Abstract
Purpose
To report the prevalence of abnormal ophthalmic exam findings in Emergency Department (ED) ophthalmology consultations and provide foundational data for assessing ancillary diagnostic tools’ effectiveness in an acute care setting.
Patients and Methods
We reviewed ophthalmic exam findings from consultations at Harborview Medical Center and University of Washington Medical Center EDs (Seattle, WA) between January 1, 2022, and December 31, 2022. Data included visual acuity (VA), intraocular pressure (IOP), visual field by confrontation (CVF), extraocular motility (EOM), pupil exam, slit lamp, and dilated exam findings. Descriptive statistics were calculated for continuous and categorical variables.
Results
A total of 2087 consults for 1946 patients were included. VA was 20/40 or better in 61.9% of right eyes and 62.4% of left eyes. Afferent pupillary defect (APD) was present in 12.6% eyes. The average IOP was 16.1 mmHg for the right eye and 16.1 mmHg for the left eye. Abnormal EOM in either eye or both eyes were reported in 17.5% and 2.5%, respectively, while abnormal CVF were reported in 16.9%; with homonymous defects in 0.8%. The most common slit lamp exam findings included cataract (31.94%), conjunctival injection (31.2%), and superficial punctate epithelial erosions (29.6%). The most common funduscopic findings were retinal hemorrhage (14.0% peripheral and 6.3% macular), posterior vitreous detachment (9.7%), and retinal vascular attenuation (6.7%).
Conclusion
This comprehensive report of findings of ED ophthalmic consultations can be used as a foundational pretest measure for guiding the implementation of appropriate ancillary diagnostic tools for emergency ophthalmic care.
Keywords: tele-ophthalmology, ophthalmic emergencies, examination findings, ophthalmic screening
Introduction
In recent years, hospital Emergency Departments (EDs) have faced decreasing access to in-person ophthalmology consultants for patients with vision and eye symptoms.1 A variety of instruments, including fundus cameras, posterior segment optical coherence tomography (OCT), and anterior segment photography, are becoming available to help ED personnel collect ophthalmic data for remote specialist screening and evaluation via tele-ophthalmology or via machine learning.2–4 However, the prevalence of pathologic findings targeted by these instruments have not been well studied, which creates a challenge in accurately assessing the true utility of any ancillary ophthalmic testing in an ED setting. While most common ophthalmic conditions in EDs have been reported to be primarily lower acuity conditions,5,6 those that require ophthalmology consultation may have higher rate of ocular pathology with greater potential benefit of ancillary ophthalmic testing and tele-ophthalmology screening. Prevalence data for ophthalmic findings and diagnoses from ophthalmology consultations may guide the utilization and interpretation of ED ancillary testing.
The purpose of this study is to report the prevalence of ophthalmic exam findings among ophthalmology consults at two tertiary, university-based medical center EDs, including a level one trauma center. The findings of this study can be used as a foundational pretest measure to guide the implementation of appropriate diagnostic tests and assess their predictive value in an emergency care setting among patients requiring ophthalmology consultation.
Materials and Methods
This retrospective study was approved by the Institutional Review Board (IRB) of the University of Washington (STUDY00018734). The IRB determined that patient consent was not required due to retrospective nature of the study. All research was performed in accordance with the principles stated in the Declaration of Helsinki and patient data remained confidential. This cross-sectional study included patients who received ophthalmic consultations at Harborview Medical Center and University of Washington Medical Center EDs (Seattle, WA) between January 1, 2022, and December 31, 2022. The study included patients who presented directly to the ED or were transferred from another ED facility with in-person consultations performed by an ophthalmology resident physician during ED encounter. Ophthalmology exam findings were initially recorded into the Epic Electronic Medical Records (EMR) system using the Kaleidoscope module by ophthalmology resident consultants at the time of the exam. Intraocular pressure was measured using the Tonopen Avia® electronic handheld tonometers (Reichert Inc., Depew, NY). All patients in 2022 with a consultation note by ophthalmology resident physicians in the Emergency Department setting were included in this study. Patients for whom ophthalmic consultation was requested but not complete at the time of the ED visit were not included.
