Most Common Ophthalmic Diagnoses in Eye
Emergency Departments: A Multicenter Study
HEBA MAHJOUB1, JOSEPH SSEKASANVU, YOSHIHIRO YONEKAWA, GRANT A. JUSTIN, KARA M. CAVUOTO,
ALICE LORCH, VRINDA MADAN, ISHWARYA SIVAKUMAR, XIYU ZHAO, MICHAEL QUINTERO,
OLIVIA FEBLES SIMEON, MIRATAOLLAH SALABATI, CONNIE M. WU1, AND FASIKA A. WORETA
• PURPOSE: To characterize the most common oph-
thalmic conditions seen in the emergency department
(ED)
• DESIGN: Cross-sectional study
• METHODS: This is a multicenter study of 64,988 pa-
tients who visited the Bascom Palmer Eye Institute, Mas-
sachusetts Eye and Ear, Wills Eye Hospital, and Johns
Hopkins Hospital/Wilmer Eye Institute from January 1,
2019, until December 31, 2019. Demographic and pri-
mary diagnosis data were extracted including gender, age,
race, ethnicity, insurance type, and ophthalmology con-
sult status. Descriptive statistics were performed on all
data using STATA IC 14 (64-bit).
• RESULTS: A total of 64,988 patients with primary oc-
ular diagnoses were seen across all 4 EDs. The major-
ity of patients were White (63.1%), non-Hispanic/Latino
(64.8%), and female (52.3%). The most frequently
seen age group was 50-64 years (28.6%). The most
common diagnoses across all institutions were con-
junctivitis (7.91%), corneal abrasions (5.61%), dry
eye (4.49%), posterior vitreous detachments (4.15%),
chalazions (3.71%), corneal ulcers (3.01%), subcon-
junctival hemorrhages (2.96%), corneal foreign bodies
(2.94%), retinal detachments (2.51%), and glaucoma
Supplemental Material available at AJO.com.
Meeting Presentation: This manuscript was presented as an oral presenta-
tion at the 2023 Annual Meeting of the American Society of Ophthalmic
Trauma (ASOT).
Accepted for publication March 11, 2023.
Wilmer Eye Institute, Johns Hopkins University School of Medicine,
Johns Hopkins Hospital (F.A.W.); Department of Epidemiology, Johns
Hopkins Bloomberg School of Public Health, Baltimore, Maryland (J.S.);
Wills Eye Hospital Retina Service, Mid Atlantic Retina, Thomas Jeffer-
son University, Philadelphia, Pennsylvania (Y.Y., M.S.); Department of
Ophthalmology, Duke Eye Center, Durham, North Carolina (G.A.J.); De-
partment of Ophthalmology, Bascom Palmer Eye Institute, University of
Miami Miller School of Medicine, Miami, Florida (K.M.C.); Department
of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School,
Boston, Massachusetts (A.L.); Department of Ophthalmology, Johns Hop-
kins University School of Medicine, Baltimore, Maryland (V.M., I.S., X.Z.,
M.Q., O.F.S.)
Inquiries to Fasika Woreta, Wilmer Eye Institute, Johns Hopkins Hospi-
tal, Baltimore, Maryland, USA; e-mail: fworeta1@jhmi.edu
1 Since completion of this study, Heba Mahjoub MD has a new up-
dated affiliation: Department of Ophthalmology, New England Eye Cen-
ter, Tufts Medical Center, Tufts University School of Medicine, Boston,
Massachusetts. Connie M. Wu MD also has a new updated affiliation: Bas-
com Palmer Eye Institute, Department of Ophthalmology, University of
Miami Miller School of Medicine, Miami, Florida.
36 PUBLISHED BY ELSEVIER INC.
Descargado para Anonymous User (n/a) en Murcia Region Health Department de ClinicalKey.es por Elsevier en noviembre 06, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
(2.12%). Specifically, viral conjunctivitis (2283 of 5139,
44.4%) and primary open-angle glaucoma (382 of 1379,
27.7%) were the most frequently seen subtypes of con-
junctivitis and glaucoma.
• CONCLUSIONS: The most regularly treated ophthalmic
conditions in high-volume EDs tend to be lower acuity
diagnoses. To combat ED overcrowding and rising health
care costs in the United States, we suggest diverting eye-
related ED visits to a specialized eye ED service or same-
day eye clinic appointment in addition to expanding ed-
ucation for patients and primary care clinicians. (Am
J Ophthalmol 2023;254: 36–43. Published by Elsevier
Inc.)
O
cular emergencies comprise roughly 1.5% of
visits across US emergency departments (EDs) ev-
ery year, indicating a rate of 646.7 eye-related vis-
its per 100,000.1 With such vast pathology, education cov-
ering ophthalmic conditions is often lacking, beginning at
the medical student level.2 In fact, the majority of resi-
dents in internal medicine, emergency medicine, and fam-
ily medicine residency programs received less than 10 hours
of formal ophthalmic education throughout their training.3
Thus, information regarding the most common diagnoses
encountered in the ED is pertinent to guide relevant and
specific training as well as streamlining ED systems. ED
overcrowding has been examined worldwide, with several
studies showing increased rates of complications in criti-
cally ill patients due to a delay in being seen by a physi-
cian.4 , 5 In addition to negatively impacting patient out-
comes, ED overcrowding also increases the cost burden
on patients of up to $800 per patient per day or up to
$6.8 million in a 3-year time period.6 Thus far, small-scale
studies have been performed internationally looking at the
most common ocular diagnoses. In Brazil, the most com-
mon diagnoses in 2017 were conjunctivitis, blepharitis, and
corneal/conjunctival foreign bodies.7 Another study pub-
lished in the United Kingdom also saw a large frequency of
conjunctivitis, blepharitis, and trauma-related eye disease
in 2019.8 Nonemergent cases such as conjunctivitis were
the most common in the United States between 2006 and
2011.9
Appropriately assessing and treating these ocular emer-
gencies is imperative to prevent permanent, long-term vi-
0002-9394/$36.00
https://doi.org/10.1016/j.ajo.2023.03.016
 TABLE 1. Summary of Patient Demographics by Institution of Patients Presenting to Eye Emergency Departments With Primary Eye
Diagnoses

