Ophthalmologic Consultation Research Articles

COVID-19 y ansiedad en oftalmólogos

Objective: To determine the prevalence of anxiety in ophthalmologists during the COVID-19 (coronavirus disease 2019) pandemic, exposed to severe acute respiratory syndrome by coronavirus type 2 (SARS-CoV-2) working in respiratory triage and outpatient ophthalmology consultation at the Hospital Central Militar in Mexico City. Material and methods: Observational, cross-sectional, descriptive and prospective study, in which a descriptive survey was applied via internet evaluating two anxiety scales (Hamilton scale and generalized anxiety disorder [GAD-7) scale). Results: Thirty-one subjects responded, 17 (54.84%) female and 14 (45.16%) male. Minimum age was 25 years and maximum age was 49 years, with an average age of 34.5 years.The survey consisted of 24 questions, of which 21 were obtained from both anxiety scales (Hamilton + GAD-7) and the remaining three were of epidemiological interest. By rating both scales separately, we observed an average score of 5.16 for the GAD-7 scale and of 8.45 for the Hamilton scale, reflecting a minimal group anxiety. Using the GAD-7 scale, we observed an anxiety prevalence of 48% (15 physicians). Of the diagnosed cases, 9 (60%) met a score listed as mild anxiety, 5 (53%) as moderate and 1 (7%) as severe. On the Hamilton scale, the prevalence was of 83% (26 physicians). Of the diagnosed cases, 23 (88%) had minimal anxiety, 2 (8%) had minimal-moderate anxiety and 1 (4%) had severe anxiety. Conclusion: The prevalence of anxiety in ophthalmologists, using the GAD-7 and Hamilton scales was of 48% and 83%, respectively, and most cases were of mild intensity.

Prevalence of Ocular Complications in Patients with Zygomatic Bone Fractures in an Iranian Population.

Objectives:Damages to the middle third of the facial bone generally involve the orbital skeleton and can lead to eye impairment. In this study, it is attempted to determine the incidence of ophthalmic injuries in maxillofacial trauma with zygomatic bone fractures.Materials and Methods:One hundred and fifteen cases with ophthalmic (ocular) involvement after maxillofacial trauma were referred to the Shariati Hospital, Tehran, Iran, and were visited at the Ophthalmology Department between 2016 and 2018. Zygomatic fractures and resulting ocular complications were evaluated in 87 males and 28 females with the mean ages of 26 and 32 years, respectively.Results:Subconjunctival ecchymosis was detected in 23.07% of men and 21.05% of women. Displacement of the palpebral fissure was detected in 26.5% of men and 27.6% of women. Furthermore, the unequal pupillary level was observed in 18.37% of men and 15.78% of women. Diplopia was detected in 8.9% of men and 10.5% of women. Additionally, enophthalmos was observed in 23.1% of men and 25% of women.Conclusion:The most common ocular presentations in midfacial trauma are diplopia and reduced visual acuity. Even after the operation, a significant number of patients experience poor vision and diplopia. Ophthalmology consultation is essential for these patients.

Review of Ocular Injuries in Patients with Orbital Wall Fractures: A 5-Year Retrospective Analysis.

PurposeThe purpose of this study was to determine the incidence of minor and major ocular injuries in patients with orbital wall fractures at Loma Linda University Health, a level-one trauma center, to help determine the most appropriate setting for the initial dilated fundus examination by ophthalmologists.MethodsA retrospective study was performed from January 2008 to January 2013 of patients diagnosed with orbital wall fracture secondary to trauma. Exclusion criteria included unknown mechanism of injury, the absence of ophthalmology consultation, or absence of imaging. Data collected included age, gender, mechanism of injury, visual acuity, and anterior/posterior segment findings. Ocular injuries were categorized as either minor or major.ResultsOf 567 charts reviewed, 460 met criteria and were included for analysis. In the analysis, 86.5% of patients were male, and 81.3% were Caucasian. The most common mechanism of orbital fracture was blunt injury. Visual acuity was better than 20/100 in 82.4% of patients. On chart review, 81.1% of patients were found to have either a minor injury, a major injury, or both. The most common injury was subconjunctival hemorrhage (53.5%). Globe rupture (2.9%) and vision-threatening posterior segment findings such as retinal tear and choroidal rupture (1.3%) were relatively rare. Only one retinal detachment (0.2%) was found, specifically in the setting of severe injury with concomitant globe rupture.ConclusionKnowledge of the common ocular injuries associated with orbital fractures will help emergency department (ED) physicians and ophthalmologists provide the dilated fundus exam in the most appropriate setting. The most frequent injuries identified were non-vision threatening, and visually significant posterior segment findings were relatively rare (1.3%). Thus, for the majority of patients presenting to the ED with orbital fracture, a dilated fundus exam can be performed at a later date in the outpatient clinic setting, unless urgent orbital fracture surgery is planned.

