Emergency eye appointments: Q&A with Rami J. Aboumourad, OD

(Image credit: Adobe Stock/©Jeff Bergen_peopleimages.com)

At Bascom Palmer in Miami, Florida, doctors are fielding emergency eye care calls in a new and interesting way: Doctors have introduced a triage telehealth service. Rami J. Aboumourad, OD, sat down with Optometry Times to tell us more about how the service works.

As the demand for efficient and effective eye care solutions grows, Aboumourad provides a comprehensive overview of the triage process, from the initial patient experience to potential treatment pathways. He explains how patients can navigate this innovative system, distinguishing between urgent and emergent situations, and emphasizes the importance of timely medical advice. Additionally, Aboumourad shares practical tips for patients experiencing eye issues and discusses how this model could potentially influence eye care practices beyond Florida.

Q & A with Rami J. Aboumourad, OD

Emily Kaiser Maharjan, Assistant Managing Editor for Optometry Times:

Hi, everyone. I'm here with Dr. Rami J. Aboumourad of Bascom Palmer to discuss some eye care triage. Welcome, Dr. Aboumourad. Thanks for being here.

Rami J. Aboumourad, OD:

Thank you so much for having me.

Kaiser Maharjan:

First, can you give me a little bit of a primer on what eye care triage looks like? What does the process look like from beginning to end?

Aboumourad:

It's an entirely audio, video, synchronous experience that a patient who, for instance, wakes up with a subconscious archival hemorrhage or a stye, if they're aware of our system, would navigate to our website. They could self-schedule an appointment, as soon as sometimes that same hour or within the day. Appointments are available 48 hours in advance to all patients, and there's almost at least one appointment available within 48 hours. We've never not had one available. Patient self-schedules, they create a UChart account or a MyChart account through Epic, and then they are scheduled.

They'll be seen by a coordinator. Coordinators are essentially our optometric technicians who help patients get connected, make sure that they have access to their MyChart account. They go over the HPI, they go over medications, over all the preliminary questions you would want. Then, they're seen by whichever doctor is covering. The clinic is covered by a little over a dozen different optometrists and ophthalmologists. They see the doctor and they go over diagnosis, patient education. If any treatment is indicated, instructions are available to them in the patient portal that they have. Medications are prescribed electronically when indicated. That's start to finish, so a patient can wake up at 6 AM, get an appointment at 8 AM, and be done by 8:30 AM if they're so lucky.

Kaiser Maharjan:

Yeah, that’s really impressive. Within the system, how do you differentiate between urgency and emergency, and at what point should patients be using this portal experience versus heading straight to the emergency department?

Aboumourad:

The intent was for patients who don't know what they have because we can look at a patient or listen to that patient and know this is something that needs to be evaluated in person versus not, what the timeframe they should be seen. This is really for patients who need to identify. Maybe a patient has flashes and floaters, and we know that we can't do any diagnostic exam virtually, but the patient doesn't know and sometimes they'll put off their symptoms for a week or two and then they come in with a terror or detachment. These patients, even though we can't necessarily examine them, the point of the triage is for them to connect with us so we can tell them what they need and help facilitate the appointment. Sometimes, we can get them the same day appointment to be seen in our clinics, if it's something like that. Sometimes, insurance is the barrier; they need a 2-to-3-week prior authorization. When we encounter that, patients can be seen (on the) same day through our emergency room.

We urge all patients to come talk to us, regardless of what they think can or cannot be completed. (We) just want to find out does it need an urgent exam, to should it be through our emergency room or clinic, and can we get them an appointment in clinic? We have multiple offices across the South Florida region, so we are able to accommodate most patients if they need a same day thing. But the other thing is that we are throughout the state; we see all patients at other parts of the state as well, North Florida. There are other cities where we're not really accessible, so really we just need to connect with patients and let them know you have to see somebody today. It can be us if you can come. It can just be your neighborhood eye doctor. You just need to see somebody. Our goal is just to make sure that patients know what needs to be seen and how urgent they need to be seen by anybody.

Kaiser Maharjan:

Have you gotten any patient feedback on this, or have you gotten any kind of metrics on prevention of emergencies?

Aboumourad:

I don't have exact numbers to give you, but I can tell you we certainly do have a lot of retinal detachments, macular holes, uveitis patients that once we get them in clinic, we're able to make these diagnoses. We've had some patients who, with their symptoms of flashes and floaters, we can facilitate a same day clinic visit. They are diagnosed with a detachment, and they can go to surgery the next day. It's not uncommon for that to happen. The bulk of our patients are much less acute or benign, chronic things. A lot of sties, a lot of sub tangible hemorrhages, a lot of flares of dry eye and blepharitis. But you do get these more acute (patients) that we have the system in place to make sure we can facilitate them in person.

Kaiser Maharjan:

What are some effective phrases or questions or keywords patients can use while describing their situation when on this triage call with you guys?

Aboumourad:

There are certain things we always ask every patient that we need to make sure we touch on. Those are the common symptoms of is there any pain? Does the patient have any light sensitivity? In regard to the redness, is it all over the eye or part of the eye? We always want to know if there's any symptoms of flashing lights, if they're seeing new floaters; those are a couple red flags.

