LO13: Eye care in the emergency department: what proportion of patients presenting to the emergency department with isolated eye related complaints could alternatively be seen by an optometrist?

Introduction: Approximately 2-3 percent of emergency department (ED) visits are due to eye-related complaints, adding to the ED workload. Many of these could be seen instead by an optometrist who specializes in the examination, diagnosis and treatment of eye-related disorders. We sought to determine the proportion of ED patients with isolated eye-related complaints that could be managed by an optometrist. Methods: We performed an administrative database study and descriptive analysis of all patients presenting to Calgary EDs with eye-related complaints during a one-year period. We determined optometry eligibility by reviewing discharge diagnoses and assessing whether that condition was within the Alberta Association of Optometrys (AAO) defined scope of practice. Patients were considered ineligible if their condition was related to bites, stings, thermal burns, assault, MVA or operative complications; if they required hospitalization or referral to a non-eye specialist (e.g. neurology); if they had associated headache, dizziness, syncope, hypertension, neurologic abnormality (e.g. diplopia); if they had facial cellulitis, orbital infections, adverse drug effects, or if they underwent observation in the ED because of concerns about a cardiac or neurological condition. Results: In 2015, 7686 patients were seen in Calgarys 5 EDs with eye related complaints. Of these, 76.2% were optometry-eligible and 75% of optometry-eligible patients arrived during day or evening hours (0800-2100). The most common presenting complaints were visual disturbance (24.8%), redness (22.1%), and pain or photophobia (16.4%). Optometry-eligible patients waited an average of 110 min and had an ED LOS of 149 min. Conclusion: Approximately 3 in every 4 patients seen in the ED for eye related complaints could alternatively be seen by an optometrist. Further research is required to establish the feasibility of diversion to an optometrist from the ED for eye-related complaints.

Bell palsy in Lyme disease–endemic regions of Canada: a cautionary case of occult bilateral peripheral facial nerve palsy due to Lyme disease

ABSTRACTLyme disease caused by the spirocheteBorrelia burgdorferiis a multisystem disorder characterized by three clinical stages: dermatologic, neurologic, and rheumatologic. The number of known Lyme disease–endemic areas in Canada is increasing as the range of the vectorIxodes scapularisexpands into the eastern and central provinces. Southern Ontario, Nova Scotia, southern Manitoba, New Brunswick, and southern Quebec are now considered Lyme disease–endemic regions in Canada. The use of field surveillance to map risk and endemic regions suggests that these geographic areas are growing, in part due to the effects of climate warming. Peripheral facial nerve palsy is the most common neurologic abnormality in the second stage of Lyme borreliosis, with up to 25% of Bell palsy (idiopathic peripheral facial nerve palsy) occurring due to Lyme disease. Here we present a case of occult bilateral facial nerve palsy due to Lyme disease initially diagnosed as Bell palsy. In Lyme disease–endemic regions of Canada, patients presenting with unilateral or bilateral peripheral facial nerve palsy should be evaluated for Lyme disease with serologic testing to avoid misdiagnosis. Serologic testing should not delay initiation of appropriate treatment for presumed Bell palsy.

Otitic Hydrocephalus: A Report of 2 Cases

Otitic hydrocephalus is a rare intracranial complication of otitis media. It is characterized by elevated cerebrospinal fluid (CSF) pressure with normal CSF biochemistry and without any focal neurologic abnormality other than those related to the increased intracranial pressure. The pathophysiology of this rare condition is unknown. The incidence of intracranial complications was reduced dramatically with the introduction of newer antibiotics, but complicated cases still occur. Serious consequences can ensue if complications are not identified and treated properly. The author reviews the literature on otitic hydrocephalus and describes 2 new cases.

Cognitive and Neurologic Development of the Premature, Small for Gestational Age Infant Through Age 6: Comparison by Birth Weight and Gestational Age