Demographic data including sex, race/ethnicity, and age were extracted from the EMR. The primary final ophthalmic diagnosis for each encounter was obtained from the electronic medical records and sorted into major categories to identify the most frequent diagnoses. Ophthalmic exam findings collected from EMR included visual acuity, intraocular pressure (IOP), visual field by confrontation, extraocular motility, pupil exam, slit lamp exam findings, and funduscopic findings. All abnormal ocular exam findings were reviewed and findings with a prevalence greater than 1% are listed in the results for a report of most common findings.
The data was analyzed with Excel and Power BI (Microsoft 6.85 (24051214), Redmond, WA). Descriptive statistics were calculated with means and standard deviations (SD) for continuous variables and proportions for categorical variables. Prevalence of findings are reported for the presence in either eye and in both eyes.
Results
A total of 2,087 ophthalmology consults for 1,946 patients, of whom 141 (6.8%) had more than one ED consult visit, were included. Sixty percent of patients were male; the most common self-reported race/ethnicity were White (68.7%), Black (13.3%), and Asian (8.9%). The mean ± SD age was 47.7 ± 19.3 years (range 0–102).
The ten most common primary visit diagnoses are reported in Table 1, with the most frequent diagnoses being orbital wall fracture (7.3%), infectious keratitis (4.9%), and open globe injury (4.1%). Baseline eye exam characteristics are reported in Table 2, including the percentages of patients with eye findings out of all patients receiving each component of the eye exam. The number of patients receiving each component of the eye exam varied; visual acuity visual field testing were not obtained when patients were unable to participate in a subjective exam, intraocular pressure measurements were deferred in cases of suspected open globe injury or in cases where patients declined or had prior enucleation. Afferent pupillary defect was present in 12.6% of all consults. Intraocular pressure was greater than 21 mmHg in approximately 10% of patients for each eye, ranging from 2 to 87 mmHg. A histogram of the distribution of intraocular pressure is shown in Figure 1. Visual field deficits were present on confrontation for 16.9% of documented exams.
Table 1.
Ten Most Common Primary Diagnoses in Emergency Department Consults
| Diagnosis | N (%) |
|---|---|
| Orbital Wall Fracture | 153 (7.3%) |
| Infectious Keratitis | 103 (4.9%) |
| Open Globe Injury | 85 (4.1%) |
| Glaucoma or Ocular Hypertension | 81 (3.9%) |
| Retinal Detachment | 73 (3.5%) |
| Corneal Abrasion | 72 (3.4%) |
| Periocular Infection (including preseptal cellulitis, orbital cellulitis, dacryocystitis) | 67 (3.2%) |
| Eyelid or Facial Laceration | 65 (3.1%) |
| Vitreous Hemorrhage | 62 (3.0%) |
| Uveitis (Anterior and Posterior) | 61 (2.9%) |
| Posterior Vitreous Detachment | 58 (2.8%) |
Table 2.
Ophthalmic Basic Eye Exam From Ophthalmic ED Consultations Between January 1, 2022 and December 31, 2022, Including Visual Acuity, Afferent Pupillary Defect, Average Intraocular Pressure, Extraocular Movement, and Confrontation Visual Field Exam
| Visual Acuity, N (%) | Right Eye | Left Eye |
|---|---|---|
| 20/40 or Better | 1170 (61.9%) | 1180 (62.4%) |
| 20/50-20/150 | 304 (16.1%) | 279 (14.8%) |
| 20/200 - Count Fingers (CF) | 208 (11%) | 216 (11.4%) |
| Hand Motion (HM) | 92 (4.9%) | 89 (4.7%) |
| Light Perception (LP) | 74 (3.9%) | 59 (3.1%) |
| No Light Perception (NLP) | 42 (2.2%) | 68 (3.6%) |
| Total Exams | 1890 | 1891 |
| Afferent Pupillary Defect, N (%) | ||
| Present | 235 (12.6%) | |
| Not Present | 1425 (76.5%) | |
| Questionable | 53 (2.8%) | |
| Not Reported | 150 (8.1%) | |
| Total Exams | 1863 | |
| Non-Reactive Pupils | 313 (15.7%) | |
| Average (SD) Intraocular Pressure | ||
| Right Eye (N=1901) | 16.1 (6.6) mmHg | |
| Greater than 21mmHg | 203 (10.7%) | |
| Total Exams | 1901 | |
| Left Eye (N=1899) | 16.1 (6.3) mmHg | |
| Greater than 21mmHg | 191 (10.1%) | |
| Total Exams | 1899 | |
| Extraocular Movement Exams, N (%) | ||
| Deficits in Either Eye | 302 (17.5%) | |
| Deficits in Both Eyes | 44 (2.5%) | |
| Total Exams | 1726 | |
| Visual Field Exams, N (%) | ||
| Deficit Present | 202 (16.9%) | |
| Right Eye | 107 (8.9%) | |
| Left Eye | 95 (7.9%) | |
| Homonymous Defects | 9 (0.8%) | |
| Total Exams | 1197 | |
Figure 1.