BPEI, n (%) MEE, n (%) Wills, n (%) Wilmer, n (%) Total, n (%) P Value

Overall total 25,937 16,275 16,144 6632 64,988

Gender
Female 13,527 (52.2) 8587 (52.8) 8661 (53.6) 3218 (48.5) 33,993 (52.3) <.01
Male 12,405 (47.8) 7688 (47.2) 7482 (46.3) 3413 (51.5) 30,988 (47.7)
Other 5 (0) 0 (0) 1 (0) 1 (0) 7 (0)
Age (y)
0-4 410 (1.6) 125 (0.8) 126 (0.8) 794 (12) 1455 (2.2) <.01
5-14 966 (3.7) 405 (2.5) 488 (3) 810 (12.2) 2669 (4.1)
15-19 743 (2.9) 439 (2.7) 513 (3.2) 367 (5.5) 2062 (3.2)
20-34 3855 (14.9) 3534 (21.7) 3596 (22.3) 1182 (17.8) 12,167 (18.7)
35-49 5097 (19.7) 3344 (20.5) 3565 (22.1) 1106 (16.7) 13,112 (20.2)
50-64 8245 (31.8) 4527 (27.8) 4515 (28) 1290 (19.5) 18,577 (28.6)
65+ 6621 (25.5) 3901 (24) 3341 (20.7) 1082 (16.3) 14,945 (23)
Blank 0 (0) 0 (0) 0 (0) 1 (0) 1 (0)
Race
White/Caucasian 18,321 (70.6) 11,323 (69.6) 8648 (53.6) 2741 (41.3) 41,033 (63.1) <.01
Black/African American 5424 (20.9) 1502 (9.2) 5103 (31.6) 2728 (41.1) 14,757 (22.7)
American Indian/Alaska Native 16 (0.1) 34 (0.2) 38 (0.2) 17 (0.3) 105 (0.2)
Asian 191 (0.7) 1108 (6.8) 697 (4.3) 286 (4.3) 2282 (3.5)
Native Hawaiian/Pacific Islander 26 (0.1) 10 (0.1) 3 (0) 1 (0) 40 (0.1)
Hispanic/Latino 0 (0) 2 (0) 1177 (7.3) 0 (0) 1179 (1.8)
Other/declined 1959 (7.6) 2296 (14.1) 478 (3) 859 (13) 5592 (8.6)
Ethnicity
Non-Hispanic/Latino 9869 (38) 12,031 (73.9) 14,380 (89.1) 5824 (87.8) 42,104 (64.8) <.01
Hispanic/Latino 15,631 (60.3) 1883 (11.6) 1250 (7.7) 738 (11.1) 19,502 (30)
Other/unknown/refused 437 (1.7) 2361 (14.5) 514 (3.2) 70 (1.1) 3382 (5.2)