Text Processing for Detection of Fungal Ocular Involvement in Critical Care Patients: Cross-Sectional Study.

BackgroundFungal ocular involvement can develop in patients with fungal bloodstream infections and can be vision-threatening. Ocular involvement has become less common in the current era of improved antifungal therapies. Retrospectively determining the prevalence of fungal ocular involvement is important for informing clinical guidelines, such as the need for routine ophthalmologic consultations. However, manual retrospective record review to detect cases is time-consuming.ObjectiveThis study aimed to determine the prevalence of fungal ocular involvement in a critical care database using both structured and unstructured electronic health record (EHR) data.MethodsWe queried microbiology data from 46,467 critical care patients over 12 years (2000-2012) from the Medical Information Mart for Intensive Care III (MIMIC-III) to identify 265 patients with culture-proven fungemia. For each fungemic patient, demographic data, fungal species present in blood culture, and risk factors for fungemia (eg, presence of indwelling catheters, recent major surgery, diabetes, immunosuppressed status) were ascertained. All structured diagnosis codes and free-text narrative notes associated with each patient’s hospitalization were also extracted. Screening for fungal endophthalmitis was performed using two approaches: (1) by querying a wide array of eye- and vision-related diagnosis codes, and (2) by utilizing a custom regular expression pipeline to identify and collate relevant text matches pertaining to fungal ocular involvement. Both approaches were validated using manual record review. The main outcome measure was the documentation of any fungal ocular involvement.ResultsIn total, 265 patients had culture-proven fungemia, with Candida albicans (n=114, 43%) and Candida glabrata (n=74, 28%) being the most common fungal species in blood culture. The in-hospital mortality rate was 121 (46%). In total, 7 patients were identified as having eye- or vision-related diagnosis codes, none of whom had fungal endophthalmitis based on record review. There were 26,830 free-text narrative notes associated with these 265 patients. A regular expression pipeline based on relevant terms yielded possible matches in 683 notes from 108 patients. Subsequent manual record review again demonstrated that no patients had fungal ocular involvement. Therefore, the prevalence of fungal ocular involvement in this cohort was 0%.ConclusionsMIMIC-III contained no cases of ocular involvement among fungemic patients, consistent with prior studies reporting low rates of ocular involvement in fungemia. This study demonstrates an application of natural language processing to expedite the review of narrative notes. This approach is highly relevant for ophthalmology, where diagnoses are often based on physical examination findings that are documented within clinical notes.

Dupilumab-Associated Ocular Surface Disease: Clinical Characteristics, Treatment, and Follow-Up.

A consecutive case series of patients with dupilumab-associated ocular surface disease (DAOSD) that describes common ocular symptoms and signs, proposes a symptom disease severity grading system, and describes treatment strategies of DAOSD patients was evaluated. A retrospective chart review of patients with concomitant dupilumab-treated atopic dermatitis and DAOSD with ophthalmic evaluation between January 2014 and May 2019 was conducted. Twenty-nine patients (mean age 46 years, M/F: 12/17) with 57 ophthalmic exams were identified. The most common ocular symptoms included irritation/pain (n = 28, 97%), redness (n = 24, 83%), pruritus (n = 18, 62%), discharge (n = 18, 62%), and light sensitivity (n = 6, 21%). The most frequent signs included conjunctival injection (n = 18, 62%), superficial punctate keratitis (n = 16, 55%), and papillary reaction (n = 8, 28%). Topical corticosteroids (TCS) (n = 23, 79%), tacrolimus (n = 6, 21%), and artificial tears (n = 7, 24%) were the most commonly used therapies. Of those with follow-up documentation (n = 21), 20 were noted to have partial or complete response with TCS based on symptoms and reduction of signs. Using our proposed symptom-based grading scale, scaled 1 to 5 based on the presence of common symptoms listed above, 66% (n = 19) requiring topical immunomodulating therapy were found in the 'severe' group (≥3 symptoms) and 17% (n = 5) were found in the 'mild' group (≤2 symptoms). This study provides insight into the commonly presenting ocular signs and symptoms associated with DAOSD and highlights the efficacy of TCS and other immunomodulators in improving symptoms associated with DAOSD. Based on our findings, we propose a symptom-based grading system that can guide nonophthalmic physicians regarding ophthalmology consult.

