.
And I think in the emergency medicine setting I saw a fair
amount of ruptured globes,
but I think in urgent care, I haven't seen that many.
And the ones that I have seen, they're usually like a workman's comp kind
of thing, where somebody was grinding with metal or, something was flying
through the air or something like that.
And I think I shared with you when I was doing one of the final
reviews of this episode I actually, of course, it's a Saturday, right?
When there's , no staff and no supplies around had a guy that came
in that had a, a penetrating injury from a lawn mowing misadventure where
something had flown into his eye.
I'm like, oh, I just reviewed eyes.
It's a good thing, you know?
so we look at the eyes and we end up seeing the fluorescein flowing out of
the edge of the ruptured globe there.
So, I turned to my medical assistant, I'm like, Hey, do
we have any hard eye shields?
And she's like, what's that?
I'm like, what do you mean no hard eye shield?
How about a paper cup?
She's like, well, I have really big foam cups so, we finally ended
up taping a urine cup to the poor man's eye to protect his eye for his
trip to the emergency department.
Joe: There's your MacGyver moment.
Tracey: Exactly, exactly.
Which is, you know, one of my other things.
so, sometimes you really have to be a, a jack of all trades
and figure out things to do.
Joe: Yeah.
Tracey: every time we review one of these, I always end up
seeing something like that.
Joe: That's an absolute, absolute can't miss injury.
I mean, you can save an eye if that patient gets surgery in time, and
if not, that's just a bad scene.
So
Tracey: Yeah.
Absolutely.
So, let's talk about history too.
Joe: Mm-hmm.
Tracey: I think getting a really good description of how the injury occurred,
and this occurs with orthopedic stuff too, that we always talk about.
If you really know the mechanism of injury, you can kind of predict
what you're gonna be looking for when you do your physical exam.
So can you comment on some of those historical elements that we think
might be the most important here?
Joe: Sure , there's a nice table in the issue that summarizes all the
questions you can ask , and there are times where asking all of them
is gonna be important , if you got a root down to what the cause is.
If somebody doesn't have a lot of insight and their eye just all of a sudden started
to hurt and there could be some trauma.
But drilling down to some of the more important ones in my opinion,
kind of that when they hit the door kind of thing would be the questions
that go along with chemical exposure.
At the time, you're starting to irrigate them immediately.
You wanna try and get some sense of what the chemical was.
We really don't measure pH right from the beginning.
So knowing at the beginning if it's alkali or acid, can kind of guide your treatment.
If the patient or somebody who accompanies them has an MSDS that can help you
kind of identify the toxicity of the substance that's in the eyes a s well.
Other high risk historical features are kinda sudden pain or foreign body
sensation in the eye when there's metal on metal contact or other projectile
type activities like you talked about the lawnmower a lawnmower blade kicking
something out from underneath it.
And sometimes people don't tell the truth, but I'm always a little bit more
careful when somebody says they're not wearing eye protection and they had
one of those type of situations, so t hose things perk up your ears for sure.
I think true diplopia in the setting of trauma can lead you
to some pretty specific diagnoses and entrapment of an intraocular
muscle or retrobulbar hematoma.
I really wish visual acuity, in terms of the patient's sense was a sensitive and
specific indicator of what might be wrong.
But in my experience, many people complain of blurriness and it doesn't end up
being anything that's too significant, so you have to ask that question.
But at the same time if somebody has a little bit of blurry
vision, it's not necessarily bad.
It's more of a magnitude thing.
And I think when you get big changes from baseline, it can
be a little bit more important.
And then certainly objectifying that measuring visual acuity gives
you a little bit better information than just the patient saying, oh
yeah, my vision's a little blurry.
Tracey: Yeah, one of my pain points with the chemical exposures is, I
don't think the front desk always appreciates the severity of that.