sion loss. However, nonemergent diagnoses might be better
served outside of the ED setting. Knowing the most com-
mon diagnoses will help guide medical training and serve
as an opportunity for quality improvement studies to divert
these cases from the ED.
We analyzed data from patients at 4 of the highest acuity
eye EDs in the United States to better understand the most
common ocular emergencies affecting patients seeking care
in EDs.
METHODS
All patient records from January 1, 2019, through Decem-
ber 31, 2019, were analyzed from the stand-alone eye EDs
at Wills Eye Hospital, Massachusetts Eye and Ear (MEE),
and the Bascom Palmer Eye Institute (BPEI). Demographic
information and data regarding primary diagnosis were col-
lected. We also studied eye emergencies at the Johns Hop-
kins Hospital (JHH) ED, but collected data using Interna-
tional Classification of Diseases, Tenth Revision (ICD-10)
codes due to the JHH free-standing eye ED closing in 2009
and integrating into the main ED. Information from the
JHH ED was collected by identifying ocular ICD-10 codes
ranging from B00-B30.9, C69, E10-E11, G24-G45, H00-
H59, L03, M31-M35, S00-S05, T15-T86, and Z90-Z98.
Data were also extracted from patients who had ED visits
with associated ophthalmology consults by the Wilmer Eye
Institute. Then, 6 authors (H.M., V.M., I.S., X.Z., M.Q.,
and O.F.S.) manually reviewed these patient charts to en-
sure the presence of a true primary ocular diagnosis.
• ANALYSIS: Once all data sets were complete, 1 author
reviewed all diagnoses and cleaned the data by eliminat-
ing duplicate diagnosis names, such as “blepharitis, right
eye” and “blepharitis, left eye” to “blepharitis.” Descrip-
tive statistics were performed using STATA IC 14 (64-bit).
All patient data were approved for collection by each in-
stitution’s institutional review board under IRB00132759
(Johns Hopkins University), 21E.828 (Wills Eye Hospital),
2021A012753 (MEE), and 20200719 (BPEI).
RESULTS
Data were collected from 64,988 patients from BPEI, MEE,
Wills Eye Hospital, and JHH. Of these, 25,937 (39.9%) pa-
tients came from BPEI, 16,275 (25.0%) from MEE, 16,144

VOL. 254 MOST COMMON OPHTHALMIC EMERGENCIES 37

Descargado para Anonymous User (n/a) en Murcia Region Health Department de ClinicalKey.es por Elsevier en noviembre 06, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
 TABLE 2. Most Frequently Used Insurance Plans by Patients Presenting to Eye EDs With
Primary Eye Diagnoses

Institution Insurance, n (% of Total Institution’s Patients)

BPEI 1. Blue Cross Blue Shield, 2657 (10.2)

2. Sunshine Health, 2369 (9.13)
3. Medicare, 2360 (9.10)
4. United Healthcare, 1548 (5.97)
5. Humana, 1521 (5.86)
MEE 1. Medicare Part A & B, 2790 (17.1)
2. Blue Cross MA PPO EPO, 1952 (12.0)
3. Blue Cross MA HMO POS, 1152 (7.08)
4. AllWays Health Partners Mass General Brigham, 790 (4.85)
5. Harvard Pilgrim HMO POS EPO, 675 (4.15)
Wills 1. Medicare, 2167 (13.4)
2. Aetna Managed Care, 1742 (10.8)
3. Personal Choice, 1439 (8.91)
4. Keystone First, 1390 (8.61)
5. Blue Cross/Blue Shield, 1350 (8.36)
Wilmer 1. Medicare, 956 (14.4)
2. Priority Partners, 759 (11.4)
3. Carefirst Blue Choice, 439 (6.62)
4. United Healthcare, 425 (6.41)
5. Amerigroup Maryland, 364 (5.49)

BPEI = Bascom Palmer Eye Institute, ED = emergency department, EPO = Exclusive Provider Orga-
nization, HMO = Health Maintenance Organization, MEE = Massachusetts Eye and Ear, POS = point
of service, PPO = Preferred Provider Organization.