Catching the red eye: A retrospective review of factors associated with retinal hemorrhage in child physical abuse

Background/PurposeAccurate identification of child physical abuse is crucial during the evaluation of injured children. Retinal hemorrhages (RH) are used for diagnosis, but clear criteria for screening with direct fundoscopic exam are lacking. We sought to identify key factors associated with RH to guide evaluations. MethodsElectronic medical records for patients <1 year of age presenting to a Level I Pediatric Trauma Center with unwitnessed head injury from January 2015 to December 2018 were retrospectively reviewed. Multivariable logistic regression was used to identify factors associated with RH. ResultsTwo hundred and seventy-six patients were included; 63% underwent direct fundoscopic examination, of which 23% were positive and 77% were negative for RH. Unscreened patients tended to be older and have isolated skull fractures. Multivariable regression analysis revealed that abnormal GCS and subdural hemorrhage were positively associated with a diagnosis of retinal hemorrhage, while isolated skull fracture was negatively associated. ConclusionsChildren under 1 year of age with subdural hemorrhage have a greater risk of associated RH and should undergo routine screening with direct fundoscopic examination. Conversely, those with isolated skull fractures may not require an ophthalmology consultation. Standardized screening protocols may help reduce the risk of missing child physical abuse. Level of EvidenceIII (Diagnostic Test).

Developing a pediatric ophthalmology telemedicine program in the COVID-19 crisis

PurposeTo describe our methodology for implementing synchronous telemedicine during the 2019 novel coronavirus (COVID-19) pandemic.MethodsA retrospective review of outpatient records at a single children's hospital from March 21 to April 10, 2020, was carried out to determine the outcome of already-scheduled face-to-face outpatient appointments. The week leading up to the March 21, all appointments in the study period were categorized as follows: (1) requiring an in-person visit, (2) face-to-face visit that could be postponed, and (3) consultation required but could be virtual. Teams of administrators, schedulers, and ophthalmic technicians used defined scripts and standardized emails to communicate results of categorization to patients. Flowcharts were devised to schedule and implement telemedicine visits. Informational videos were made accessible on social media to prepare patients for the telemedicine experience. Simultaneously our children's hospital launched a pediatric on-demand e-consult service, the data analytics of which could be used to determine how many visits were eye related.ResultsA total of 237 virtual ophthalmology consult visits were offered during the study period: 212 were scheduled, and 206 were completed, of which 43 were with new patients and 163 with returning patients. Following the initial virtual visit, another was required on average in 4 weeks by 21 patients; in-person follow-up was required for 170 patients on average 4.6 months after the initial virtual visit. None needed review within 72 hours. The pediatric on-demand service completed 290 visits, of which 25 had eye complaints.ConclusionsWith proper materials, technology, and staffing, a telemedicine strategy based on three patient categories can be rapidly implemented to provide continued patient care during pandemic conditions. In our study cohort, the scheduled clinic e-visits had a low no-show rate (3%), and 8% of the on-demand virtual access for pediatric care was eye related.

An Unusual Presentation of Retinal Detachment and Conjunctivitis: A Case Report.

