Ocular Urgencies and Emergencies

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Ocular Urgencies and Emergencies
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To determine an optometrists legal obligations
for urgencies and emergencies, 4 questions must
be addressed1what are ocular urgencies and
emergencies?2what is an optometrists legal
responsibility to examine a patient seeking
urgent or emergency care?3what is the standard
of care that will be applied to an optometrist
who renders urgent or emergency care?4what is
an optometrists legal responsibility for the
timely scheduling of patients who require urgent
or emergency care?
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There are 2 true ocular emergencies (conditions
that require treatment within minutes to preserve
vision)1chemical burns of the
cornea2central retinal artery occlusionOther
conditions must be considered ocular urgencies
(requiring treatment within one to several hours
to preserve vision).
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The treatment for chemical burns is immediate and
copious lavage.Acid burns cause damage within
the first few hours, whilealkali burns may
continue for hours if the substance (lye,lime,
ammonia) remains in contact with the eye.
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Treatment requires

• Irrigation of the eye with watercopiously
• Removal of all particulate matter in contact with
  the eye (anesthetic needed)
• Use of pH paper to ascertain if eye pH is back to
  normal
• Antibiotic, steroid, cycloplegic treatment based
  on the severity of injury
• Referral of severe cases
• to a specialist

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The treatment of central retinal artery occlusion
is intermittent massage of the eye (moderate
pressure applied to the eye for 5 seconds,
released,then repeated),until IOP is lowered,
the central retinalartery dilates, and the
embolus moves further along arterial
circulation.
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Paracentesis of the anterior chamber (inserting a
needle and withdrawing aqueous) may also be
attempted tolower IOP and movethe embolus.
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Situation
ConditionTrue EmergenciesTherapy should be
instituted Chemical burns of the
corneawithin minutes
Central retinal artery occlusion
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Semi-urgent Situations

Optic neuritisTherapy should be
instituted within days Ocular
tumorswhenever possible, or sometimes within
weeks
Exophthalmos, acute

Previously undiagnosed chronic
open-angle

glaucoma Old
retinal detachment

Strabismic or other remediable amblyopias in
young children Blow-out
fracture of the orbit
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Urgencies that have created liability issues for
optometrists include

• Penetrating eye injury

Referral without delay is required
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Corneal foreign body
Removal and antibiotic therapy is necessary
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Acute angle closure glaucoma and pupillary block
glaucoma
Mechanical or medical means must be timely used
to lower IOP
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Corneal abrasion
Treatment must be prompt to prevent infection
Broad spectrum antibiotics must be prescribed
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Corneal ulcer
Central ulcers should be referred
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Acute retinal tear
Usually caused by PVD Timely referral is required
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Endophthalmitis
Most often found post-op cataract surgery
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Can an optometrist refuse to examine a
patient?An optometrist in private practice may
refuse to examine a patient, even a patient
requiring emergency care.However, the legal
right to refuse treatment is at conflict with the
ethical obligation of an optometrist to render
emergency care.
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The AOAs Standards of Conduct saysA request
for optometric care in all emergency should
receive immediate response. Once having
undertaken an emergency case, an optometrist
shall neither abandon nor neglect the
patient.But an optometrist who provides
emergency care is acting legally as a
volunteer.
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A volunteer is defined legally asone who
assists a person who is unable to aid, protect,
or care for himself.Such a person must
exercise reasonable care while providing aid and
will be held liable for any negligence that
causes injury.
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Fear of negligence lawsuits when helping accident
or disaster victims led to passage of state Good
Samaritan statutes.The purpose of these laws
is to provide immunity from suit for physicians
(and others named in the statute), even if they
were negligent.The Alabama law is typical.
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When any doctor of medicine or dentistry, nurse,
member of any organized rescue squad, member of
any police or fire department, member of any
organized volunteer fire department,
Alabama-licensed emergency medical technician,
intern or resident practicing in an Alabama
hospital with training programs approved by the
American Medical Association, Alabama state
trooper, medical aidman functioning as a part of
the military assistance to safety and traffic
program, chiropractor, or public education
employee gratuitously and in good faith, renders
first aid or emergency care at the scene of an
accident, casualty, or disaster to a person
injured therein, he or she shall not be liable
for any civil damages as a result of his or her
acts or omissions in rendering first aid or
emergency care, nor shall he or she be liable for
any civil damages as a result of any act or
failure to act to provide or arrange for further
medical treatment or care for the injured person.
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Emergency treatment of heart attack victims is
usually included in the law A person or
entity, who in good faith and without
compensation renders emergency care or treatment
to a person suffering or appearing to suffer from
cardiac arrest, which may include the use of an
automated external defibrillator, shall be immune
from civil liability for any personal injury as a
result of care or treatment or as a result of any
act or failure to act in providing or arranging
further medical treatment where the person acts
as an ordinary prudent person would have acted
under the same or similar circumstances, except
damages that may result for the gross negligence
of the person rendering emergency care. This
immunity shall extend to the licensed physician
or medical authority who is involved in automated
external defibrillator site placement, the person
who provides training in CPR and the use of the
automated external defibrillator, and the person
or entity responsible for the site where the
automated external defibrillator is located. This
subsection specifically excludes from the
provision of immunity any designers,
manufacturers, or sellers of automated external
defibrillators for any claims that may be brought
against such entities based upon current Alabama
law.
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It should be noted that Good Samaritan laws do
not provide protection for optometrists in some
states, only apply to aid rendered at scenes of
an accident or disaster, and thus do not apply to
efforts by optometrists to provide first aid or
treatment in an office setting.So if an
optometrist does provide emergency or urgent
care, what is the legal standard to which he or
she will be held?
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As a volunteer an optometrist who examines a
patient with an urgency or emergency must act
reasonably and conform to the standard of care
expected under the circumstances, which is
medical.A medical standard of care applies to
the examination and treatment of patients with
ocular urgencies or emergencies.Thus
optometrists must act as ophthalmologists do in
rendering care.
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Under vicarious liability law optometrists are
liable for the acts or omission of employees that
occur in the line and scope of the employees
duties and cause injury. Therefore, an
optometrist may be held legally responsible for
the failure of a receptionist to schedule a
patient for a timely appointment.
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Employees who schedule patient appointments must
be able to triage complaints and identify
patients with emergencies or urgencies for
examination on a same-day basis (or make a timely
referral).Is documentation of calls for care
also an important legal responsibility?
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Assistants scheduling urgent or emergency
patients must either make a same day appointment
or promptly refer the caller to another provider
or clinic for care. Documentation of calls (in
writing) should be retained even if the call is
the only contact with the patient. A triage
form is a good way to keep a record of patient
appointments or referrals.
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The form prompts the assistant to ask 3
questions1are symptoms acute or
chronic?2are symptoms severe or mild?3are
symptoms progressive or stable?Based on the
callers responses, triage can be determined
and the caller can be scheduled appropriately or
referred. The form can also be reviewed by the
doctor prior to examination of the patient.
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