(24.8%) from Wills Eye Hospital, and 6632 (10.2%) from

JHH. The majority (33,993 of 64,988, 52.31%) of pa-
TABLE 3. Summary of Top Diagnoses of Patients
tients were female, and 18,577 (28.59%) of patients were
Presenting to 4 Eye Emergency Departments With Primary
in the age group of 50-64 years. White patients made
Eye Complaints
up 63.14% (41,033 of 64,988) of the population studied,
and 64.79% (42,104 of 64,988) of patients identified as Diagnosis n (% of Total
non-Hispanic/Latino (Table 1). Medicare (8273 of 64,988, Diagnoses)
12.7%) was the most frequently used insurance at all insti-
1. Conjunctivitis 5139 (7.91)
tutions except BPEI, where Blue Cross Blue Shield predom-
2. Corneal abrasion 3643 (5.61)
inated (2657 of 25,937, 10.2%) (Table 2).
3. Dry eye 2919 (4.49)
The most common overall diagnosis was conjunctivitis
4. Posterior vitreous detachment 2697 (4.15)
(5139 of 64,988, 7.91%), particularly viral conjunctivitis 5. Chalazion 2408 (3.71)
(2283 of 5139, 44.4%) (Supplemental Table 1). Corneal 6. Corneal ulcer 1959 (3.01)
abrasions (3643 of 64,988, 5.61%), dry eye (2919 of 64,988, 7. Conjunctival hemorrhage 1921 (2.96)
4.49%), posterior vitreous detachments (PVDs) (2697 of 8. Foreign body in cornea 1909 (2.94)
64,988, 4.15%), and chalazions (2408 of 64,988, 3.71%) 9. Retinal detachment 1634 (2.51)
followed in frequency (Table 3). Figure 1 shows the 5 10. Glaucoma 1379 (2.12)
most common conditions across the institutions studied. 11. Visual disturbance 1292 (1.99)
At BPEI, the top diagnoses were conjunctivitis (2240 of 12. Vitreous hemorrhage 1092 (1.68)
13. Hordeolum externum 1085 (1.67)
25,937, 8.64%), dry eye (1720 of 25,937, 6.63%), chalazion
14. Blepharitis 945 (1.45)
(1375 of 25,937, 5.30%), corneal abrasions (1041 of 25,937,
15. Ocular pain 920 (1.42)
4.01%), and PVDs (956 of 25,937, 3.69%) (Table 4).
16. Iridocyclitis 907 (1.40)
At MEE, corneal abrasions (947 of 16,275, 5.82%), con- 17. Cataract 860 (1.32)
junctivitis (873 of 16,275, 5.36%), PVDs (783 of 16,275, 18. Other specified disorders of eye and adnexa 577 (0.89)
4.81%), visual disturbances (660 of 16,275, 4.06%), and oc- 19. Corneal disorder due to contact lens 501 (0.77)
ular pain (636 of 16,275, 3.91%) were seen most commonly 20. Blurred vision 480 (0.74)
(Table 5). Corneal abrasions (1122 of 16,144, 6.95%), con-