IntroductionVision loss is an ophthalmologic emergency with broad differential requiring prompt medical attention.Case ReportWe describe a 55-year-old male presenting to the emergency department (ED) with unilateral, painless visual field deficit with ipsilateral conjunctivitis induced by a presumed foreign body. The patient described a foreign body sensation nine days prior to developing visual changes. In the ED, the patient was diagnosed with a retinal detachment using point-of-care ultrasonography, and emergent ophthalmologic consultation was obtained.ConclusionConcurrent retinal detachment and conjunctivitis in a patient is extremely rare. Healthcare providers should be aware that foreign body-induced conjunctivitis could lead to retinal detachment.

Man with facial rash.

A 43-year-old male presented to the emergency department (ED) with a rash to his right cheek 4 days after hyaluronic acid filler injections by a non-credentialed beautician. Examination was notable for serpiginous, violaceous erythema with overlying yellow crusting to the right mid-face and involvement of the nasal tip. Patient did not have vision complaints at this time. Accidental facial arterial cannulation with dermal filler injections can cause occlusion and embolization. Risks of embolization may depend on practitioner experience, injection pressure, rate of filler injection, and location of injection.1 On ED presentation, emergent dermatology and/or plastic surgery consult is required. There are serious adverse effects including tissue necrosis, blindness, or neurologic deficits.2, 3 Of all blood vessels affected, the ophthalmic artery was significantly associated with irreversible blindness. There are 2 common fillers used, autologous fat injections and hyaluronic acid. Autologous fat injection is more associated with vascular complications than is hyaluronic acid and has been reported to have more severe outcomes with higher rates of permanent blindness. Ophthalmology consult is required if the patient endorses vision changes or there are signs of skin involvement in the V1 distribution. Neurology consult is required if the patient endorses neurologic complaints. Treatment involves direct injection of hyaluronidase within and around the affected vessel, with multiple injections diffusely across the affected skin. Additional treatments include nitroglycerin paste and oral aspirin.4 Oral antibiotics should be considered if fat necrosis is present. Once blindness occurs, rates of full recovery are low so initial precautions during filler placement, including slow injection rates with low pressure, are crucial. The patient received hyaluronidase injections and nitroglycerin paste and started on oral aspirin and antibiotics. After a 3-month follow-up in plastic surgery clinic, the patient reported full recovery of the rash with no other sequelae.

Periocular Facial Scald Burns in Children: Is Ophthalmology Consultation Necessary?

Criteria that predict the need for ocular injury treatment in children who suffer periocular facial scald burns are not known. The purpose of this study was to evaluate the incidence and management of ocular injuries among children sustaining facial scald burns and to determine predictors of injuries requiring additional treatment. Children treated at a burn center with periocular facial scald burns were analyzed. Patient and injury profiles were compared between those evaluated and not evaluated by an ophthalmologist. Factors associated with an ocular injury requiring treatment were determined, and treatment differences before and after ophthalmology consultation were evaluated. Seventy-three children with facial scald burns were identified, none with a full-thickness injury. Thirteen children had ocular findings on examination including corneal abrasion, conjunctivitis, scleral burn, and chemosis of the conjunctiva. Twenty-three patients received erythromycin ointment, only 8 of whom had a documented ocular injury. Children seen by an ophthalmologist (n = 24) more often had a positive finding on examination (37.5% vs 8.2%, P = 0.007) and received treatment (66.7% vs 14.3%, P < 0.001). Only 4 patients had modification in their treatment plan after consultation, 3 of whom were started on treatment despite not having a positive finding on examination. Ocular injury after periocular facial scald burns is an infrequent finding. Among children with partial-thickness periocular facial scald burns, initial evaluation and treatment without ophthalmology consultation are appropriate. Ophthalmic antibiotic ointment is an appropriate initial treatment in most symptomatic patients, with ophthalmologic consultation being limited to children without symptomatic improvement.

Predictors of traumatic eye injuries at high-risk for ophthalmic complications in children.

