CPO FREE CPO Ocular Emergencies and Triage Questions and Answers 2 — Questions and Answers
Question 1: A patient calls describing symptoms in their right eye that began after a penetrating injury to their left eye two months ago. They report increasing light sensitivity and blurry vision in the right, uninjured eye. Which of the following conditions should be suspected, warranting an immediate referral to an ophthalmologist?
- Traumatic cataract in the left eye
- Sympathetic ophthalmia (Correct answer)
- Corneal abrasion in the right eye
- Post-traumatic stress response
Correct answer: Sympathetic ophthalmia
Sympathetic ophthalmia is a rare, bilateral granulomatous uveitis that can occur after a penetrating injury or surgery to one eye (the 'inciting' eye). The inflammation then develops in the uninjured eye (the 'sympathizing' eye), typically weeks to months later. The symptoms of photophobia and blurred vision in the fellow eye are classic indicators.
Question 2: When triaging a chemical burn, what is the most critical initial action, especially in the case of an alkali burn?
- Applying a neutralizing agent to the eye
- Patching the eye immediately to prevent infection
- Assessing visual acuity before any intervention
- Initiating copious and prolonged irrigation with water or saline (Correct answer)
Correct answer: Initiating copious and prolonged irrigation with water or saline
For any chemical burn, but especially for alkali burns which penetrate ocular tissue rapidly, immediate, copious, and prolonged irrigation is the most critical first step to dilute and remove the chemical. Neutralizing agents can cause further thermal injury and are contraindicated. Assessing vision and patching are secondary to the emergency irrigation that can save sight.
Question 3: A patient presents with a painful, red eye and blurred vision. On examination, a dome-shaped elevation of a posterior ocular layer is suspected. Which feature would most strongly suggest a choroidal detachment over a rhegmatogenous retinal detachment?
- The presence of flashes and floaters
- A history of high myopia
- The elevation is smooth, dome-shaped, and extends anteriorly to the ciliary body (Correct answer)
- The patient reports a 'curtain' falling over their vision
Correct answer: The elevation is smooth, dome-shaped, and extends anteriorly to the ciliary body
Choroidal detachments are characteristically smooth, dome-shaped (convex), and can extend to the ciliary body. In contrast, rhegmatogenous retinal detachments are often more mobile, may have folds, and are attached at the optic disc and ora serrata. While flashes and floaters are classic for retinal detachments, they are less specific. A 'curtain' is also a classic symptom of retinal detachment.
Question 4: Which of the following telephone triage scenarios presents the HIGHEST risk for a retinal tear or detachment and requires the most urgent evaluation?
- A 65-year-old reporting a few new, stable floaters for the past week in both eyes.
- A 30-year-old with a history of migraines reporting jagged, colorful lights in their vision for 20 minutes.
- A 58-year-old myope reporting a sudden onset of hundreds of tiny floaters ('like pepper') and flashes of light in one eye that started 3 hours ago. (Correct answer)
- A 70-year-old pseudophakic patient reporting a single, large, cobweb-like floater that has been present for months.
Correct answer: A 58-year-old myope reporting a sudden onset of hundreds of tiny floaters ('like pepper') and flashes of light in one eye that started 3 hours ago.
A sudden onset of numerous new floaters, often described as a shower or 'pepper', combined with photopsia (flashes) in a myopic patient, represents the highest risk profile for an acute posterior vitreous detachment (PVD) with a concurrent retinal tear. The other scenarios represent lower-risk situations such as a simple PVD, ocular migraine, or chronic, stable floaters.
Question 5: A patient with a history of a scleral buckle procedure for a past retinal detachment presents for a routine check-up. An ultrasound B-scan shows a smooth, convex elevation in the periphery. What finding would help differentiate the scleral buckle from a new choroidal detachment?
- The presence of high reflectivity on the B-scan
- A shadow behind the elevated structure
- The elevation has a fixed, circumferential appearance and lacks after-movement (Correct answer)
- The patient is asymptomatic
Correct answer: The elevation has a fixed, circumferential appearance and lacks after-movement
A scleral buckle is a surgically placed band that indents the sclera. On ultrasound, it appears as a fixed, circumferential structure that does not show the after-movements typical of a fluid-filled choroidal detachment. A shadow can be seen behind the buckle, which helps confirm its solid nature compared to a serous or hemorrhagic choroidal detachment.
Question 6: A patient calls after being hit in the eye with a racquetball. They report significant pain, photophobia, and slightly blurred vision. There is no visible laceration. In this case of blunt trauma, the presence of white blood cells and protein in the anterior chamber, known as traumatic iritis, is a primary concern. What is another urgent condition that MUST be ruled out, often associated with similar symptoms?
- Subconjunctival hemorrhage
- Corneal abrasion
- Angle-recession glaucoma (Correct answer)
- Dry eye syndrome
Correct answer: Angle-recession glaucoma
Blunt trauma can cause damage to the trabecular meshwork in the angle of the eye, leading to angle recession. This damage can impede aqueous outflow and cause a significant, delayed spike in intraocular pressure (angle-recession glaucoma), which is an emergency requiring immediate management to prevent optic nerve damage. While a corneal abrasion and subconjunctival hemorrhage are common, the risk of secondary glaucoma is a more severe, sight-threatening complication that must be urgently assessed.
CPO FREE CPO Ocular Emergencies and Triage Questions and Answers 2
A patient calls describing symptoms in their right eye that began after a penetrating injury to their left eye two months ago.
They report increasing light sensitivity and blurry vision in the right, uninjured eye.
Which of the following conditions should be suspected, warranting an immediate referral to an ophthalmologist?