Telephone triage: Recognize potential visual disturbance emergencies

Rebecca L. Johnson, CPOT, COT, COE

Triage is described as “a process in which things are ranked in terms of importance or priority.” Because improper triage is a source of potential malpractice claims, it is critical that any office staff member who answers the telephone is trained to recognize possible emergencies and schedule patients appropriately. 

Proper documentation of the telephone conversation with a patient is crucial because recollections of what was discussed weeks and months later can be unreliable and-without notations in the patient's record to back them up-open to dispute.

This article discusses triaging the complaint of “visual disturbance.” While triage guidelines are provided here, an ophthalmic staff member should always comply with the telephone triage policies and procedures of the practice in which she is employed.

Related: 3 patient scenarios show triage doesn't need to be difficult

“My vision is blurry”
While a complaint of blurred vision can suggest a multitude of conditions, the line of questioning for triage purposes can be standardized. The appointment priority will depend on one or all of four factors: symptom(s), onset, duration, and severity. 

Asking patients the following questions will determine these factors:

• Is the vision blurred in one or both eyes?
• Do you have double vision?
• Are you experiencing associated symptoms, such as “spots” in your vision, flashes of light, pain, or are straight lines appearing wavy?
• Can you see your fingers in front of your face?
• When did you first notice the problem?
• Did the vision decrease gradually or suddenly?
• What were you doing when you first noticed the problem?
• How has the problem progressed?

Based on a patient’s answers to this questioning, the priority of the blurred vision is placed into one of three categories:

• Emergency
• Urgent
• Routine

Related: Troubleshooting optical complaints

Emergency visual disturbance
True ophthalmic emergencies are situations in which there is a possibility of vision loss if the patient is not immediately treated. This patient must be worked in to the schedule immediately.

Central retinal artery occlusion (CRAO)
A CRAO occurs when an embolus blocks the central retinal artery, causing a decrease in the flow of blood to the retina. Without the oxygen supplied by the normal blood flow, vision rapidly deteriorates.

Any medical condition that causes stasis of blood flow-diabetes, hypertension, polycythemia (a condition marked by an abnormally large number of red blood cells), and glaucoma-can increase the risk of developing a CRAO.

The patient with a CRAO will experience painless, rapid vision loss in the affected eye. 

Related: A closer look at central retinal artery occlusionDecreased vision with pain
Any patient who complains of decreased vision with pain needs to be seen as soon as possible to evaluate the possibility of an acute angle-closure glaucoma attack.

Acute angle-closure glaucoma can cause a rapid decrease in vision.

Associated signs and symptoms of these patients can be redness around the cornea, pain, halos around lights, and nausea.

Permanent vision loss can occur if the patient is not treated soon and aggressively.

Related: Consider the whole patient when treating glaucomaRecent onset of flashes and/or floaters with one or more of the following should be treated as an ocular emergency: 

• Blurred vision
• Seeing “curtains, shadows or web-like” objects
• Recent eye surgery

The phenomena of flashes of light and floaters are most often harmless but can be a sign of retinal detachment. Because people with significant myopia have a higher risk factor for retinal detachment, a high myope (>-5.00 D) with complaints of flashes and floaters should be seen immediately. 

Any type of trauma to the eye, including surgery, may pre-dispose the patient to retinal disturbance, leading to detachment. A patient who describes “curtains, shadows or spider webs” in his vision may be experiencing a retinal detachment.

Related: Choose your words carefully with surgery patients

Urgent visual disturbance
A patient with an urgent case must be seen within 24 hours. Although it can be difficult to determine whether a case should be classified as emergent or urgent, it is always best to err on the side of safety and general welfare of the patient. 

In addition, if the patient is uncomfortable and/or extremely worried about his condition, promptly working him into the schedule provides for a good patient-doctor relationship.

