When EM physician, Craig Harrison, M.D., MPH, recounts his experience with a young woman with diabetes-related increased intraocular pressure, he emphasizes how imperative it is that clinicians rely on their own knowledge, experience, resources and intuition to deliver the best in care.

“In the field of emergency medicine, we have many slogans, such as ‘time is brain tissue’ or ‘time is cardiac muscle.’ Such mantras are meant to reflect the urgency of certain time-sensitive situations like a stroke or heart attack, when time is of the essence, as we try to preserve these vital organs and offer quick diagnoses with appropriate treatment plans.

Another less common but equally important slogan is ‘time is vision.’ One such instance is when we as physicians are concerned about acute angle-closure glaucoma. Classically, these would be older patients who present with sudden onset painful vision loss, perhaps after entering a dark room (which forces dilation of the pupil, thus triggering the glaucoma). But there are other populations at risk as well, and this is what I recently encountered at the Broward General Emergency Department.

Earlier this fall, a young lady in her 20s with a history of poorly controlled type 1 diabetes, already on hemodialysis for her renal failure, presented with a few weeks of worsening vision and 12 hours of complete and painful vision loss in her right eye. She had not seen an ophthalmologist in many years. She appeared to be in moderate distress, had been actively vomiting all day, had a dilated and sluggish right pupil on gross inspection, and reported no light perception with visual acuity exam. These were all red flags for glaucoma, given her history.

As many of us know in our field, checking intraocular pressures is a critical next step but is sometimes challenging given our instrumentation, which is less sophisticated than what ophthalmologists have in their office. Intraocular pressures greater than 20 are generally consistent with a diagnosis of glaucoma, but when I checked her pressures, they were repeatedly ‘non-diagnostic’ or in the range of 10-15, which just didn’t fit her clinical picture.

I quickly reviewed her case over the phone with our ophthalmologist on-call, and he agreed with the plan to empirically administer a myriad of eye drops to temporarily bring down her pressure and supportive measures to mitigate her pain and nausea. Ultimately, however, she needed eye surgery, and it needed to be done urgently in an attempt to restore any of her vision. I spoke to the nearest emergency ophthalmology surgical center, about 25 miles away, and they shared our concern for glaucoma, particularly neurovascular glaucoma given her medical history. They were happy to see her that same night, but like many other similar advanced ophthalmology centers, they don’t accept official hospital transfers. This meant that the patient needed to be discharged from our emergency department and to find her own transport there. I called her family in and explained the urgency of the situation, but they were also very sick with their own medical problems and were without a functional vehicle or enough funds to take her there by taxi.

This is when the realization hit me: I decided to take her there myself. After all that work, it was the last good remaining option to get her there quickly. It wasn’t a real inconvenience for me; it was on the way home, and I was near the end of my shift. Nonetheless, we as clinicians generally do not like to transport patients in our private vehicles for a variety of legitimate reasons. In this instance, however, I have no regrets.

I got her upstairs that night to the emergency eye hospital and handed her off directly to the same ophthalmologist with whom I’d consulted earlier. When I followed up the next day, he informed me that using their instrumentation, he had determined that her intraocular pressure was severely elevated at 70. After laser eye surgery and paracentesis (surgical removal of excess fluid), they were able to get the pressures down to 20 and to dramatically improve the chances of restoring her long-term vision.

This was certainly a healthy reminder of why we should trust our clinical judgement, even when we suspect that our instrumentation is giving us false-negative reports and is non-diagnostic. In the larger sense, these are the types of patients that remind us why we went into medicine to begin with, where we can make a real tangible difference in their quality of life. These are the cases that stick with us and that we remember for the rest of our careers.

This was certainly a healthy reminder of why we should trust our clinical judgement, even when we suspect that our instrumentation is giving

— Craig Harrison, M.D., MPH
EM Physician, Broward Health Medical Center