38 AMERICAN JOURNAL OF OPHTHALMOLOGY OCTOBER 2023

Descargado para Anonymous User (n/a) en Murcia Region Health Department de ClinicalKey.es por Elsevier en noviembre 06, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
 FIGURE 1. Top 5 diagnoses of patients presenting to 4 eye EDs with primary eye complaints. BPEI = Bascom Palmer Eye Institute, ED = emergency department, MEE = Mas-
sachusetts Eye and Ear, PVD = posterior vitreous detachment.
VOL. 254 MOST COMMON OPHTHALMIC EMERGENCIES 39
Descargado para Anonymous User (n/a) en Murcia Region Health Department de ClinicalKey.es por Elsevier en noviembre 06, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
 Wills Eye Hospital (Table 6). At JHH, conjunctivitis (1053
TABLE 4. Summary of Top Diagnoses of Patients of 6632, 15.9%), corneal abrasions (533 of 6632, 8.04%),
Presenting to Bascom Palmer Eye Institute (BPEI) eyebrow lacerations (272 of 6632, 4.10%), orbital fractures
Emergency Department With Primary Eye Complaints (212 of 6632, 3.20%), and eye pain (193 of 6632, 2.91%)
were most typical (Table 7). Among the 6632 ophthalmic
Diagnosis n (% of Total BPEI Diagnoses)
complaints addressed in the JHH ED, 3054 (46.05%) were
1. Conjunctivitis 2240 (8.64) specifically seen as consults by the Wilmer Eye Institute.
2. Dry eye 1720 (6.63)
3. Chalazion 1375 (5.30)
4. Corneal abrasion 1041 (4.01)
5. Posterior vitreous detachment 956 (3.69)
6. Conjunctival hemorrhage 946 (3.65) DISCUSSION
7. Glaucoma 825 (3.18)
8. Corneal ulcer 824 (3.18) This study offers a comprehensive report of the most widely
9. Foreign body in cornea 769 (2.96) presenting ophthalmic emergencies in 4 high-volume EDs
10. Retinal detachment 647 (2.49) in the United States in 2019, including 3 eye-specific EDs.
11. Blepharitis 604 (2.33) Importantly, our study showed that the top diagnoses in
12. Cataract 564 (2.17)
2019 were largely those that are typically considered to be
13. Vitreous hemorrhage 494 (1.90)
nonemergent. We found that conjunctivitis, corneal abra-
14. Acute anterior uveitis 446 (1.72)
15. Eye irritation 340 (1.31)
sions, dry eye, PVDs, and chalazions were among the top
16. Blurred vision 291 (1.12)
presenting diagnoses at all institutions. The Association of
17. Eye foreign body 228 (0.88) American Medical Colleges predicts a physician shortage
18. Proliferative diabetic retinopathy 224 (0.86) between 37,800 and 124,000 physicians by the year 2034,
19. Decreased vision 211 (0.81) largely impacted by the COVID-19 pandemic.10 Given
20. Vitreous floater 199 (0.77) this, it is essential to streamline the time and efforts of
physicians in all settings. Our results show a gap in care for
low-acuity eye emergencies that end up ultimately diverted
junctivitis (973 of 16,144, 6.03%), PVDs (866 of 16,144, to the ED. However, perhaps these cases would be bet-
5.36%), dry eye (703 of 16,144, 4.35%), and foreign bod- ter suited for urgent ophthalmology clinic visits. Singman
ies in cornea (592 of 16,144, 3.67%) were most frequent at and associates11 performed a retrospective quality improve-

TABLE 5. Summary of Top Diagnoses of Patients Presenting to

Massachusetts Eye and Ear (MEE) Emergency Department With
Primary Eye Complaints

Diagnosis n (% of Total MEE Diagnoses)

1. Corneal abrasion 947 (5.82)

2. Conjunctivitis 873 (5.36)
3. Posterior vitreous detachment 783 (4.81)
4. Visual disturbance 660 (4.06)
5. Ocular pain 636 (3.91)
6. Foreign body in cornea 536 (3.29)
7. Chalazion 533 (3.27)
8. Retinal detachment 487 (2.99)
9. Hordeolum externum 469 (2.88)
10. Corneal ulcer 456 (2.80)
11. Dry eye 417 (2.56)
12. Unspecified injury of eye and orbit 385 (2.37)
13. Conjunctival hemorrhage 361 (2.22)
14. Iridocyclitis 325 (2.00)
15. Foreign body in external eye 318 (1.95)
16. Vitreous hemorrhage 294 (1.81)
17. Vitreous opacities 280 (1.72)
18. Other specified disorders of eye and adnexa 278 (1.71)
19. Dizziness and giddiness 236 (1.45)
20. Headache 216 (1.33)

40 AMERICAN JOURNAL OF OPHTHALMOLOGY OCTOBER 2023

Descargado para Anonymous User (n/a) en Murcia Region Health Department de ClinicalKey.es por Elsevier en noviembre 06, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
 TABLE 6. Summary of Top Diagnoses of Patients Presenting to the
Wills Eye Institute Emergency Department With Primary Eye
Complaints

Diagnosis n (% of Total Wills Diagnoses)