Histogram Intraocular pressure measurements from ophthalmic ED consultations between January and December in 2022. Dark blue bars indicate the right eye and light blue bars indicate the left eye.
Slit lamp and funduscopic findings are reported in Table 3. Most common location of abnormal findings was conjunctiva, with 56.5% of eyes showing at least one abnormal finding, followed by cornea (47.2%), lens (41.8%), and retina periphery (34.3%). The most common conjunctival finding was injection (31.2%), followed by chemosis (14.8%) and subconjunctival hemorrhage (14.7%). The most common corneal findings included superficial punctate epithelial erosions (29.6%), epithelial defects (10.92%), Descemet folds (5.5%), and corneal infiltrate or ulcer (4.9%). Among lens findings, most frequent findings included cataract (31.9%) and intraocular lens (13.5%). Of 1813 patients with a retinal exam documented, 13% were reported to have no view of the macula. Among peripheral retinal findings, most frequent findings included hemorrhage (14.0%), laser scars (6.7%), retinal tear (4.4%), and lattice degeneration (3.8%). The least common location of abnormal findings was the iris, with 7.1% of patients having an abnormal finding in either eye.
Table 3.
Slit Lamp and Funduscopic Findings Present in >1% of Ophthalmic ED Consultations in 2022, Including External Eye, Lid/Lashes, Conjunctiva, Cornea, Anterior Chamber, Iris, Lens, Vitreous, Nerve, Macula, Vessel, and Periphery
| External Eye | Either Eye, N (%) | Both, N (%) |
| Edema | 173 (8.65%) | 29 (1.45%) |
| Laceration | 114 (5.69%) | 26 (1.30%) |
| Ecchymosis | 114 (5.69%) | 20 (1.00%) |
| Abrasion | 89 (4.45%) | 11 (0.55%) |
| Proptosis | 27 (1.35%) | 3 (0.15%) |
| Vesicle | 22 (1.10%) | 1 (0.05%) |
| Any External Eye Findings | 394 (19.69%) | |
| Total Exams | 2001 | |
| Lid/Lashes | Either Eye, N (%) | Both, N (%) |
| Edema | 534 (25.76%) | 98 (4.73%) |
| Ecchymosis | 282 (13.60%) | 47 (2.27%) |
| Meibomian Gland Dysfunction/Blepharitis | 199 (9.60%) | 171 (8.25%) |
| Laceration | 172 (8.30%) | 5 (0.24%) |
| Ptosis | 145 (6.99% | 32 (1.54%) |
| Dermatochalasis | 37 (1.78%) | 32 (1.54%) |
| Lesion | 24 (1.16%) | 4 (0.19%) |
| Any Lid/Lash Findings | 563 (27.16%) | |
| Total Exams | 2073 | |
| Conjunctiva | Either Eye, N (%) | Both, N (%) |
| Injection | 647 (31.21%) | 106 (5.11%) |
| Chemosis | 306 (14.76%) | 54 (2.60%) |
| Subconjunctival Hemorrhage | 305 (14.71%) | 26 (1.25%) |
| Laceration | 91 (4.39%) | 2 (0.10%) |
| Papillae / Follicles | 31 (1.50%) | 16 (0.77%) |
| Any Conjunctiva Findings | 1171 (56.49%) | |
| Total Exams | 2073 | |
| Cornea | Either Eye, N (%) | Both, N (%) |
| Superficial Punctate Epithelial | ||
| Erosions | 612 (29.57%) | 390 (18.84%) |
| Epithelial Defect | 226 (10.92%) | 24 (1.16%) |
| Descemets Fold | 114 (5.51%) | 6 (0.29%) |
| Infiltrate/Ulcer | 101 (4.88%) | 6 (0.29%) |
| Edema | 90 (4.35%) | 4 (0.19%) |
| Keratic Precipitate | 69 (3.33%) | 17 (0.82%) |
| Laceration | 65 (3.14%) | 1 (0.05%) |