If we hear patients with any of those things, we really need to figure out how urgent might this be, and that would depend on how they describe their symptoms, what their medical tree is, what their eye history is, and a combination of that would dictate how soon they would be referred in person for evaluation. We try and triage patients based on their whole system, what is going on in their body as well as their eyes. We really try and ease out those sorts of questions. The typical dry eye patients have this fluctuating vision when they blink (that) gets better with the tears. They don't have really a lot of pain, but if they do, they usually have been seen by us before and diagnosed with severe dry eyes. If they're new to us, we still try and get them in to rule out other stuff.

Kaiser Maharjan:

For patients who are facing some sort of eye emergency, do you have any first aid tips, things they should and shouldn’t do while waiting for their appointment?

Aboumourad:

Usually, there aren't a lot of things that I would tell them not to do. In the cases of trauma, I think, depending on the nature of the trauma, there may be some things you don't want to do if we're worried about a severe trauma to the eye. We usually try and get those patients in, and based on their history, would determine if we're going to tell them something not to do. I would say a patient should be using preserved artificial tears anytime they think something's wrong. It will never hurt, and it can only help and sometimes resolve some concerns. It never hurts to do a couple warm compresses or eyelid scrubs too. That often resolves more than people would have imagined.

Kaiser Maharjan:

How can this process be extrapolated to other eye care systems, or does Bascom Palmer have plans to expand this program to take this further than Florida?

Aboumourad:

At this time, we haven't identified a plan to expand outside of Florida yet. I think this system may exist in other parts of the world, but I don't think it's in practice elsewhere in the US. I think we're fortunate that we have our optometric emergency department, which really gives us the ability to make sure that any patient that does need to be seen has a way to be seen. Now, any patient can drive over to CS and we're open 24/7, 365. I think that gives us a unique ability to make sure that no one falls through a crack, whereas when you're dealing with clinics, you have to deal with insurances approving appointments, you can sometimes get held on prior authorization for too long for some patients, and I think that's a real barrier.

I think it can be extrapolated if patients are maybe directed toward somewhere that can be consulted with an eye doctor. If you're in a place where you know that if you send a patient to this emergency room or this urgent care that there's someone who's trained in eye care that would be consulted, it can be extrapolated in those settings too. I think the biggest limitation quite honestly is finances in general. Some people don't have any insurance, and that's also a barrier. Fortunately, in the emergency room setting, finances are wiped off the table. You see all patients regardless of ability to pay, so I think that really levels the playing field.

Kaiser Maharjan:

What are some red flags that patients should be looking for in their vision when they should definitely be calling to use this system?

Aboumourad:

Sometimes, it can be subtle, and I would recommend the first thing is cover one eye and cover the other eye. A lot of times, patients don't really realize which eye is involved. Is it one eye? Is it both eyes? The next thing to identify would be is this something that's involving their central vision, or is this maybe involving just a peripheral vision, just the upper half, maybe just the sides of both eyes, or the same side of both eyes? That's a really important distinction. Something that a patient can do at home is maybe Google an Amsler grade and print it out and do an at- home Amsler grade if they don't have one already. That can look for metamorphopsia and scotomas. A quick and sturdy at-home thing that I'll tell patients do sometimes is to one eye at a time maybe look at a doorframe, something you know to be perfectly straight, and look for any kinks or bins in there. Sometimes, you can pick up on subtle things; that maybe it's hard for them to understand instructions for an amso grid, but with a quick glance at a door frame, they can see that that is kind of bent. That’s a really helpful thing that patients can do.

Another thing to look at would be does the quality change. Is it getting better and worse throughout the day, or is it static? If they're seeing a bunch of floaters or spots in their vision, do the spots move? Or are they mobile? Are they just fixed in their central vision? But that's a really good start for trying to identify eye central, peripheral, mobile, or immobile in the visual field, and correlating that with other symptoms when moving their eyes to elicit this, or is there any pain in any directions? Sometimes, it might just be one eye, super foggy vision, and just hurts when they move their eyes, and that can lean you in certain directions.

Kaiser Maharjan:

Is there anything else that you want to mention that I haven’t touched on?

Aboumourad:

Well, we try and be available, so I would say availability is a key for us. We're trying to be available six days a week, Monday through Saturday. I think the most interesting thing I've noticed is our volume seems to be higher in the mornings. I think people wake up with these problems, they try and get in as soon as possible. Oftentimes, it is not as filled up in some afternoons, but mornings they fill up pretty quickly.

I would say the most important thing is if you're not sure what's going on with your eyes, or your health in general, to connect with somebody. It may be nothing, but then you can be reassured just from a simple conversation. Sometimes, you can talk to somebody and you can just tell that what they're worried about is not something of medical sickness and you can reassure them. Maybe they just have an eyelid twitch, super easy to reassure a patient with just an eyelid twitch, but they may have something much more ominous or obscure, and I would always recommend just connecting with somebody, talk to somebody if it's serious. If it's not serious, it's an easy thing to reassure. When there's something potentially concerning, all you have to do is find somebody, doesn't matter who you see. Connect with somebody when you're unsure and see somebody, if you need to.

Kaiser Maharjan:

Thank you so much for taking the time to chat with me today about eye trauma and triage and what Bascom Palmer has in place to help with that. It’s been a really thoughtful and educational conversation, and I really appreciate your insights.

Aboumourad:

Thank you so much for having me.