Objective. To compare the neurologic and cognitive outcomes of 129 premature small for gestational age (SGA) infants with 300 premature appropriate for gestational age (AGA) infants through 6 years of age. Design. Infants born at ≤37 weeks gestational age and ≤2500 g with birth weight 2 standard deviations or more below the mean birth weight for gestational age were categorized as SGA. Cognitive and neurologic outcomes of SGA and AGA prematures at 1, 2, 3, and 5 and/or 6 years of age were compared when the infants were stratified by gestational age in 2-week intervals or by birth weight in 500-g intervals. The association between SGA/AGA and neurologic status on cognitive outcomes at each age was also examined. Results. SGA infants had significantly poorer cognitive scores at each age when compared with AGA infants of similar gestational ages. Normal neurologic status was more likely at all assessments for the AGA than for SGA infants of comparable gestational age. There were no differences between SGA and AGA children in cognitive or neurologic outcomes at any age when grouped by birth weight. Cognitive impairment was closely associated with neurologic abnormality in both SGA and AGA groups. There was, nevertheless, a significant effect of SGA on cognitive outcome independent of neurologic status at all ages except 3 years. Conclusions. Irrespective of degree of prematurity, SGA infants are at greater risk for neurodevelopmental impairment than are equally premature AGA infants. The cognitive impairment can be largely, but not entirely, attributed to a higher incidence of neurologic abnormalities in the SGA infants at each gestational age.

Visual attention abnormalities in autism: Delayed orienting to location

These studies provide evidence for slowed spatial orienting of attention in autism. A group of well-defined adult autistic subjects and age-matched normal controls performed a traditional spatial cueing task in which attention-related response facilitation is indexed by speed of target detection. To address the concern that motor impairment may interfere with interpretation of response time measures in those with neurologic abnormality, we also used a new adaptation of the traditional task that depended on accuracy of response (target discrimination) rather than speed of response. This design allowed separation of time to process and respond to target information from the time to move and engage (orient) attention. Results from both tasks were strikingly similar. Normal subjects oriented attention very quickly, and showed maximal performance facilitation at a cued location within 100 ms. Autistic subjects oriented attention much more slowly and showed increasing benefits of a spatial cue with increasing cue-to-target delays. These results are consistent with previous reports that patients with autism, the majority of whom have developmental abnormalities of the cerebellum, as well as those with acquired damage to the cerebellum, are slow to shift attention between and within modalities. This paper also addresses the variability in behavioral findings in autism, and suggests that many of the apparently contradictory findings may actually reflect sampling differences in patterns of brain pathology. (JINS, 1996, 2, 541–550.)

Adductor Spastic Dysphonia: Heterogeneity of Physiologic and Phonatory Characteristics

Physiologic and phonatory characteristics of 23 subjects with adductor spastic dysphonia were studied, including examination of the laryngeal appearance by fiberoptic nasoendoscopy, neurologic examination, and measurement of phonatory airflow and speaking fundamental frequency. These characteristics displayed considerable heterogeneity among the subjects investigated. Three patterns of laryngeal appearance during phonation were observed: Vocal fold adduction, associated ventricular fold constriction, and approximation of the laryngeal inlet. Eight of 13 subjects demonstrated some neurologic abnormality. For the majority of subjects, the airflow demonstrated marked variability during sustained phonation; for different subjects, this variability was observed to be associated with either an oscillatory or irregular airflow pattern. The modal speaking fundamental frequency for the women and men with adductor spastic dysphonia was not significantly different from that for age- and sex-matched controls.

Creatine Kinase Brain Isoenzyme: Relationship of Cerebrospinal Fluid Concentration to the Neurologic Condition of Newborns and Cellular Localization in the Human Brain

Immunocytochemical study of human brain showed creatine kinase brain isoenzyme (CKBB) present in both neurons and astrocytes. Because creatine kinase brain isoenzyme is an intracellular enzyme that might be released with brain injury, its concentration in the CSF of newborns was measured using a radioimmunoassay. Infants who suffered a documented neurologic insult (a cerebroventricular hemorrhage or a CNS infection) were found to have a greater mean CSF creatine kinase brain isoenzyme concentration than those without a history of neurologic insult. Infants with a high concentration had a poor short-term outcome (death or neurologic abnormality when discharged) more frequently than did those with a lower concentration. Infants with a grade 3 or 4 cerebroventricular hemorrhage had a higher mean concentration than did those with a grade 1 or 2 hemorrhage. These data are consistent with the hypothesis that CSF creatine kinase brain isoenzyme is a metabolic indicator of brain damage in newborns.

Letters to the Editor

Dr. Knight's letter questions the predictive value of the neonatal neurologic examination. It states that the neurofindings of Nelson and Ellenberg (Pediatrics 64:225, 1979) indicate a high false-positive rate for the relation between an abnormal neonatal neurologic examination and subsequent neurologic abnormality (ie, "cerebral palsy"). Because of this, Dr Knight indicates that "many would interpret the data as questioning the predictive value of the neonatal neurologic examination." I would disagree with such an interpretation of the Nelson and Ellenberg data for several reasons.