And frequently I'll see somebody, their worker's comp, so by the
time they get approval and all the paperwork gets done and whatever,
now the patient sat out there in the waiting room for heaven knows how long,
or their employer took an hour to decide whether or not they needed to
come to the urgent care center, so I always like to keep the board scanned.
I always like to look at that tracking board, and if I see something out there
that looks like it's some sort of eye or exposure, I'll go up to the front desk and
kind of scope it out and make sure that it's not something that needs emergent
irrigation, because this is not something you wanna wait for the paperwork for.
You wanna get the fluids going right away to help flush out that eye.
So I encourage you to scan the tracking boards for these sorts of things,
squadcaster-h174_1_07-02-2025_173538: You're so
Joe: Good, Tracy.
Tracey: oh, I know, I know.
Thanks.
Alright, so physical, what's the important p hysical things.
I mean, I always say that a visual acuity exam is the most important vital sign
for the eye, and it absolutely kills me when it's not already done and on
the chart before I walk in the room.
It is really one of the first things that the MA or nurse, depending upon
what you have, should really do and make sure it's available on the chart.
And one thing that I didn't even realize until recently is in my d
ocumentation, when the MAs put it in, it goes into some nebulous form somewhere
and it doesn't pull into my note.
So, people would have the impression that maybe I didn't check visual acuity
because it's not physically in my note.
So you really wanna make sure that visual acuity pulls, into your
note and look at it, you know.
Don't just look at it.
I was reviewing a chart of another provider not too long ago, and it was
a patient was like their third visit for an workman's comp eye injury.
And on the second visit, their right eye had gone from 2040 to 2070.
Joe: Oh, wow.
Tracey: And the comment was patient's feeling better
improving follow up one week.
And I'm thinking you just missed that huge drop in visual acuity.
Joe: Mm-hmm.
Tracey: Definitely make sure that you look at 'em and one reading is
not always what you're looking for.
Maybe you wanna do multiple readings before and after treatment,
especially if you're doing some sort of procedure like removing a
foreign body or something like that
Joe: Mm-hmm.
Tracey: Or those sorts of things.
So visual acuity is super, super important.
Make sure not only do you do it, but it's documented and it
shows up in your notes somewhere.
So, like I said, it's very important for medical legal purposes, but also
helpful for your medical decision making.
It's gonna be a lot different for you if they have normal vision versus
they clearly have abnormal vision.
If visual acuity is normal and the patient subsequently has vision loss
later, then you know, you can say that it wasn't there when I saw the patient.
Do you have any tips that make visual acuity testing easier or,
say somebody's having a significant difficulty with pain in their eye
or say they forgot their glasses.
Any ideas?
Joe: Yeah, so well, I'll start by agreeing with everything you said.
Visual acuity objectifies the situation.
It absolutely needs to be done.
If the patient's uncomfortable, has some blepharospasm.
It might not be the first thing that you're able to do.
So get a topical anesthetic in the eye.
Have them gradually feel a little more comfortable opening it.
You wanna do it close to the beginning of your exam 'cause it does give
you some information, but sometimes it can't be done immediately.
And so, I think anesthesia or analgesia and then, taking a little
bit of time so that the patient feels comfortable doing it's important.
It's really important to have good lighting.
I've worked at a couple places where the Snellen chart was at
the end of a dark kind of hallway.
And it's hard to read when there's not good light.
You wanna make sure that there's good light on the chart itself, otherwise
you won't get an accurate reading.
When patients wear corrective lenses and don't have them with them at the
time they're having their visual acuity measured in the clinic, you're gonna
have a lower value than would be ideal.
And that's where they talk about this pinhole.
And I find that that really works a lot of people who measure visual acuities, like
even our ER nurses or medical assistants in the clinics don't necessarily
think about that automatically.
Or they may not quote, have a pinhole, that basic plastic thing
that has the hole poked in it.
And you can just do this with poking a hole in a piece of paper.
People ask, how big does the hole need to be?
And it is literally a pinhole.
It's the smallest hole through which they can see.
