This study aimed to evaluate the profile of patients attending the eye emergency clinic, emphasizing the differentiation between true ocular emergencies (TEE) and non-emergency eye conditions (NEE). Our findings highlighted several significant aspects that warrant detailed discussion.
A very small proportion of patients presenting to the emergency department with eye complaints constitute conditions that may pose serious problems if not intervened. Central Retinal Artery and Central Retinal Artery branch occlusions [10], Giant Cell Arteritis, Open Globe injuries [10, 11, 12], Cavernous Sinus Thrombosis, Acute Angle-Closure Glaucoma [12], Endophthalmitis, Orbital Cellulitis [12], Alkali chemical eye injuries [10, 11, 12], retinal detachment without macular involvement [10, 11, 12], and various types of keratitis are among the urgent eye conditions [13, 14]. When looking at the literature, similar rates were found as in the study [2, 3]. However, patients were not classified according to the order of urgency as done in the study. When looking at the subcategories, it was found that true ocular emergencies were very low compared to all ocular emergencies in the study. The rate of true ocular emergencies among all patients admitted to the emergency department was found to be 0.2%. To help differentiate non-urgent eye complaints from genuine ones, it is important to establish robust protocols for triage and coding systems, as well as the implementation of adequate training platforms. These measures can improve patient care by providing healthcare workers with the knowledge and skills necessary for accurate diagnosis and treatment [6–8].
The annual incidence of retinal detachment is reported to be between 6.3 and 17.9 cases per 100,000 [15]. In this study, this rate was 19 cases per 100,000. Studies have indicated that retinal detachment without macular involvement is considered an urgent condition, while retinal detachment with macular involvement is relatively urgent [16]. The reason for the slightly higher retinal detachment rate in the study compared to other studies may be that the hospital is a tertiary care hospital and admits more trauma patients.
Giant Cell Arteritis can cause optic neuropathy leading to blindness and is seen in about 15–25 cases per 100,000 [17]. No cases of Giant Cell Arteritis were encountered in our study over the course of a year. The disease can sometimes have a subclinical course, leading to either an undiagnosed state or patients not presenting to the emergency department with primary eye complaints.
Central retinal artery and branch occlusions are among the most urgent conditions in ophthalmology practice. The incidence is reported as 1 in 100,000, and among ophthalmology referrals, it is found to be 1 in 10,000 [18]. In our study, central retinal artery occlusion was diagnosed in 3 patients, and central retinal artery branch occlusion was diagnosed in 3 patients. A higher incidence rate than that of the literature was observed. This could be attributed to the development of new diagnostic methods.
Open globe injury is the most common cause of unilateral visual blindness worldwide [20]. Its incidence ranges from 2 to 6 cases per 100,000 annually [20]. In this study, the incidence was 10.7 cases per 100,000. Among patients with ophthalmic complaints, the rate was found to be 0.7%. Due to its poor prognosis, open globe injury correlates with being the most common cause of unilateral visual loss worldwide, as observed in our study.
Microbial keratitis is an urgent condition that results in blindness if not treated early. It is seen with varying frequencies in different regions worldwide, with an incidence ranging from 6.6 to 40.3 cases per 100,000 [21, 22]. In this study, the rate was 15.3 cases per 100,000. As one moves towards rural areas in Turkey, this rate might be even higher. Acute angle-closure glaucoma is frequently encountered among true ophthalmic emergencies. In Europe, the incidence of acute angle-closure glaucoma ranges from 3.9 to 4.1 cases per 100,000 [23, 24]. In this study, the incidence was 4.7 cases per 100,000. Apart from acute angle-closure glaucoma, open-angle glaucoma and congenital glaucoma have also presented to our emergency department. Endophthalmitis has varying incidences depending on the causative agent but is a common reason for emergency eye visits [25]. In this study, the incidence was 2.6 cases per 100,000.
Chemical substance exposure to the eye, especially alkali chemical exposure, is one of the most critical eye emergencies [26]. It constitutes 10–12% of patients presenting to the emergency department with eye complaints [27]. In this study, chemical injuries accounted for 3.3%. This was lower compared to the literature. The reason might be the separate consideration of corneal foreign bodies as a distinct group in our study. The incidence of orbital cellulitis ranges from 1.6 to 6 per 100,000 in those under 18 years and from 0.6 to 2.4 per 100,000 in adults [28, 29]. In this study, the incidence of orbital cellulitis was 2.45 per 100,000, constituting 0.2% of those presenting with eye complaints. Cases of preseptal cellulitis, dacryocystitis, and cellulitis due to other causes were also included in the true eye emergencies category due to the potential progression to orbital cellulitis. Overall, the incidence of eye and periocular cellulitis was 48.3 per 100,000, constituting 3.1% of total eye emergencies.
