Risk Management

Ancillary Personnel Should Know Their Limits When Screening Patients

By Richard H. Birdsong, MD

Argus, Nov.-Dec., 1996

Increasingly, ophthalmologists are relying on ancillary personnel to screen patients, but as the following case history illustrates, ancillary personnel need to understand their clinical limitations. When faced with serious eye problems beyond their training and experience, they should know when to refer patients to an ophthalmologist.

A 15-year-old male was struck in the left eye with a dart-like projectile. After removing the projectile, the boy noted “tearing” and sought medical attention. He presented to the emergency room of a community hospital, where he was referred to the ophthalmology clinic within the same hospital. The patient initially was seen by a technician who, following the clinic’s protocol, took a brief history, obtained a visual acuity, and performed a non-contact tonometry (NCT). The patient noted that the “tearing” from the injured eye ceased after the NCT.

After these screening steps, one of the clinic’s ophthalmologists evaluated the patient, noting a central full thickness corneal laceration, air in the anterior chamber and lens damage. The patient was immediately referred to the nearby supporting medical center for emergent evaluation and repair.

At the medical center, the examination revealed VA of count fingers two and one-half feet OS. In addition to the corneal laceration, there was lens cortex and capsule to the wound. The patient underwent emergent repair of the corneal laceration, lensectomy and sulcus fixated posterior chamber intraocular (IOL) placement. Intravitreal hemorrhage was noted nasal to the disc, consistent with an exit wound. Systemic and subconjunctival antibiotics and subconjunctival steroids were given.

Two days later, the patient developed endophthalmitis and returned to surgery, at which time the IOL was removed, a core vitrectomy was performed, and intravitreal antibiotics were given. Cultures revealed gram positive cocci in chains and pairs, gram negative rods and gram positive rods.

Four days after the initial injury, the patient again returned to surgery for repeat intravitreal antibiotics and cultures, which revealed persistent gram positive cocci. The endophthalmitis resolved, but four weeks later there was a corneal wound melt, which was treated with cyanoacrylate glue. Two weeks later, further cortical vitrectomy was performed for a traction retinal detachment and nonclearing vitreal debris. Presently, the patient has VA of CF at three feet with +12 correction and a cloudy central cornea. VA by Potential Acuity Meter is 20/160, and a penetrating keratoplasty is planned for the future.

In this case, the proper use of screening procedures by ancillary clinic staff prior to patient evaluation by the ophthalmologist was called into question. While the dart was the likely source of bacterial contamination, introducing air into the anterior chamber during NCT was almost certainly a contributing factor. This could have been avoided if the technician had recognized the significance of the patient’s history and presenting complaints as well as the urgent need to consult the ophthalmologist before proceeding further.

Screening protocols are clearly an efficient time-saving tool since most patients present with common clinical problems that can be handled well by a division of labor between the ophthalmologist and the clinical staff. However, these protocols can contribute to adverse outcomes if they don’t include eye trauma and selected eye emergencies, particularly when clinic staff who are inadequately trained or unfamiliar with potentially serious eye conditions perform screening tests. In this case, the technician was unable to determine that the patient’s history indicated a very strong possibility of an open globe, which contraindicated NCT.

Screening procedures should allow for some flexibility, and technicians should be encouraged to ask the ophthalmologist to initially examine patients who present with non-routine problems.