And the principle is that you're restricting their vision to the
central visual axis where they're gonna have their best vision.
Most people who have refractive problems are because as you expand that visual
axis, irregularities in the cornea or the shape of the eye or the distances
between the cornea and the lens in the back of the eye all come out of focal
alignment . And that's why people need corrective lenses in the first place.
So, definitely the pinhole helps to get an accurate visual acuity in situations
where a patient wears corrective lenses and doesn't have them with them.
The gold standard is to look at a Snellen chart from a 20 foot distance.
But there are hand cards or even people have apps on their phones
that you can hold in front of a patient to measure visual acuity.
Just make sure you're holding at the proper distance for
whatever tool you're using.
That's important 'cause that is h ow you make the calculation and it translates
that into the 20 20, 20 40 for you.
You had mentioned pediatrics and sometimes if people potentially can't read, or kids
haven't learned all their letters , there are picture Snellen charts or picture
eye charts that can be used where there's a dog or a cat or a boat or a sun or
even, something that looks like the letter E where the prongs of the E are
pointing to the left, to the right or up or down, and there are different sizes
that correlate with the visual acuity and people can tell you, oh yeah, up, down,
right, left, or something like that.
So all of those things make it so you can adapt the exam to situations where
it's not incredibly straightforward and all of those are helpful.
And the main thing is you just gotta do it.
Gotta get it on the chart.
Tracey: Yep.
Absolutely.
So you mentioned a little earlier that you know those bread and butter
things, the things that you really need to know how to do, the things
that we see the most of with eyes.
Can we talk about maybe treatment for those things?
Joe: Yeah, sure.
Foreign bodies I think are pretty common just in experience and statistically
and they need to be removed.
So you need to feel comfortable removing 'em.
There's a, variety of ways to do it.
Sometimes you can with a moist sterile cotton tip applicator,
just swipe it off the cornea.
The more embedded it is, the more difficult it may be.
If it's just loosely on there or on the conjunctiva, you might be
able to get it off with irrigation.
You just need to make sure that you can kind of catch it
as it moves around the eye.
Occasionally can get under the lid when you do that, so just be careful.
And in situations where you can't remove the foreign body, that's one
of those things that's time sensitive.
You wouldn't necessarily leave a foreign body in the eye and have
somebody follow up the next day.
Those are people you would have to send to the ED or to an ophthalmologist.
If you have a good relationship with somebody who will see somebody
from the urgent care center.
Most metallic foreign bodies will start to rust fairly quickly.
It's pretty surprising.
And that rust can either form a ring around the outside of the foreign body
or even stain the cornea in the divot that it makes once it's embedded.
I know years ago we used to try to get those out and we had burrs
and we would use 31 gauge needles and kind of try to scrape away the
layers of the corneal epithelium.
Honestly, you don't wanna do that unless you feel really comfortable doing it and
have some experience, and it does not need to be done at urgent care or even r
eferring to the ED to do it immediately.
If the patient could get in to see an ophthalmologist within a day or so,
24 hours or so, then they can do that.
And I've even seen them do it on a delayed basis.
The corneal epithelium can grow over the stain and then
they'll just expose it later.
For abrasions or other kind of traumatic corneal defects, whether it's either the
primary injury from getting scratched by like a tree branch or a fingernail
or something like that, or c reated by that foreign body being embedded.
Those will heal on their own.
So we don't necessarily have to do much.
And unfortunately there's not a lot of data about whether we need to do
the main thing that we do in these situations, which is use antibiotics.
Some studies show that it decreases the chance of infection.
Some don't.
And in the end, the initial authors of the article said you know, there's
no convincing evidence so you can feel comfortable going ahead and using
erythromycin and I think that probably the chance of harm with that is pretty low.
It tends to be somewhat soothing, whether it really changes the
chance of an infection, which is kind of uncommon anyway.
It's hard to know.