Orbital wall fractures also require a multidisciplinary approach and referral to the Eye Emergency Clinic. In a study conducted in Korea, the incidence was 46.9 per 100,000, and 26.8% of these patients underwent surgery [30]. In a study conducted in America, the incidence ranged from 7.7 to 11 per 100,000 [31]. A study with 500 patients found muscle entrapment or entrapment in 3 patients [32]. In our study, the incidence of orbital fractures was 35.5 per 100,000, constituting 2.3% of all ocular emergencies. The number of patients with muscle entrapment among all orbital fractures was 5.4%. Overall, the incidence of true eye emergencies in the study was generally in line with the literature.
Corneal foreign body is one of the most common reasons for seeking emergency care for the eye. It is often seen among industrial workers dealing with materials, construction workers, and motorcycle riders who do not wear protective eyewear. In some studies, it has been identified as the most frequent cause of emergency visits. In a study focusing on patients with ocular trauma presenting to the emergency department, corneal foreign body accounted for 58.2%, followed by corneal erosion at 24.9%, and blunt eye trauma at 12.6% [33]. In this study, similar to this research, the proportion of patients presenting with ocular trauma among all ophthalmic emergencies was 56.8%. Among patients with ocular trauma, corneal foreign body comprised 45.1%, corneal erosion followed at 29.1%, and blunt eye trauma accounted for 9.9%, ranking second and third, respectively. In this study, patients with corneal foreign body and corneal erosion were classified under the relative emergency group. Some patients present to the emergency department immediately, and some present a few days after the trauma, giving us an idea about the urgency of the situation. In another study, among patients presenting to the emergency department with eye complaints, the highest rate was 40.9% for ocular trauma, 29% for ocular infections, and approximately 45% for conditions they didn't consider as urgent [34]. In this study, ocular infections were identified in 18.4% of patients with ocular complaints, of which 12.2% were cases of conjunctivitis, aligning with findings from the same cohort.
The primary objective of this study was to assess the prevalence of urgent eye pathologies among patients visiting the general emergency department. Comparing our findings with existing literature, it's notable that our cohort's percentage of ocular infections is lower. This prompts an exploration into potential reasons behind this variation. It raises questions about healthcare-seeking behavior, access to services, and possibly differing diagnostic practices between regions or urban versus rural settings. For instance, could a higher utilization of general practitioners for minor conditions such as conjunctivitis contribute to this discrepancy?
In a study conducted in the UK, it was found that 37% of patients presenting with eye complaints did not require urgent care [35]. Similarly, another study reported that 50.4% of patients presenting to the emergency department with eye complaints did not have an urgent condition [36]. The findings contribute to this understanding, indicating that 27.3% of patients presenting with eye complaints in the emergency department did not have urgent conditions. Among these, the largest subset (10.2%) comprised patients reporting eye irritation and foreign body sensation, often attributed to dry eyes [37].
Analyzing the comparatively lower proportion of urgent cases in our cohort can offer valuable insights into service provision and potentially guide improvements. Understanding why the cohort's figures differ from those in the literature may unveil opportunities for optimizing pathways to care, enhancing service accessibility, and refining diagnostic protocols within the healthcare system.
The proportion of patients presenting to the emergency department for refractive errors was 1.1%. These groups consisted of individuals who were unable to find an appointment at any clinic for dry eye issues and eyeglass prescriptions. In our study, the proportion of patients presenting with no sequelae subconjunctival hemorrhage (SCH) was 4%. A similar study with a comparable patient count reported an incidence of SCH at 2.9% [38]. In our study, due to its predominantly benign course, SCH was included in the non-urgent eye conditions group. However, it should be carefully evaluated as sometimes it can be a precursor symptom of an underlying condition.
A study in the United States revealed that emergency physicians often felt uncomfortable examining patients with eye complaints [39]. There is a similar situation in Turkey. Another study showed that there was a high level of agreement when patients whose initial examination in the emergency department was performed by emergency medicine residents trained in ophthalmology triage were re-evaluated by ophthalmologists[40]. This indicates that both globally and in Turkey, when evaluating patients with eye complaints in the emergency department, doctors who will be the first point of contact with the patient should receive additional training in the field of ophthalmology in addition to their basic medical education.
Limitations
In this study, diseases were not categorized using any scoring system. Additionally, detailed distinctions between pediatric and adult conditions were not made. These can be considered limitations of our study.