Eye injuries are important cause of ocular morbidity in children. There is lack of data regarding predictors for high-risk injuries that will result in ophthalmic complications. Most cases are managed by the emergency department (ED) physicians without immediate ophthalmologist evaluation. Our aim was to identify predictors for ophthalmological complications and to imply indications for early ophthalmologic consultation in the ED. A retrospective chart review of 834 patients ages 0-18years who presented to the emergency department at Tel Aviv Medical Center between 2015 and 2018 following traumatic eye injuries was performed. All cases which later needed ophthalmological care were considered as high-risk for ophthalmic complications. An increased rate of eye injury was revealed over the years, but high-risk injury rate was stable. High-velocity mechanism, sport injury, orbital, anterior chamber, and retinal involvement were all significantly more common in the high-risk group compared to the low risk group. Only 10 patients, which represent 1.2% of all the patients, had decreased visual acuity on the last follow up, with significantly more injuries of high-velocity mechanism and anterior chamber involvement, in comparison to patients with normal visual acuity on the last follow up.Conclusion: High-velocity mechanism by itself, even with normal visual acuity and eye examination by the ED physician, should prompt to consider an urgent ophthalmologist consult. What is Known: •Traumatic eye injuries are an important cause of ocular morbidity in children. • Most injuries can be handled by a trained ED physician, but there are indications for an urgent ophthalmologist consultation. • It is crucial to discriminate between low and high-risk ocular injuries. What is New: • High-velocity mechanisms stand out as the most likely risk factor for final impaired visual acuity. • Normal visual acuity on presentation is not reassuring. • We recommend urgent ophthalmologist consultation in cases of high-velocity injury, even if visual acuity is preserved at presentation.

Utility of Neonatal Ophthalmologic Examination for Detection of Infectious Etiologies for Symmetric Intrauterine Growth Restriction

To determine the utility of ophthalmologic examination as part of evaluation for infection in infants with intrauterine growth restriction (IUGR). This is a single-institution retrospective chart review of neonates diagnosed with symmetric IUGR or small for gestational age (SGA) who underwent complete ophthalmologic consultation to assess for intraocular findings suggestive of congenital infection. Data collected included other factors that may cause IUGR, findings of general and ophthalmologic examinations, and results of investigation for intrauterine infection. Cost minimization analysis was also performed. One hundred neonates met the study's inclusion criteria (IUGR, n=24; SGA, n=45; IUGR and SGA, n=31). The mean gestational age at birth was 34.6±3.0weeks, and the mean birth weight was 1691±530g; 74% had an identifiable risk factor for IUGR and 84 patients underwent investigation for intrauterine infection. Two of the 73 patients who had urine culture for cytomegalovirus (CMV) were positive (1 of whom had systemic signs of severe congenital infection without eye involvement, the other who had no clinical signs of congenital CMV); evaluations for infection were negative otherwise. No patients had any ophthalmologic signs of congenital infection. Current literature suggests that routine evaluation of neonates with isolated IUGR for congenital infection may be low-yield and not cost-effective. Our study found that routine ophthalmologic evaluation in newborns with symmetric IUGR who have no systemic signs of intrauterine infection is of little value.

Current Models for Inpatient and Emergency Room Ophthalmology Consultation in U.S. Residency Programs

Abstract Objective This article examines models of patient care and supervision for hospital-based ophthalmology consultation in teaching institutions. Design This is a cross-sectional survey. Methods An anonymous survey was distributed to residency program directors at 119 Accreditation Council for Graduated Medical Education accredited U.S. ophthalmology programs in the spring of 2018. Survey questions covered consult volume, rotational schedules of staffing providers, methods of supervision (direct vs. indirect), and utilization of consult-dedicated didactics and resident competency assessments. Results Of the 119 program directors, 48 (41%) completed the survey. Programs most frequently reported receiving 4 to 6 consults per day from the emergency department (27, 55.1%) and 4 to 6 consults per day from inpatient services (26, 53.1%). Forty-seven percent of programs reported that postgraduate year one (PGY-1) or PGY-2 residents on a dedicated consult rotation initially evaluate patients. Supervising faculty backgrounds included neuro-ophthalmology, cornea, comprehensive, or a designated chief of service. Staffing responsibility is typically shared by multiple faculty on a daily or weekly rotation. Direct supervision was provided for fewer of emergency room consults (1–30%) than for inpatient consults (71–99%). The majority of programs reported no dedicated didactics for consultation activities (27, 55.1%) or formal assessment for proficiency (33, 67.4%) prior to the initiation of call-related activities without direct supervision. Billing submission for consults was inconsistent and many consults may go financially uncompensated (18, 36.7%). Conclusion The majority of hospital-based ophthalmic consultation at academic centers is provided by a rotating pool of physicians supervising a lower level resident. Few programs validate increased levels of graduated independence using specific assessments.