But the ointment sometimes kind of soothes the eye and helps take the patient's mind
off of it, I think in, my experience.
The main take home point from that is that you don't need to use
moxifloxacin or big gun broad spectrum antibiotic eyedrops in these patients.
I'm not sure whether it leads to antimicrobial resistance on the
surface of the eye, let's say.
But they tend to be a lot more expensive.
And, we wanna save those for the times when they're really necessary.
For contact lens wearers who have corneal abrasions, they do recommend
broader coverage just because they have some kind of baseline ischemia
of their cornea, regardless of the type of contact lens they wear.
So they're a little more likely to have issues that r elate to any
kind of damage, either primarily an ulcer, which is an infection itself
or an abrasion that's healing.
It takes a little bit longer and they're a little bit more
likely to have complications.
So that's when you would use a little broader spectrum antibiotic eye drop.
But whether you know exactly how much of a difference it makes , there's
not really good research, which probably have somebody to do a study.
Tracey: Ooh, good idea.
Joe: Yeah.
Tracey: Alright, so, we kind of touched on chemical exposures a little bit.
Is there anything that we should really talk about?
I mean, I guess irrigation, right?
Joe: Yeah, probably a couple high points here.
You know, the solution to pollution is dilution, right?
And that means irrigation.
so regardless of what the chemical is, acid base or something in between
if it's just kind of corrosive , and some corrosive materials don't have
to be acid or based, they will degrade tissue on a different basis, an
oxidative basis or a reactive basis.
So any kind of chemical in the eye, you want to get started
with irrigation right away.
And there's a number of ways to do that.
There's the quote c ommercially available contact lens type thing
with a tubing system that puts the irrigant directly on the eye.
You can use an eyewash station, you can use a nasal cannula and direct
by basically plugging it into your IV bag, direct IV fluid into either
or both eyes at the same time.
Just wanna make sure you're kind of catching the water
and not making a total mess.
That's more of a challenge sometimes in the irrigation.
Maybe except for hF or hydrofluoric acid, there should be no attempt to
neutralize whatever's in the eye.
So it's not the sort of thing where if there's an acid, you wanna try
and put some base in the eye, or if there's a base, you wanna put some
acid, you just want to irrigate like crazy, at least a liter or so.
After a liter and or 30 minutes, you can go ahead and check the pH at that point.
You really don't even delay irrigation to do any sort of an in-depth exam.
Maybe get a real gross look at the eye to begin with to make sure it's not something
worse than just the chemical exposure.
And then after you've done your irrigation you can check a pH.
If they're still symptomatic or the pH is abnormal, you irrigate more.
If they're feeling okay and the pH is neutral, you're okay to stop at that
point and do the rest of your exam.
And then, there's been some research in terms of what the quote, best
irrigant to use, and there's really not a lot of big difference between normal
saline or lactated ringers or other sorts of solutions or even tap water.
So, you can use whatever is a clean solution.
It doesn't even really have to be sterile to get this job done in tap
water is fine if that's all you have.
Tracey: Yeah, actually that's what we use.
We don't do IV fluids in my center.
So we generally have, we have an emergency eyewash station and we put
some tetracaine drops in there and let 'em hold open their eyes and have at
it over the emergency eyewash station.
The beauty of that is it doesn't make a mess.
I mean, it makes a little bit of a mess, but certainly not as
much as if you're using the other irrigation devices that are available.
Joe: You made an important point too.
I didn't mention it, but you really want to get some
anesthetic eye drops in the eye.
This is really impossible to do if the eye's not numb.
And if you're Irrigating for about 30 minutes, you might need to even put
another dose in either or both eyes that you're irrigating in the course
of your first irrigation, just because it can wear off during that time.
Tracey: Yeah, I mean, I think you're kind of washing the drops outta their eyes, so.
Joe: Exactly.
Tracey: so yeah, definitely.
So I just wanna mention, you know, we're really not gonna go over , the
really traumatic eye injuries that we see because they're so
much less common in urgent care.