1. Corneal abrasion 1122 (6.95)

2. Conjunctivitis 973 (6.03)
3. Posterior vitreous detachment 866 (5.36)
4. Dry eye 703 (4.35)
5. Foreign body in cornea 592 (3.67)
6. Iridocyclitis 560 (3.47)
7. Corneal ulcer 559 (3.46)
8. Chalazion 456 (2.82)
9. Conjunctival hemorrhage 434 (2.69)
10. Retinal detachment 395 (2.45)
11. Corneal disorder due to contact lens 379 (2.35)
12. Visual disturbance 369 (2.29)
13. Keratoconjunctivitis due to adenovirus 353 (2.19)
14. Hordeolum externum 332 (2.06)
15. Glaucoma 318 (1.97)
16. Other visual disturbances 311 (1.93)
17. Other specified disorders of eye and adnexa 299 (1.85)
18. Ocular pain 274 (1.70)
19. Vitreous hemorrhage 254 (1.57)
20. Punctate keratitis 251 (1.55)

tients spent on average 7.30 hours in an ED visit, compared

TABLE 7. Summary of Top Diagnoses of Patients with 1.55 hours in a clinic visit. Professional fees associ-
Presenting to the Johns Hopkins Hospital Emergency ated with an outpatient same-day clinic visit were 37% less
Department With Primary Eye Complaints when compared with those of an ED visit.11 This type of
system relies on the fact that many urgent visits are in fact
Diagnosis n (% of Total Wilmer Diagnoses)
for nonurgent diagnoses. In addition to our own study find-
1. Conjunctivitis 1053 (15.9) ings, Channa and associates9 also found that almost half of
2. Corneal abrasion 533 (8.04) all eye-related ED visits consisted of nonurgent conditions.
3. Eyebrow laceration 272 (4.10) In our study, we saw that conjunctivitis was the most
4. Orbital fracture 212 (3.20) common overall diagnosis, which corresponds with find-
5. Eye pain 193 (2.91) ings seen in similar studies.8 As this is typically considered a
6. Blurred vision 189 (2.85) low acuity diagnosis, education directed toward the general
7. Conjunctival hemorrhage 180 (2.71)
public may prove useful to combat the nationwide physi-
8. Visual disturbance 167 (2.52)
cian shortage and divert cases from the ED to same-day
9. Preseptal cellulitis 165 (2.49)
clinic appointments. In 2015, one tertiary center in New
10. Eyelid laceration 148 (2.23)
11. Eye trauma 135 (2.04)
York City analyzed 1090 records of patients with eye com-
12. Ocular foreign body 134 (2.02) plaints and found that the majority were retrospectively
13. Hordeolum externum 125 (1.88) considered “low acuity.”12 Patients with conjunctivitis are
14. Corneal ulcer 120 (1.81) more suitable for same-day clinic visits or primary care visits
15. Vision loss 114 (1.72) unless certain red flag features are noted, such as sudden vi-
16. Retinal detachment 105 (1.58) sion loss or unremitting pain. Especially at institutions that
17. Glaucoma 104 (1.57) do not have an eye-specific ED, it is crucial for front-line
18. Posterior vitreous detachment 92 (1.39) physicians to be well versed in typical eye emergencies to
19. Diplopia 83 (1.25)
prevent avoidable vision loss.
20. Dry eye 79 (1.19)
Among the other top diagnoses seen across all insti-
tutions were PVDs. Patients with PVDs may experience
flashes of light or floaters, and the main concern for ED
ment study in 2019 that showed that creating same-day eye providers is impending vision loss from a subsequent retinal
clinic appointments led to a reduction in length of visit and detachment. Approximately 14.5% of patients with symp-
overall hospital and professional costs. They found that pa- toms of PVDs will develop or have an associated retinal
VOL. 254 MOST COMMON OPHTHALMIC EMERGENCIES 41
Descargado para Anonymous User (n/a) en Murcia Region Health Department de ClinicalKey.es por Elsevier en noviembre 06, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
tear.13 As retinal detachments were the ninth most fre-
quent diagnosis among all institutions we studied, it is im-
portant to determine which patients are at highest risk.
One method for differentiating which patients have a PVD
only, as opposed to a retinal detachment, is through use
of point-of-care ultrasonography, which offers a sensitiv-
ity of 96.9% of diagnosing retinal detachments.14 , 15 This
is a quick examination that can be performed in the ED
