What is the first thing to do for a chemical burn to the eye?

Irrigate immediately with large volumes of sterile saline or water for a minimum of 15-30 minutes. This takes priority over everything else, including checking vision, taking history, or waiting for the physician. After irrigation, check the tear film pH with litmus paper and continue flushing until pH reaches neutral (7.0-7.4). Remove any particulate matter from under the eyelids. Document the chemical involved when possible.

What symptoms suggest a retinal detachment?

The classic triad includes sudden onset of new floaters (spots, cobwebs, strands), flashes of light (photopsia, especially in peripheral vision), and a progressive curtain or shadow moving across the visual field. Any combination of these symptoms requires same-day dilated examination to rule out retinal tears or detachment. Prompt treatment of retinal tears can prevent progression to full detachment.

How do you triage ocular emergencies over the phone?

Ask about symptom onset (sudden vs. gradual), presence and severity of vision loss, any chemical exposure or trauma, pain characteristics, and associated symptoms like nausea, headache, flashes, or floaters. Chemical burns and sudden vision loss are emergent (come immediately). Corneal ulcers, acute angle-closure, and orbital cellulitis are urgent (seen today). Chronic redness, mild irritation, and routine refraction requests are routine (scheduled appointment).

Emergency Triage in Ophthalmology: COA Exam Guide

Understanding Ocular Emergency Triage

Emergency triage is the process of rapidly assessing patients to determine the urgency of their condition and prioritize care accordingly. In an ophthalmology practice, you will encounter patients with a wide range of complaints, from routine irritation to sight-threatening emergencies. As a COA, your ability to recognize true emergencies can directly preserve a patient's vision.

True Ocular Emergencies

The following conditions require immediate attention, often before any other testing or paperwork:

Chemical Burns

Chemical burns to the eye are the highest-priority ocular emergency. Alkali burns (from substances like lye, cement, or oven cleaner) are more dangerous than acid burns because alkali penetrates deeper into ocular tissues.

The immediate response:

Irrigate immediately with large volumes of sterile saline or water for a minimum of 15-30 minutes
Do NOT wait for the physician, do NOT try to determine the chemical first
Check pH of the tear film with litmus paper after irrigation; continue until pH is neutral (7.0-7.4)
Remove any particulate matter from the conjunctival fornices
Document the chemical, concentration, and exposure time when possible

For chemical burns, irrigation comes before everything. Before checking vision. Before checking history. Before calling the doctor. Every second of delay allows deeper tissue penetration, especially with alkali substances. Start flushing the moment the patient arrives.

Sudden Vision Loss

Acute, painless vision loss may indicate:

Central retinal artery occlusion (CRAO): "stroke of the eye," requires emergency intervention within hours
Central retinal vein occlusion (CRVO): sudden painless vision loss with extensive retinal hemorrhages
Retinal detachment: patient may describe a curtain or shadow moving across their vision
Vitreous hemorrhage: sudden onset of floaters or dark vision

Retinal Detachment Warning Signs

A classic triad of symptoms should raise immediate concern:

New floaters: sudden onset of spots, cobwebs, or strands in vision
Flashes of light (photopsia): especially in peripheral vision
Curtain or shadow: progressive visual field loss from one direction

Dismissing new floaters as harmless. While most floaters are benign (posterior vitreous detachment), new onset of multiple floaters with flashes requires same-day dilated examination to rule out retinal tears or detachment. Never reassure a patient over the phone without having them examined.

Penetrating Ocular Trauma

Any injury where a foreign body may have entered the eye (grinding, hammering, explosions) or where the globe integrity is in question requires urgent evaluation. Signs of a ruptured globe include:

Irregular or peaked pupil
Shallow anterior chamber
Visible wound or prolapsed tissue
Severe subconjunctival hemorrhage obscuring view

If globe rupture is suspected, protect the eye with a rigid shield (no pressure), keep the patient calm, and do not apply drops or ointment until the physician evaluates.

Urgent but Not Immediate

Some conditions require same-day or next-day evaluation but do not typically need interruption of the current schedule:

Acute angle-closure glaucoma: severe eye pain, nausea, halos around lights, mid-dilated fixed pupil
Corneal ulcer: white infiltrate on the cornea with pain and redness
Orbital cellulitis: painful, swollen, red eyelids with fever and restricted eye movement
Hyphema: blood in the anterior chamber, usually from trauma

Phone Triage Skills

Many triage decisions happen over the phone. Key questions to ask callers:

When did the symptoms start?
Is there vision loss? If so, how sudden and how severe?
Was there any chemical exposure or trauma?
Is there pain? Describe the character (sharp, dull, pressure).
Are there associated symptoms (nausea, headache, flashes, floaters)?

Based on responses, categorize as: emergent (come immediately), urgent (seen today), or routine (scheduled appointment).

Why This Matters for COAs

You are often the first clinical staff member a patient encounters. Your quick assessment and appropriate response, whether initiating chemical burn irrigation or ensuring a retinal detachment patient is seen immediately, can directly preserve vision. Knowing what constitutes a true emergency versus a routine concern prevents both dangerous delays and unnecessary disruptions.

Key Takeaways

Chemical burns: irrigate immediately for 15-30 minutes before any other evaluation
Alkali burns penetrate deeper than acid burns and are more dangerous
New floaters with flashes and curtain vision require same-day dilated exam
Suspected ruptured globe: shield the eye, no drops, no pressure
Phone triage: ask about timing, vision loss, trauma, chemical exposure, and pain character
Categorize presentations as emergent, urgent, or routine to prioritize appropriately