I mean, I think a lot of people sort of self-select for the ED if they have
some gaping, bulging, nasty eye injury.
But you know, you do need to know about these.
So I would strongly advise you to dive into the issue a little more in
depth i f you're a subscriber and if you're not a subscriber, hey, why not?
Joe: Yeah,
Tracey: So I Firmly encourage you , to look at these things.
It's what's the term?
Oh, it's a halo thing.
It's a high acuity, low occurrence.
Definitely something you need to familiarize yourself about a bit.
oh, yes.
I'm dying to ask you this question.
Patients always ask me, you know, not providers so much, but the
patients always say, Hey, doc, you put those drops in my eye.
They feel so great.
Can I take them home?
I think one out of every three or four patients will ask me that.
I was always taught that that is a terrible idea.
That if your eye is numb, you can cause yourself more trauma
by accidentally poking yourself in the eye and not realizing it.
or that the overuse of the stuff is toxic to the corneal epithelium.
But I think thoughts on that are changing.
What does the evidence say?
Joe: Yeah,
squadcaster-h174_1_07-02-2025_173538: you know,
Joe: I was taught that way too.
I think we were both taught at around the same time and, went through, went
through practice and it was probably eight or 10 years ago that somebody
thought, well, why don't we test this?
Same two reasons.
When the eye is numb, somebody's likely to injure it more, or maybe there's something
toxic about the drops themselves.
And I think there is some evidence that they might slow c orneal healing.
The initial studies that were done actually used dilute alcaine or tetracaine
drops rather than the full strength.
People could put it into periodic intervals for up to 24 or 48 hours.
And, this is one of those things where our acute care literature and
the specialty literature diverge.
And there's just plain difference of opinion.
And most of these studies were done in the ED.
and they showed that people did okay, that there was a really low likelihood of harm.
Even placebo controlled studies, their pain was lower and they
didn't rub their eye and incur more injury or have any toxic effects.
So it was the basis for a while for there to be kind of a, standard practice of
letting patients not necessarily take the whole bottle with them, but giving
them a kind of a dilute amount that they could use for analgesia over time.
But in the ED literature, there are pro con things and it's almost
always an ophthalmologist on the other side who basically says, our
literature shows you can't do this.
And I think that was basically the basis of what we learned because it was only
ophthalmologists who were studying it before that E D literature came out.
So, it's not something that I regularly do.
I would say occasionally you have that person that just has blepharospasm
and they're so uncomfortable.
And I found, the issue talks about topical NSAIDs, which I would have to say even
for myself when I've used them, they don't really seem like they help that much.
And systemic analgesia doesn't seem to help.
Ibuprofen, acetaminophen and then when you talk about doing an opioid for just
a corneal abrasion, that's kind of a lot.
So how are you gonna help make this person more comfortable?
I will rarely do it and I haven't heard anything bad about those for my n of four,
but it's not something to do routinely.
I think until our ophthalmologists tell us it's okay, and they
may never tell us that.
Tracey: Yeah.
Yeah.
Entirely true.
Lastly, let's talk about some specialty referral.
How do you decide who needs to go now versus, in a day or two versus whenever
Joe: Yeah, you gotta kind of know what you're dealing with.
It's really based on the diagnosis or if you can't make a diagnosis,
how bad is the situation.
So, if you can either make the diagnosis with your side L sign, like you talked
about, of a rupture or a perf of the globe, that person needs to go right away.
They're pretty much gonna go to the operating room.
So sending 'em to the ophthalmologist's office is not necessarily gonna be the
right thing, but send 'em to the ED.
Retrobulbar hematoma, again, rare.
But if you have a patient with that, they need to go to the
ER to have a decompression.
Any suspicion or positive diagnosis of an intraocular foreign body or foreign body
that you can't remove, those patients need to go immediately to the ED and then you
may not know that you're dealing with any one of those, but I would say anytime the
patient has severe pain or any kind of visual loss, even if they don't have any
of those, I would send those patients.