Eyelid Disorders in Ophthalmology Practice: Results from a Large International Epidemiological Study in Eleven Countries.

PurposeAnecdotal evidence suggests that eyelid disorders are common, although estimates of prevalence vary. The current study determines the prevalence of eyelid disorders, meibomian gland dysfunction (MGD) and related diseases (specifically ocular surface disease) in a population of patients presenting for routine ophthalmologic consultations.MethodsThis cross-sectional epidemiologic survey evaluated patients presenting for routine ophthalmic visits. During the consultation an ophthalmologist completed a questionnaire, and each patient underwent an ophthalmic examination and completed a quality of life questionnaire.ResultsThree hundred forty-nine ophthalmologists, recruited from 11 countries, provided data on 6525 patients. Patients were predominantly females (61.6%). The mean age of the study population was 57.0 ± 17.6 years. Eyelid disorders were diagnosed in 5109 (78.3%) patients and were statistically associated with: atopic dermatitis, seborrheic dermatitis, dry eye, age-related macular degeneration, diabetes, cataract, allergy and MGD (P < 0.05, all associations). Eyelid abnormalities were identified in 59.6% of patients; conjunctival or corneal abnormalities were observed in 64.9% and 28.1% of patients, respectively. MGD was diagnosed in 54.3% patients and was statistically significantly associated with the presence of eyelid disorders and eyelid margin abnormalities (P < 0.001, both comparisons). Dry eye was diagnosed in 61.8% of patients. Concurrent dry eye and MGD were present in 67.6% of patients. Most patients reported some degree of impaired vision and daily/work activities related to dry eye. Impact on contact lens usage, emotions and quality of sleep was also reported. The effects on daily life were associated with the presence of MGD.ConclusionIn conclusion, eyelid disorders were highly prevalent in this ‘real-world’ population of patients from ophthalmology clinics. Routine ophthalmologic consultations provide an opportunity to improve patient quality of life and to modify topical therapy in patients who may be predisposed to eyelid disorders.

Eye Injury- Baseball

HISTORY: A 12 year-old male sustained an injury to left eye during a baseball game. While playing first base, the outfielder threw a ball to him so patient could tag the runner out. When catching the ball, he missed, and instead the ball struck him in the face in the area of the left eye. There was no loss of consciousness, vomiting, hematoma or altered mental status. He initially had difficulty seeing out of the eye, but vision returned soon after and appeared blurry. PHYSICAL EXAMINATION: Normocephalic. With the exception of limitation in upward gaze of left eye, the remaining extraocular movements were intact. Hyphema of left eye noted. Pupils equal, round and reactive to light bilaterally. Moderate left periorbital edema and ecchymosis. Vision intact to left eye. Sensation intact in V1-V3 distribution, facial nerve function intact bilaterally. Normal occlusion, midface stable. Hearing to spoken voice intact and TM’s clear with no evidence of hemotympanum. Remainder of examination was normal. DIFFERENTIAL DIAGNOSIS: 1. Orbital Ridge Fracture 2. Orbital Blowout Fracture 3. Hyphema 4. Retinal detachment 5. Commotio Retinae 6. Globe Rupture TEST AND RESULTS: CT facial bones: -Blowout fracture of left inferior and medial wall of left orbit -Left orbital emphysema with small contusion vs hematoma within the retrobulbar fat -Minimal blood within the left ethmoid and maxillary sinus Ophthalmology Consult: -Visual Acuity 20/30 Right, 20/200 Left -3 mm Hyphema of left eye -Commotio Retinae of left macula -Normal intraocular pressure FINAL/WORKING DIAGNOSIS: Left orbital floor fracture, Traumatic Hyphema, Commotio Retinae involving the macula TREATMENT AND OUTCOMES: 1. CT scan without significant displacement and no ocular muscle entrapment on repeat exam, no operative repair needed; follow-up with plastic surgery 1-2 weeks 2.Per ophthalmology recommendations: a. Ongoing observation for cataract, retinal detachment, and glaucoma due to increased risk from blunt ocular trauma b. Bed rest with bathroom privileges 3-4 days c. Ophthalmic prednisolone and ophthalmic atropine for hyphema with monitoring for absorption and rebleed d. Monitor for macular hole as increased risk secondary to commotio retinae e. Follow-up in 1-2 days

Ocular Anterior Segment Pathology in the Emergency Department: A 5-Year Study.