| Endothelial pigment | 63 (3.04%) | 16 (0.77%) |
| Neovascularization | 59 (2.85%) | 7 (0.34%) |
| Corneal Thinning | 46 (2.22%) | 7 (0.34%) |
| Pterygium | 39 (1.88%) | 21 (1.01%) |
| Foreign Body | 23 (1.11%) | 1 (0.05%) |
| Any Cornea Findings | 977 (47.20%) | |
| Total Exams | 2070 | |
| Anterior Chamber | Either Eye, N (%) | Both, N (%) |
| Cell/Hypopyon | 166 (8.03%) | 55 (2.66%) |
| Hypopyon | 57 (2.77%) | 2 (0.10%) |
| Flare | 223 (10.78%) | 23 (1.11%) |
| Hyphema | 132 (6.38%) | 3 (0.15%) |
| Shallow | 69 (3.34%) | 20 (0.97%) |
| Any Anterior Chamber Findings | 500 (24.18%) | |
| Total Exams | 2068 | |
| Iris | Either Eye, N (%) | Both, N (%) |
| Posterior Synechiae | 53 (2.56%) | 12 (0.58%) |
| Neovascularization | 49 (2.37%) | 9 (0.43%) |
| Misshapen pupil | 39 (1.88%) | 0 (0.00%) |
| Iris Transillumination Defect | 24 (1.16%) | 4 (0.19%) |
| Any Iris Findings | 146 (7.06%) | |
| Total Exams | 2069 | |
| Lens | Either Eye, N (%) | Both, N (%) |
| Cataract | 656 (31.94%) | 493 (24.00%) |
| White/Traumatic Cataract | 24 (1.17%) | 1 (0.05%) |
| Intraocular Lens | 278 (13.53%) | 163 (7.94%) |
| Any Lens Findings | 859 (41.82%) | |
| Total Exams | 2054 | |
| Vitreous | Either Eye, N (%) | Both, N (%) |
| Posterior Vitreous Detachment | 144 (9.68%) | 45 (3.03%) |
| Vitreous Cell | 133 (8.94%) | 31 (2.08%) |
| Vitreous Hemorrhage | 50 (3.36%) | 5 (0.34%) |
| Vitreous Haze | 23 (1.55%) | 1 (0.07%) |
| Any Vitreous Findings | 283 (19.03%) | |
| Total Exams | 1487 | |
| Nerve | Either Eye, N (%) | Both, N (%) |
| Cup to Disc Ratio ≥ 0.6 | 144 (12.77%) | 65 (5.76%) |
| Total Exams | 1128 | |
| Pallor | 122 (6.61%) | 38 (2.06%) |
| Edema | 56 (3.03%) | 34 (1.84%) |
| Cupped, Enlarged, Notch | 49 (2.65%) | 16 (0.87%) |
| Hemorrhage, Disc Heme | 45 (2.44%) | 6 (0.32%) |
| Neovascularization of the Disc | 39 (2.11%) | 10 (0.54%) |
| Any Nerve Findings | 243 (13.16%) | |
| Total Exams | 1847 | |
| Macula | Either Eye, N (%) | Both, N (%) |
| No View | 236 (13.02%) | 28 (1.54%) |
| Heme (Dot Blot Hemorrhages, Flame, Intraretinal, Preretinal) | 114 (6.29%) | 26 (1.43%) |
| Drusen | 64 (3.53%) | 27 (1.49%) |
| Exudate | 51 (2.81%) | 15 (0.83%) |
| Microaneurysms | 47 (2.59%) | 16 (0.88%) |
| Detachment | 37 (2.04%) | 5 (0.28%) |
| Traction or Tractional Retinal Detachment | 12 (0.66%) | 5 (0.28%) |
| Commotio or Berlin’s Edema | 35 (1.93%) | 3 (0.17%) |
| Geographic Atrophy / Macular Scar | 33 (1.82%) | 10 (0.55%) |
| Cotton Wool Spots | 24 (1.32%) | 2 (0.11%) |
| Other Retinal Abnormalities (Thickening, Hole, Lesions) | 24 (1.32%) | 0 (0.00%) |
| Any Macula Findings | 301 (16.60%) | |
| Total Exams | 1813 | |
| Vessel | Either Eye, N (%) | Both, N (%) |
| Attenuation | 119 (6.63%) | 52 (2.90%) |
| Tortuosity | 50 (2.79%) | 33 (1.84%) |
| Any Vessel Findings | 161 (8.97%) | |
| Total Exams | 1794 | |
| Periphery | Either Eye, N (%) | Both, N (%) |
| Hemorrhage | 245 (14.04%) | 81 (4.64%) |
| Laser Scars / Panretinal Photocoagulation | 117 (6.70%) | 32 (1.83%) |