setting with proper training. However, point-of-care ultra-
sonography does not reliably detect retinal tears, which can
quickly lead to retinal detachments; thus, if ED providers
are suspicious for urgent pathology, it is typical to consult
the on-call ophthalmology resident or fellow. Clinically,
there are means to stratify patients regarding their risk of
retinal detachment in the setting of a new PVD. Shen and
associates16 enacted a protocol in the Mayo Clinic ED to
triage patients to either a deferred outpatient ophthalmol-
ogy appointment or an urgent ophthalmology consult in the
ED. By using a protocol identifying visual acuity differences,
visual field deficits, and history of ocular trauma or retinal
tears or detachments, they found no retinal detachments in
patients with a new PVD who qualified for deferred exam-
ination.16 As with conjunctivitis, it may, in fact, save time
and resources to also divert patients with light flashes or
floaters to same-day ophthalmology clinic appointments.
At the JHH ED, Wilmer Eye Institute staff are consulted
for undifferentiated or higher acuity cases almost half the
time an eye concern presents to the ED. A previous study
in Taiwan proposed visual acuity as an indicator to clar-
ify the priority of eye emergencies, helping to alert consul-
tants appropriately.17 A similar technique could be useful
to employ in EDs across the United States, as this would
reserve consultant resources for truly emergent cases and
reduce the time for a patient to receive definitive care for
their presenting concern. However, a survey conducted in
Funding/Support: G.A.J.: is supported by the Heed Ophthalmic Foundation. Financial Disclosures: The authors indicate no financial support or conflicts
of interest. All authors attest that they meet the current ICMJE criteria for authorship.
REFERENCES
1. Vaziri K, Schwartz SG, Flynn HW, Kishor KS, Moshfeghi AA.
Eye-related emergency department visits In the United States,
2010. Ophthalmology. 2016;123(4):917–919. doi:10.1016/j.
ophtha.2015.10.032.
2. Shah M, Knoch D, Waxman E. The state of ophthalmology
medical student education in the United States and Canada,
2012 through 2013. Ophthalmology. 2014;121(6):1160–1163.
doi:10.1016/j.ophtha.2013.12.025.
3. Gelston CD, Patnaik JL. Ophthalmology training and com-
petency levels in caring for patients with ophthalmic com-
plaints among United States internal medicine, emergency
medicine, and family medicine residents. J Educ Eval Health
Prof. 2019;16(25):14. doi:10.3352/jeehp.2019.16.25.
4. Pines JM, Pollack CV, Diercks DB, Chang AM, Shofer FS,
42 AMERICAN JOURNAL OF OPHTHALMOLOGY
Descargado para Anonymous User (n/a) en Murcia Region Health Department de ClinicalKey.es por Elsevier en noviembre 06, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
the United Kingdom showed a decline in basic ophthalmic
training for junior physicians in emergency settings.18 To
tackle this lack of ophthalmic emergency training and the
overarching issue of ED overcrowding, it is essential to focus
education on basic ophthalmic skills such as accurate visual
acuity testing. In combination with appropriately diverting
nonurgent cases to same-day clinic appointments, this may
begin to relieve EDs and allow for the time and resources to
care for more medically complex patients. This is especially
crucial as we have entered a time where EDs are still caring
for patients with long-term effects of COVID-19 disease in
addition to screening and treating other public health emer-
gencies that emerge, such as monkeypox virus.19
• LIMITATIONS: Although this is the largest and most re-
cent analysis of its kind in the United States, there are some
limitations to consider. Although our study examines 4 of
the highest volume EDs in the northeast, east coast, and
south that care for eye-related emergencies, it is possible
that different diagnoses may predominate in other regions
of the country and different ED settings. The authors also
recognize that similar diagnoses may be documented dif-
ferently between the 4 institutions studied, slightly alter-