Patients with ocular complaints frequently present to emergency departments (EDs) for care. Emergency department practitioners are often the first to evaluate these patients and determine the next steps in their care, which can be a challenging task. The purpose of this study is to determine the frequency of anterior segment pathology in the setting of the ED in hopes that this information will be useful in creating more effective management algorithms. A retrospective study based on electronic patient charts from the University of California Davis ED that included ophthalmology consults. We reviewed the charts for demographic data, as well as visual acuity (VA), intraocular pressure (IOP), and diagnosis as determined by ED and ophthalmology personnel, respectively. The most common anterior segment diagnoses were uveitis, corneal abrasion, corneal ulcer, meibomian gland dysfunction/dry eyes/blepharitis/punctate epithelial erosions, and conjunctivitis/epidemic keratoconjunctivitis. Emergency Department personnel measured the VA and IOP in 40.8% and 16.7% of patients, respectively. The ophthalmologist measured the VA and IOP in 78.4% and 95.1% of patients, respectively. The percentage agreement in VA measurement between ophthalmology and ED was 11.8%. The percentage agreement in IOP measurement between ophthalmology and ED was 0.86%. The percentage agreement in diagnosis between ophthalmology and ED was 49.4%. Most ocular conditions that present in the ED are nonurgent and can be treated in an outpatient setting. However, ED personnel are often unable to obtain the proper "ocular vital signs" (the VA and IOP) and diagnoses. Our findings suggest a need for clear interprofessional discussion in creating an algorithm for triage and the management of eye conditions in the ED to deliver effective care.

Experience of a non-pediatric-trained ophthalmic hospitalist at a children's hospital

The relatively novel role of ophthalmic hospitalist at our institution includes evaluation and management of all inpatient and emergency department ophthalmology consultations. This report reviews the management of consultations at a children's hospital by the non-pediatric-trained ophthalmologist in this role. Within the study period of 2months, 61 pediatric patients were evaluated by the ophthalmic hospitalist service. The pediatric ophthalmology department was consulted in 15 cases (25%), 10 of which were for discussion alone. This model of care illustrates an effective way to provide an ophthalmology consult service at a children's hospital in conjunction with pediatric ophthalmology subspecialists for management.

SUN-596 A Rare Presentation of Early Onset Wernicke Encephalopathy Following Sleeve Gastrectomy

Background: Wernicke encephalopathy (WE) has been reported after malabsorptive bariatric surgeries but is an uncommon complication of sleeve gastrectomy. Since 2011, the number of patients receiving a sleeve gastrectomy has tripled, with almost 60% of patients undergoing bariatric surgery receiving a sleeve gastrectomy in 2017 (1). We present a case of WE in a young woman as a rare and early complication of sleeve gastrectomy. Clinical Case: A 32-year old female with a past medical history significant for hypertension, pseudotumor cerebri, and morbid obesity status post sleeve gastrectomy two months prior presented to the emergency department with complaints of blurry vision and lower extremity numbness. Physical examination showed sluggish light reflex and decreased extraocular movements. Given history of pseudotumor cerebri, patient underwent a therapeutic lumbar puncture with removal of 13 ml of CSF. Opening pressure was 20 cm of water and patient experienced no relief of her symptoms. Ophthalmology consult did not offer an explanation for the blurry vision. MRI-brain with and without contrast showed findings highly suggestive of WE. It showed faint linear symmetric hyperintensities along the bilateral mesial thalamus, dorsal midbrain and periaqueductal gray matter, which were determined to be acute in nature in comparison with a MRI performed three weeks prior. Upon further investigation, thiamine level was low at 43.6 nmol/L [66.5 – 200] confirming the diagnosis of WE. Thiamine supplementation was started immediately and patient reported improvement of her vision the next day with return to baseline in 3 days. Conclusion: There have been a handful of cases of WE reported in literature as a complication of sleeve gastrectomy. Zheng, L also reported a case of WE 7 weeks after sleeve gastrectomy (2). Although sleeve gastrectomy does not directly affect the primary absorptive pathway of thiamine in the gastrointestinal tract, it is imperative to consider WE in patients presenting with suspicious neurologic symptoms after a recent sleeve gastrectomy. WE was suspected in our case due to typical MRI findings and neurological presentation after bariatric surgery, which was later confirmed by low serum thiamine level. Early detection and thiamine supplementation resulted in complete reversal of symptoms in our patient. WE is a rare but severe and preventable consequence of bariatric surgery that warrants attention given its rapid onset and detrimental course. Reference: (1) Estimate of Bariatric Surgery Numbers, 2011-2017. (2018, June 26). Retrieved from https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. (2) Zheng, L. (2016).Wernicke Encephalopathy and Sleeve Gastrectomy. American Journal of Therapeutics, 23(6).