| Retinal Tear, Hole, or Operculum | 77 (4.41%) | 13 (0.74%) |
| Lattice Degeneration | 66 (3.78%) | 25 (1.43%) |
| Retinal Detachment | 51 (2.92%) | 1 (0.06%) |
| Commotio | 48 (2.75%) | 3 (0.17%) |
| Exudates | 30 (1.72%) | 7 (0.40%) |
| Neovascularization | 21 (1.20%) | 4 (0.23%) |
| Any Periphery Findings | 599 (34.33%) | |
| Total Exams | 1745 |
Discussion
Prior studies have focused on common ophthalmic conditions encountered in the ED5–7 and the need for advanced diagnostic tools for remote screening to alleviate issues of ED overcrowding, high costs, and shortage of ophthalmologists in rural areas, and to expedite the diagnosis of time-sensitive conditions.8–11 The current literature still lacks a comprehensive analysis of the frequency of ophthalmic exam findings among patients, a necessary step to accurately determine the effectiveness and prognostic value of any diagnostic tool. We report the prevalence of ophthalmic examination findings from over 2,000 ED ophthalmology consults, highlighting the most frequently observed abnormal eye findings among ophthalmology consults in an ED of an academic tertiary center and level 1 trauma center.
Other authors have reported that the most common ophthalmic conditions in the ED tend to be lower acuity diagnoses such as conjunctivitis, corneal abrasions, dry eye, posterior vitreous detachments, and chalazions,1,7 the evaluation of which may lead to delay of care for higher priority cases in which vision loss is of greater risk. In contrast to these prior studies of all eye-related presentations to the ED, this study focuses on those receiving ophthalmic consultation, for which the acuity of findings is higher than previous reported. Our study demonstrates higher percentages of ophthalmic consults involving diagnoses that require urgent intervention, including infectious keratitis, open globe injury, and retinal detachment.
Additionally, the rate of abnormal eye vitals was high, with the prevalence of a visual acuity of 20/200 or worse in any eye greater than 20%, and the prevalence of afferent pupillary defects, extraocular movement deficits, visual field deficits, and ocular hypertension greater than 10%. This high prevalence of pathology supports the utility of ancillary ophthalmic testing in emergency ophthalmic consults, especially in the setting of difficulty obtaining in-person ophthalmology evaluation.1 Additionally, the high rate of abnormalities on ophthalmic exam suggests that access to in-person ophthalmic consultation is important for appropriate treatment of potentially vision threatening conditions. That there is a high prevalence of abnormal ophthalmic findings among ophthalmic consultations may reflect the high volume of trauma-related consults at a level 1 trauma center. Additionally, the higher rate of more urgent diagnoses may reflect the efficacy of ED triage for ophthalmic complaints, in which less acute problems do not receive ophthalmic consultation.