ing the outcomes. Studies such as ours also assume that
all diagnoses are accurate. Some patients’ diagnoses may
change when subsequently evaluated by subspecialists dur-
ing follow-up. ICD-based studies also rely on the accuracy
of coding the diagnoses, which has its inherent limitations,
such assignments by trainees that may be inaccurate or
nonspecific and may affect results. Despite the aforemen-
tioned limitations, our findings are crucial for educating pa-
tients and guiding frontline workers. Future studies explor-
ing the effects of increased education on these common top-
ics could prove useful as a means to combat US and inter-
national physician shortages.
Hollander JE. The association between emergency depart-
ment crowding and adverse cardiovascular outcomes in pa-
tients with chest pain. Acad Emerg Med. 2009;16(7):617–625.
doi:10.1111/j.1553-2712.2009.00456.x.
5. Jo S, Kim K, Lee JH, et al. Emergency department crowd-
ing is associated with 28-day mortality in community-acquired
pneumonia patients. J Infect. 2012;64(3):268–275. doi:10.
1016/j.jinf.2011.12.007.
6. Krochmal P, Riley TA. Increased health care costs associated
with ED overcrowding. Am J Emerg Med. 1994;12(3):265–
266. doi:10.1016/0735- 6757(94)90135- x.
7. Araújo TAC, Melo CRO, Mendes LP, et al. Analysis of oc-
ular emergencies in a reference eye center in Brazil. Arq
Bras Oftalmol. 2021;85(4):377–381. doi:10.5935/0004-2749.
20220016.
8. Poyser A, Deol SS, Osman L, et al. Impact of COVID-19 pan-
OCTOBER 2023
 demic and lockdown on eye emergencies. Eur J Ophthalmol.
2021;31(6):2894–2900. doi:10.1177/1120672120974944.
9. Channa R, Zafar SN, Canner JK, Haring RS, Schneider EB,
Friedman DS. Epidemiology of eye-related emergency de-
partment visits. JAMA Ophthalmol. 2016;134(3):312. doi:10.
1001/jamaophthalmol.2015.5778.
10. IHS Markit Ltd. The Complexities of Physician Supply and De-
mand: Projections From 2019 to 2034. AAMC; 2021.
11. Singman EL, Smith K, Mehta R, et al. Cost and visit
duration of same-day access at an academic ophthalmol-
ogy department vs emergency department. JAMA Oph-
thalmol. 2019;137(7):729–735. doi:10.1001/jamaophthalmol.
2019.0864.
12. Rai RS, Mehta N, Larochelle R, Rathi S, Schuman JS.
A summary of eye-related visits to a tertiary emergency
department. Sci Rep. 2021;11(1):3823. doi:10.1038/
s41598- 021- 83351- 5.
13. Bond-Taylor M, Jakobsson G, Zetterberg M. Posterior vit-
reous detachment—prevalence of and risk factors for reti-
nal tears. Clin Ophthalmol. 2017;11:1689–1695. doi:10.2147/
OPTH.S143898.
14. Castilla-Guerra L, Gómez-Escobar A, Carmona-González E.
Usefulness of point-of-care ultrasound for the evalua-
tion of non-traumatic eye emergencies. Med Clin (Barc).
2021;156(10):503–508. doi:10.1016/j.medcli.2020.11.031.
15. Lahham S, Shniter I, Thompson M, et al. Point-of-care ul-
trasonography in the diagnosis of retinal detachment, vitre-
ous hemorrhage, and vitreous detachment in the emergency
department. JAMA Netw Open. 2019;2(4):e192162. doi:10.
1001/jamanetworkopen.2019.2162.
16. Shen BY, Salman AR, Shah SM, et al. Clinical outcomes fol-
lowing implementation of a formalized “flashes and floaters”
emergency department triage protocol. Am J Ophthalmol.
2022;242:125–130. doi:10.1016/j.ajo.2022.06.007.
17. Kang EYC, Tai WC, Lin JY, et al. Eye-related emergency de-
partment visits with ophthalmology consultation in Taiwan:
visual acuity as an indicator of ocular emergency. Sci Rep.
2020;10(1):982. doi:10.1038/s41598- 020- 57804- 2.
18. Sim PY, La CJ, Than J, Ho J. National survey of the manage-
ment of eye emergencies in the accident and emergency de-
partment by foundation doctors: has anything changed over
the past 15 years? Eye (Lond). 2020;34(6):1094–1099. doi:10.
1038/s41433- 019- 0645- 2.
19. Guarner J, del Rio C, Malani PN. Monkeypox in 2022—
What clinicians need to know. JAMA. 2022;328(2):139–140.
doi:10.1001/jama.2022.10802.

VOL. 254 MOST COMMON OPHTHALMIC EMERGENCIES 43

Descargado para Anonymous User (n/a) en Murcia Region Health Department de ClinicalKey.es por Elsevier en noviembre 06, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.