Related: 10 steps to a phenomenal patient experience

Posterior vitreous detachment (PVD)
Recent onset of light flashes and floaters without symptoms of emergent category could indicate a degenerative change in the vitreous, allowing it fall away from the retina. This is called PVD. The symptoms of PVD are an increase in floaters and, on occasion, flashes of light.

Patients over 70 years of age are most likely to experience a PVD, although it can occur at a younger age. While PVD usually does not cause permanent damage to the eye, it is possible for the retina to tear as the vitreous pulls away from it. Therefore, the patient should have a dilated retinal evaluation.

Ophthalmic migraines
About 18 percent of women and 6 percent of men experience migraine headaches in the U.S. About 20 percent of migraine sufferers experience what are known as “focal neurological symptoms” (migraine aura).1

Migraine aura often causes visual disturbances, such as flashing lights, zigzagging lines, or partial loss of vision. Other symptoms may include numbness, tingling, speech difficulties, and muscle weakness on one side of the body.

A patient experiencing these symptoms, especially on the first occurrence, is usually upset and needs reassurance by the doctor.

Related: Relieve migraines with tinted contact lenses

Changes in Amsler grid
A patient with changes in the Amsler Grid or a complaint of “straight lines look wavy” may have developed macular edema, which can be caused by macular degeneration or diabetic retinopathy. 

Diplopia (double vision)
The sudden onset of diplopia can suggest a wide variety of conditions ranging from Graves’ disease (a condition caused by thyroid abnormality) to a dislocated intraocular implant. A patient who has blurred vision may describe the problem as “double vision.”

Asking appropriate questions to differentiate whether the vision is actually double or only blurry is important. If it is determined that the patient is experiencing double vision, an appointment should be made immediately.

Related: Simple tips help address diplopia

Routine visual disturbance
An eye condition that has been present for several weeks or more is normally considered routine. Even though these conditions are not vision threatening, the patient should be seen as soon as the schedule allows, usually within a few days or a week.

Floaters or “spots” in vision
The most commonly described type of floater is “a black spot that comes and goes.” Often these are small remnants of embryonic blood vessels, flecks of pigment floating freely in the aqueous fluid in the front of the eye, or strands in the more jelly-like vitreous in the back of the eye.

Complaints of occasional floaters without flashes of light or a noted decrease in the vision are common and usually insignificant.

However, the fact that the patient called to report the floaters is reason enough to make an appointment for an evaluation of the retina and vitreous. If the patient is very concerned about the floaters, it is not advisable to have him wait a long period of time for an appointment.

Related: Recognizing retinal detachment

Blurred vision after prolonged use of near vision
Blurred vision associated with prolonged use of near vision is normally a sign of a non-corrected refractive problem. This condition can be particularly disabling to a person whose job or hobbies require use of near vision for long periods of time.

An appointment should therefore be given to the patient as early as the schedule allows. 

Gradual onset of blurred vision at distance or near
While this problem usually is indicative of a non-corrected refractive error, it could be a sign of other conditions, such as fluctuating blood sugar in diabetes.

Take particular note of the complaint if the patient is diabetic. The earliest appointment on the schedule should be given to that patient.

Summary
Patients experiencing visual disturbances can often be anxious about their vision changes. These patients need to be treated professionally and with empathy. However, offering false reassurance concerning the condition is not acceptable.

Every telephone conversation between a staff member and a patient must be documented in detail immediately. Failing to document the details of the conversation could leave the doctor open to legal dispute. If there is ever any doubt about when the patient should be seen, the doctor should be consulted. 

Regardless of the experience or expertise of a staff member, the doctor is the only person qualified to give opinions concerning the cause of the patient’s symptoms.

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About the authorRebecca L. Johnson, CPOT, COT, COE, is the founder and president of Eyetrain4you and the executive director of business services for GPN.
rebecca.johnson@eyefinity.com

Disclosures:

1. Migraine Research Foundation. About migraine. Available at: https://migraineresearchfoundation.org/about-migraine/migraine-facts/. Accessed 5/30/19.