What is the first action for a patient presenting with a chemical burn to the eye?

Immediately begin copious eye irrigation before taking a history, before calling the physician, and before performing any tests. Use the nearest clean water, sterile saline, or lactated Ringer's. Continue for at least 20-30 minutes (longer for alkalis). Check conjunctival pH with pH strips and continue until pH is 7.0-7.4. Never attempt to neutralize the chemical with its opposite -- this causes additional thermal injury.

What are the signs of acute angle-closure glaucoma?

Acute angle-closure glaucoma presents with severe eye pain (often described as the worst eye pain of their life), headache, nausea and vomiting, halos around lights, blurred vision, a rock-hard eye (very elevated IOP, sometimes 40-70 mmHg), a mid-dilated and fixed pupil, and a hazy cornea from epithelial edema. This is a true ocular emergency requiring immediate physician intervention.

How is a ruptured globe managed before the physician arrives?

Place a rigid protective shield over the eye (not a pressure patch, which would press on the eye and expel intraocular contents). Do not instill drops, attempt examination with contact on the eye, or apply pressure. Keep the patient NPO (nothing by mouth) in anticipation of emergency surgical repair under general anesthesia. Alert the physician immediately. Document what the patient reports about the injury mechanism.

What symptoms suggest a retinal detachment requiring same-day evaluation?

Sudden onset of a shower of new floaters, flashing lights (photopsia, especially in the peripheral visual field), or a shadow, curtain, or veil across part of the visual field suggests a retinal tear or detachment. Same-day evaluation is critical -- if the macula has not yet detached, surgical repair preserves central vision. If the macula is detached, vision outcomes after repair are significantly worse.

What four questions should the CPOA ask when triaging a patient on the phone?

The four key triage questions are: (1) Is there pain? Severe pain suggests acute angle-closure, keratitis, or uveitis. (2) Has your vision changed? Sudden vision loss is a red flag for CRAO, retinal detachment, or acute glaucoma. (3) Was there any trauma or chemical exposure? This immediately elevates urgency. (4) Are you a contact lens wearer? CL wear raises concern for microbial keratitis with any red eye or discomfort.

Emergency Triage in Ophthalmology

Triage in the Ophthalmic Setting

Ophthalmic triage is the process of prioritizing patients based on urgency. The CPOA is often the first clinical contact for patients calling or presenting with eye problems -- including true emergencies. Recognizing which presentations require immediate physician attention and which can safely wait is a critical CPOA competency. Errors in triage can result in permanent vision loss.

True Ocular Emergencies (Act Immediately)

These situations require immediate physician notification and cannot wait for a routine appointment:

Chemical Burns

Chemical burns to the eye are the most time-critical ocular emergency. Every minute of contact with alkali or acid increases damage. Action:

Begin copious irrigation immediately -- before any history is taken, before the physician arrives
Use sterile water, saline, or lactated Ringer's -- whatever is available fastest
Irrigate for a minimum of 20-30 minutes (longer for alkali burns)
Check pH of the conjunctival fornix every 5 minutes until pH is 7.0-7.4 and stable
Alkali burns (lye, cement, cleaning products) are worse than acid burns because alkali penetrates more deeply

⚠️ Common Mistake: Do NOT attempt to neutralize a chemical (do not pour acid into an alkali-burned eye or vice versa). This creates an exothermic reaction that causes additional thermal injury. Only irrigation with water or saline is appropriate initial treatment.

Acute Angle-Closure Glaucoma

Features: severe eye pain, headache, nausea, vomiting, halos around lights, blurred vision, a rock-hard eye, mid-dilated fixed pupil, and hazy cornea. IOP may be 40-70 mmHg. This requires immediate treatment to lower IOP (IV acetazolamide, topical IOP-lowering drops, laser peripheral iridotomy) to save vision and prevent fellow eye involvement.

Central Retinal Artery Occlusion (CRAO)

Sudden, painless, severe monocular vision loss in a patient with cardiovascular risk factors. CRAO is a stroke of the eye. Time is critical -- permanent retinal damage occurs within 90-100 minutes of ischemia. Immediate referral to the emergency department may allow for treatment (ocular massage, anterior chamber paracentesis, systemic workup for embolic source).

Ruptured Globe / Penetrating Ocular Injury

Signs: full-thickness wound, obvious laceration, peaked or irregular pupil, prolapsed uveal tissue, markedly reduced vision, low IOP, hyphema. Actions: place a rigid shield over the eye (no pressure), keep NPO (nil per os -- nothing by mouth) for potential surgery, alert physician immediately.

Orbital Cellulitis

Fever, proptosis, restricted painful eye movements, reduced vision. A postseptal infection that can spread intracranially. Requires emergency referral, IV antibiotics, and imaging (CT scan).

Urgent (Same-Day Evaluation)

Retinal Detachment

Sudden shower of floaters, flashing lights, or a curtain/shadow across vision. May represent retinal tear with fluid tracking under the retina. Same-day evaluation required; repair (pneumatic retinopexy, scleral buckle, vitrectomy) before the macula detaches preserves central vision.

Acute Anterior Uveitis (Iritis)

Deep aching eye pain, photophobia, decreased vision, circumlimbal (ciliary) flush, irregular constricted pupil. Must be evaluated and treated promptly to prevent synechiae (iris adhesions) and elevated IOP.

Hyphema

Blood in the anterior chamber after trauma. The blood can obstruct trabecular meshwork, raising IOP. Risk of re-bleed on days 3-5. Patient should restrict activity, wear protective shield.

Corneal Ulcer

Painful red eye with white corneal infiltrate and overlying epithelial defect in a contact lens wearer or after trauma. Cultures and urgent topical antibiotics are needed.

💡 Clinical Tip: When taking a call from a patient with an eye complaint, always ask: (1) Is there pain? (2) Has vision changed? (3) Was there any trauma or chemical exposure? (4) Are you a contact lens wearer? These four questions help identify emergencies quickly and triage appropriately.

Urgent but Not Emergent (Next-Day or 1-2 Days)

New floaters without flashes or curtain (PVD without retinal tear -- needs evaluation within 24-48 hours)
Subconjunctival hemorrhage without trauma or anticoagulants (usually benign; resolves in 1-2 weeks)
New onset diplopia (concerning but rarely minutes-matter urgent unless with headache/pupil change)

Non-Urgent (Routine Appointment)

Gradual vision loss over weeks/months
Stable redness without pain, discharge, or vision change
Itchy, watery eyes consistent with allergies
Routine contact lens follow-up

Key Takeaways

Chemical burns require immediate copious irrigation before anything else -- minutes matter
Acute angle-closure: rock-hard eye, severe pain, mid-dilated pupil, hazy cornea -- emergency
CRAO: sudden painless monocular vision loss -- stroke of the eye; immediate referral
Ruptured globe: shield the eye, keep NPO, do not patch with pressure
Retinal detachment (curtain/floaters): same-day evaluation before macula detaches
Triage phone screening: ask about pain, vision change, trauma, contact lens wear

Emergency Triage in Ophthalmology | CPOA Exam