MON-707 Improving Screening for Diabetic Retinopathy in a Resident Based Clinic

Introduction Diabetic retinopathy is the leading cause of blindness in US Adults. In order to improve screening rates, we partnered with the Division of Ophthalmology and installed an onsite retinal camera at our primary care clinic. This led to an improvement in EMR reported screening rates from 20.5% to 44% over the first 3 months. We noticed that any fundus photo, whether gradable or not, led to an automatic annotation in EMR (EPIC) health Maintenance that screening had been completed. Abnormal or ungradable (quality too poor to interpret) retinal photos must be followed up with a complete ophthalmologic evaluation. We designed a chart audit to investigate further whether ungradable retinal photos were being followed up appropriately. Methods A retinal camera was installed in the clinic, and patients obtained DR screening during their routine visits from May through October 2018. The nursing staff received training on using the camera and ensuring image quality. These images were then sent to an Ophthalmologist and resulted within the work week. Patients with an abnormal or poor-quality retinal photo were contacted by their resident PCP. We did a retrospective chart review of patients with ungradable photos evaluating whether patients were contacted and whether they followed up with Ophthalmology in the 3 month period after the initial intervention. Results Of the 131 patients who received fundus photos in the study period, 29 (22%) had ungradable photos. Twenty-four of these patients were contacted and ophthalmology consults were placed for 22 patients. Eleven (38%) of these patients went on to complete screening with Ophthalmology within 3 months of the ungradable photo. Eighteen patients, or 62% of ungradeable photos, remained incorrectly identified as having completed retinopathy screening by EMR. Discussion Over reliance on EMR reporting features can lead to incorrect assumptions about DR screening. Based on this analysis, we need to design better interventions for following up on ungradable photos and ensuring appropriate follow up. One such intervention may be changing how EMR reports ungradable photos. EPIC is a widely used EMR in outpatient settings and other practices may be facing similar issues.

A special on epidemic prevention and control:screening for novel coronavirus related conjunctivitis among the patients with coronavirus disease 2019

This article was published ahead of print on the official website of Chinese Journal of Ophthalmology on April 16,2020. Objective: To screen for novel coronavirus related conjunctivitis among patients with coronavirus disease 2019. Methods: Prospective series case study. Eighty-one patients diagnosed as coronavirus disease 2019 in Guangxi Zhuang Autonomous Region People's Hospital were enrolled with ophthalmological consultation and screening for novel coronavirus related conjunctivitis, including the inquiring of eye symptoms and checking for conjunctivitis-related signs. Novel coronavirus nucleic acid testing of conjunctival swabs was performed on patients with clinical manifestations of conjunctivitis. Results: Only 3 of the 81 patients (3.70%) complained of eye discomfort, which appeared on day 16.67±9.29 after the diagnosis of coronavirus disease 2019. The eye signs were not typical of viral conjunctivitis. Novel coronavirus nucleic acid tests of conjunctival swabs were negative in both eyes. There was no evidence to support the diagnosis of novel coronavirus related conjunctivitis. The remaining 78 patients showed no clinical symptoms or signs of conjunctivitis. Conclusions: The occurrence of novel coronavirus related conjunctivitis may be low in patients with coronavirus disease 2019.(Chin J Ophthalmol, 2020, 56: 433-437).