We talked about the fact that rust staining doesn't need to be an
immediate referral, but within 24 hours.
So that person, you could make a referral to an ophthalmologist and
then maybe say if the ophthalmologist that was supposed to see them didn't
see them, then they could go to the ED where they have some ophthalmology
backup to take care of that for them.
For things like hyphema, corneal ulcer and traumatic iritis if you can't get
in touch with an ophthalmologist to guide you and to let you know that
they're going to see the patient the next day or so then those patients
should be referred promptly to the ED.
If you can talk to a consulting ophthalmologist who will do the follow
up, they don't even need to go to the ED.
You can be managed definitely ulcers or traumatic iritis at home.
And then small hyphemas in patients without a high risk for re-bleeding.
There's actually a move toward managing them at home also.
And then our biggest group of patients where we've removed a foreign body
or they have a corneal abrasion.
If those patients are doing well they don't need to be referred at all.
You can either give them kind of anticipatory guidance or have
them follow up with us if it's not getting better at a particular rate.
If they have any immediate worsening, obviously they should
seek care in that situation.
Tracey: Yeah, definitely makes sense.
I've said this on many of the other
squadcaster-0826_1_07-02-2025_203538: episodes,
Tracey: but, make friends with your local ophthalmologist.
I find many of them are very willing to see people, either
the same day or the next day.
And I know none of us really wanna make a phone call in the middle of our busy
day when you've got 10 patients waiting.
But you could save the patient some time and potentially an ED visit because
they may do the same thing at the ED and just call the ophthalmologist
and send the patient there.
So, save them an extra bill . Make friends with your ophthalmologist.
You know, fine.
It's only Monday through Friday, nine to five, but, at least if you
have somebody to talk to, to give you some guidance, you may avoid that ED
visit or they may tell you something insightful that's helpful to you.
Joe: Yep, for sure.
Tracey: So listen, we splint ortho injuries prior to referral.
If we send somebody to the ED with an eye injury, what do we do with 'em?
Should we patch them?
Joe: Well, hey, I was gonna kind of mention this back
when we talked about pain.
And this is one of those things also where the research may not exactly
agree with your experience, or it's not a one size fits all thing.
It's like, bronchodilators for bronchiolitis.
The guidelines say don't give 'em to anybody.
It's like don't give 'em to anybody.
And I think my experience with patching is it's not the thing you should be doing
to every patient with a corneal abrasion.
It's not a standard treatment, but some people are actually
more comfortable with their eye closed when they have an abrasion.
And if you're having that patient who just is so uncomfortable with their eye
open, you're trying to figure out what to do to make them more comfortable,
and you put some erythromycin ointment in their eye if you have it and you
have them close it and it's soothing and they feel better, that might be
that rare patient that you would patch.
Again, it's not gonna help them get better any faster.
May be some evidence obviously if they open their eye under the
patch, it's gonna scratch it more.
Again, not something you can do for everybody, but if you individualize the
care that little splint for the eye, if you wanna think of it that way might be
the right thing to do in that one case.
But not standard treatment.
Again, years ago we used to do it for just about every eye problem,
gosh, for just about everything.
And it's not necessary except maybe in those rare cases.
Tracey: just keep in mind,
squadcaster-0826_1_07-02-2025_203538: you know,
Tracey: for it to work properly, it really has to be kind of tight,
Joe: Mm-hmm.
Tracey: the whole purpose of it is to keep the eyelid shut.
So if you just throw one little soft patch on there and you tape it loosely,
that's not really gonna do the job.
And it's kinda like C collars in my mind.
It has to be tight enough that it's actually uncomfortable to have it on.
And most patients will not tolerate that with an eye patch.
Now, on the other hand, when we're talking about significant trauma, you
want to use one of those metal eye shields or the paper cup routine to
protect the eye from any future trauma.