ED physicians are often the first to triage ophthalmic conditions, but often have limited training and comfort in ocular examinations,12,13 translating into low rate of acquisition and accuracy of ED evaluation of ophthalmic vitals and examination findings.14,15 Automated technologies such as smartphone visual acuity testing,16,17 virtual reality-based automated pupillometry,18 and virtual reality or screen-based visual field testing19–21 have potential in ED settings to improve assessment of eye vitals. Additionally, when an in-person evaluation is not available, the use of diagnostic and screening ophthalmic imaging tools to collect data for a remote ophthalmologist or machine deep learning interpretation has been considered for use in the triage and evaluation of emergency ophthalmic conditions. Video and photograph assessments for evaluation of the lids and adnexa, smartphone photography of corneal pathology2,4,22 and anterior segment optical coherence tomography (OCT) for corneal pathology,23 angle closure, and cell and flare24 have potential use for ED evaluation of anterior segment anterior diagnoses. Furthermore, OCT and fundus photography have become essential components in the remote or automated evaluation of papilledema,25 new onset visual field/visual acuity defect,26 retinal detachment/tear, and the ophthalmology trauma work up.27
The implementation of these tools allows ED providers and ophthalmologists to capture and transmit essential ophthalmic exam data and high-quality images for ophthalmology evaluation. However, prevalence data in the ED setting is critical to determine the utility of such tools. For example, fundus photography and OCT testing would not be expected to be a valid screening tool for 13% patients with no view to the macula on clinical exam. Fundus imaging of the posterior pole without peripheral imaging may miss peripheral fundus findings in over 30% of patients. Additionally, prevalence data is critical to the interpretation of testing; it allows for the determination of positive and negative predictive values of testing results, which is paramount for screening of rare conditions or time-sensitive pathologies.28 The prevalence data from our study can be used for interpretation of diagnostic tools to determine predictive values for abnormal results.
Our study has several limitations. The study was conducted at two tertiary, university-based medical center EDs that serve as major referral centers for a large geographic region, and our findings may not be generalizable to all ED settings with different referral patterns and consultation practices. The findings also only represent those receiving ophthalmic consultation and does not include less severe ophthalmic pathology that the general ED provider may treat without ophthalmic consultation. The accuracy of ophthalmic exam findings documented may vary, affecting the reliability of the study’s findings. Additionally, not all patients had documentation of all exam findings, either due to the clinical scenario (ie, no visual acuity documented on a sedated patient) or due to documentation error.
Conclusion
Our study provides a comprehensive report of ophthalmic findings of patients receiving ophthalmic consults in the EDs of an academic tertiary care hospital and level 1 trauma center. There is a high prevalence of decreased visual acuity, pupillary abnormalities, ocular hypertension, and anterior segment and posterior segment slit lamp exam findings among ophthalmic consults in the ED, representing the high acuity of ophthalmic consults in academic EDs.
Acknowledgment
The abstract of this paper was presented at the Association of Research in Vision and Ophthalmology as a poster presentation with interim findings. The poster’s abstract was published in ‘Poster Abstracts’ in Investigative Ophthalmology & Visual Science: [https://iovs.arvojournals.org/article.aspx?articleid=2799927].
Funding Statement
This work was supported in part by an unrestricted grant from Research to Prevent Blindness and by the Latham Vision Research Innovation Award. The funders had no role in the design of the study, collection, analysis, or interpretation of the data, preparation of the manuscript, or decision to submit the manuscript for publication.
Disclosure
Dr Andrew Chen reports personal fees or grants from Visual Field Inc, Janssen LLC, American Glaucoma Society, and Department of Defense, outside the submitted work. The authors report no other conflicts of interest in this work.
References
- 1.Who’s on Call? Emergency Care Crisis Looms. American Academy of Ophthalmology; 2019. Available from: https://www.aao.org/eyenet/article/whos-on-call-emergency-care-crisis-looms. Accessed February 28, 2024. [Google Scholar]
- 2.Armstrong GW, Liebman DL, Ashourizadeh H. Implementation of anterior segment ophthalmic telemedicine. Curr Opin Ophthalmol. 2024;35(4):343–350. doi: 10.1097/ICU.0000000000001052 [DOI] [PubMed] [Google Scholar]
- 3.De Arrigunaga S, Aziz K, Lorch AC, Friedman DS, Armstrong GW. A review of ophthalmic telemedicine for emergency department settings. Semin Ophthalmol. 2022;37(1):83–90. doi: 10.1080/08820538.2021.1922712 [DOI] [PubMed] [Google Scholar]
- 4.Cao B, Vu CHV, Keenan JD. Telemedicine for cornea and external disease: a scoping review of imaging devices. Ophthalmol Ther. 2023;12(5):2281–2293. doi: 10.1007/s40123-023-00764-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Mahjoub H, Ssekasanvu J, Yonekawa Y, et al. Most common ophthalmic diagnoses in eye emergency departments: a multicenter study. Am J Ophthalmol. 2023;254:36–43. doi: 10.1016/j.ajo.2023.03.016 [DOI] [PubMed] [Google Scholar]
- 6.Channa R, Zafar SN, Canner JK, Haring RS, Schneider EB, Friedman DS. Epidemiology of eye-related emergency department visits. JAMA Ophthalmol. 2016;134(3):312–319. doi: 10.1001/jamaophthalmol.2015.5778 [DOI] [PubMed] [Google Scholar]
- 7.Okrent Smolar AL, Ray HJ, Dattilo M, et al. Neuro-ophthalmology emergency department and inpatient consultations at a large academic referral center. Ophthalmology. 2023;130(12):1304–1312. doi: 10.1016/j.ophtha.2023.07.028 [DOI] [PubMed] [Google Scholar]
- 8.Lema GMC, De Leacy R, Fara MG, et al. A remote consult retinal artery occlusion diagnostic protocol. Ophthalmology. 2024;131(6):724–730. doi: 10.1016/j.ophtha.2023.11.031 [DOI] [PubMed] [Google Scholar]
- 9.Hennein L, Jastrzembski B, Shah AS. Use of telemedicine in pediatric ophthalmology in the underserved population. Semin Ophthalmol. 2023;38(2):116–123. doi: 10.1080/08820538.2022.2152703 [DOI] [PubMed] [Google Scholar]
- 10.Li JPO, Liu H, Ting DSJ, et al. Digital technology, tele-medicine and artificial intelligence in ophthalmology: a global perspective. Prog Retin Eye Res. 2021;82:100900. doi: 10.1016/j.preteyeres.2020.100900 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Morse AR. Telemedicine in ophthalmology: promise and pitfalls. Ophthalmology. 2014;121(4):809–811. doi: 10.1016/j.ophtha.2013.10.033 [DOI] [PubMed] [Google Scholar]
- 12.Gelston CD, Patnaik JL. Ophthalmology training and competency levels in care of patients with ophthalmic complaints in United States internal medicine, emergency medicine and family medicine residents. J Educ Eval Health Prof. 2019;16:25. doi: 10.3352/jeehp.2019.16.25 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Uhr JH, Governatori NJ, Zhang QE, et al. Training in and comfort with diagnosis and management of ophthalmic emergencies among emergency medicine physicians in the United States. Eye Lond Engl. 2020;34(9):1504–1511. doi: 10.1038/s41433-020-0889-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Bojikian KD, Leveque TK, McEvoy A, et al. Assessment of emergency department intraocular pressure and visual acuity assessment as a screening exam. Clin Ophthalmol Auckl NZ. 2025;19:683–690. doi: 10.2147/OPTH.S511327 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Alangh M, Chaudhary V, McLaughlin C, Chan B, Mullen SJ, Barbosa J. Ophthalmic referrals from emergency wards-a study of cases referred for urgent eye care (The R.E.S.C.U.E Study). Can J Ophthalmol J Can Ophtalmol. 2016;51(3):174–179. doi: 10.1016/j.jcjo.2016.01.004 [DOI] [PubMed] [Google Scholar]