That would be the indication of when you would definitely wanna patch an eye
because you don't want any further trauma.
You don't want them pressing on their globe and squirting out
through all their vitreous fluid.
You want to kind of preserve that as much as you can.
So definitely that's the place for the eye patch.
But you know you're right.
It's case by case basis for everybody else.
Joe: Yeah.
And that's just getting them safely to their next kind of definitive care really.
It's not part of the treatment.
You're just sort of protecting it.
So you're absolutely right.
Tracey: Yeah let's hope my poor guy with the urine cup tape to his face.
It's so long.
He's like, do I need to go out in public with this on my face?
I'm like, yeah, just until you get to the emergency room.
Joe: Yes, oh gosh,
Tracey: He also said, oh,
Joe: I feel so much better with the tetracaine.
Do I really have to go?
I'm like, yes, yes.
yes.
Yep.
If you wanna have an eye.
Tracey: All right, so I think we've done a nice review of the article.
Can we wrap it up?
Are there any final tips that we wanna do about eye trauma?
Joe: Yeah, I can, maybe just summarize I guess we as urgent care clinicians need
to know how to identify those rare, super time sensitive conditions or know when
to suspect them, even if we can't tell.
If we suspect, those patients get referred.
We need to feel really comfortable characterizing those common,
uncomplicated, low risk conditions and feel comfortable with the treatment.
We didn't talk too much about POCUS.
The article does a little bit.
It's kind of a cutting edge thing, and I use it in the ED.
We don't have one in urgent care, but it's actually changed my approach to
patients with possible retinal detachment.
Those can happen spontaneously.
Probably more of 'em are, but they can also happen with a globe contusion.
So, it's actually catching on.
People are really interested at the conferences, so if you can get your hands
on an ultrasound and learn how to use it not only on the eye, but elsewhere.
That's sort of a, kind of a nice tip.
And then finally no pun intended, keep your eyes open for some of the
resolution to some of these controversies.
Like, can we give people tetracaine to go home and do we really need
to use antibiotics and those sorts of things 'cause our knowledge
is always growing and changing.
Tracey: You said keep your eyes open.
I was gonna say be on the lookout.
But both of them work
Joe: There you go, that's why the eyes are so important.
Tracey: There you go.
Fortunately we have two of them.
Alright, so I let Joe do all the work here and I'm sure he'll get
me back when we do low back pain in a few months 'cause that's the
one that I'm working on right now.
We really gave a brief overview and there's lots of useful tidbits and
really extensive discussion in the issue.
So be sure to check that out and make sure that you claim and pick up your CME.
You pay for it, so you might as well grab it, right?
So I encourage you to really go through it.
There's also some really cool free content on FOAMEd as well.
So if you're not familiar with that, go to the EB medicine site and check out FOAMEd.
There's some questions and there's all sorts of freebies on there,
which are useful some of which will follow this issue as well.
And as always we recommend that you stay up to date on the latest evidence-based
practices so you can really hone your skills and practice the safest most
effective urgent care medicine possible.
I was gonna say, not sure what next month is, but I can now reveal to
the masses that next month is acute diverticulitis which we've really
worked on well, and there's a lot of new evidence and a lot of changes
Joe: Mm-hmm.
Tracey: So, we look forward to that and we will talk about that next month.
Joe: Sounds great.
Tracey: All right.
Take care everybody.
See you in a month.
squadcaster-h174_1_07-02-2025_173538: Take care everyone.
Bye-bye.
Tracey: I want to thank everybody to listening to this month's evidence based
urgentology podcast . Just a reminder that subscribers can go to ebmedicine.
net and read the full issue if you want more information, if you haven't already,
Joe: And if you're not a subscriber head to the site.
That's ebmedicine.
net to check out what they have.
If you subscribe you'll get access to the article as well as future articles
and the whole archive of all past issues.
Tracey: Look forward to seeing you there.