- 16.Pathipati AS, Wood EH, Lam CK, Sáles CS, Moshfeghi DM. Visual acuity measured with a smartphone app is more accurate than Snellen testing by emergency department providers. Graefes Arch Clin Exp Ophthalmol Albrecht Von Graefes Arch Klin Exp Ophthalmol. 2016;254(6):1175–1180. doi: 10.1007/s00417-016-3291-4 [DOI] [PubMed] [Google Scholar]
- 17.Suo L, Ke X, Zhang D, et al. Use of mobile apps for visual acuity assessment: systematic review and meta-analysis. JMIR MHealth UHealth. 2022;10(2):e26275. doi: 10.2196/26275 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Bruegger D, Grabe HM, Vicini R, Dysli M, Lussi D, Abegg M. Detection of relative afferent pupillary defects using eye tracking and a VR headset. Transl Vis Sci Technol. 2023;12(6):22. doi: 10.1167/tvst.12.6.22 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Stapelfeldt J, Kucur SS, Huber N, Höhn R, Sznitman R. Virtual reality-based and conventional visual field examination comparison in healthy and glaucoma patients. Transl Vis Sci Technol. 2021;10(12):10. doi: 10.1167/tvst.10.12.10 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Chen YX, Meyerov J, Skalicky SE. Online circular contrast perimetry via a web-application: establishing a normative database for central 10-degree perimetry. Clin Ophthalmol Auckl NZ. 2024;18:201–213. doi: 10.2147/OPTH.S440964 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Meyerov J, Deng Y, Busija L, Bigirimana D, Skalicky SE. Online circular contrast perimetry: a comparison to standard automated perimetry. Asia-Pac J Ophthalmol Phila Pa. 2023;12(1):4–15. doi: 10.1097/APO.0000000000000589 [DOI] [PubMed] [Google Scholar]
- 22.Ludwig CA, Newsom MR, Jais A, Myung DJ, Murthy SI, Chang RT. Training time and quality of smartphone-based anterior segment screening in rural India. Clin Ophthalmol Auckl NZ. 2017;11:1301–1307. doi: 10.2147/OPTH.S134656 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Garcia Marin YF, Alonso-Caneiro D, Vincent SJ, Collins MJ. Anterior segment optical coherence tomography (AS-OCT) image analysis methods and applications: a systematic review. Comput Biol Med. 2022;146:105471. doi: 10.1016/j.compbiomed.2022.105471 [DOI] [PubMed] [Google Scholar]
- 24.Objective quantification of anterior chamber inflammation: measuring cells and flare by anterior segment optical coherence tomography – PubMed. Available from: https://pubmed.ncbi.nlm.nih.gov/28625685/. Accessed March 25, 2025. [DOI] [PubMed]
- 25.Lin MY, Ray HJ, Pendley AM, et al. Emergency department nonmydriatic fundus photography expedites care for patients referred for papilledema. Ophthalmology. 2025;132:S0161–6420. doi: 10.1016/j.ophtha.2025.01.024 [DOI] [PubMed] [Google Scholar]
- 26.Vasseneix C, Bruce BB, Bidot S, Newman NJ, Biousse V. Nonmydriatic fundus photography in patients with acute vision loss. Telemed J E-Health off J Am Telemed Assoc. 2019;25(10):911–916. doi: 10.1089/tmj.2018.0209 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Shah YS, Fliotsos MJ, Alaqeel A, et al. Use of teleophthalmology for evaluation of ophthalmic emergencies by ophthalmology residents in the emergency department. Telemed J E-Health off J Am Telemed Assoc. 2022;28(6):858–864. doi: 10.1089/tmj.2021.0334 [DOI] [PubMed] [Google Scholar]
- 28.McKay KM, Lim LL, Gelder RNV. Rational laboratory testing in uveitis: a Bayesian analysis. Surv Ophthalmol. 2021;66(5):802–825. doi: 10.1016/j.survophthal.2021.02.002 [DOI] [PubMed] [Google Scholar]