Introduction

Eye emergencies can result in vision loss or dysfunction without early intervention [1]. Studies have shown that the proportion of patients presenting to general emergency departments with eye complaints ranges from 1 to 6% [2, 3]. A proportion of patients presenting to general emergency departments or directly to eye emergency departments with eye complaints do not actually require emergency care [4]. This proportion varies from 37 to 50.4% across different studies [4, 5]. Some hospitals worldwide have implemented triage systems in their emergency departments, and patients with ocular complaints are initially assessed by general practitioners, trained nurses or ophthalmology residents [6]. Studies using triage and coding systems have shown that it is easier to distinguish true ocular emergencies from non-urgent ocular complaints, allowing more time to be allocated to true ocular emergencies and reducing pre-examination waiting times [7, 8].

In previous studies, the criteria for ocular emergencies were defined as conditions and diseases that threaten vision and lead to functional impairment if not treated early. The main causes are giant cell arteritis, open globe injuries, retinal artery occlusions, acute angle closure glaucoma, retinal detachment, keratitis, uveitis, orbital fractures, endophthalmitis, chemical injuries, burns due to chemical substances or direct caustic conditions such as fire and orbital fractures [9]. Several studies have been conducted worldwide on the prevalence of ocular emergencies, such as in Spain (Galindo-Ferreiro et al., 2021) [5] and China (Chen et al., 2023) [6]. However, there are no similar studies published from Turkey. The aim of this study was to provide valuable data on the prevalence of eye emergencies in patients attending the general emergency department of a tertiary hospital, filling an important gap in theliterature.

In addition, we aimed to determine the actual percentage of eye emergencies among the cases examined and explore potential solutions.

Methods

Study setting and participants

The study is a retrospective, cross-sectional, single-centre epidemiological study. Ethical approval was obtained from the Ethics Committee of Başakşehir Cam and Sakura City Hospital for the study (Approval No: 2023.02.84). The study was conducted in accordance with the principles of the Helsinki Declaration. Patients who presented to the general emergency department of a tertiary hospital with eye problems and were referred to the Eye Emergency Department from January 2022 to December 2022 were included in the study. Patients with undetermined diagnoses, incomplete file data, or referrals from other hospitals were excluded. All patients with eye-related issues who presented to the general emergency department were initially evaluated by an emergency resident without any interventions and then referred to the eye emergency department. In the Eye Emergency Department, the diagnosis was made by ophthalmology resident doctors. Patients with diagnostic challenges were evaluated by ophthalmology specialists. The initial complaint and visual acuity of all patients were noted. After tests for light reflex and eye movements were conducted, a detailed examination of the anterior segment and retina was performed via biomicroscopy. Imaging techniques were used when necessary. In some cases, patients were referred to Neurology, Ear Nose Throat, and other relevant specialty departments. The study included patients aged 0 to 100 years. Patients were categorized into three groups on the basis of their urgency status by a specialist in ophthalmology: top eye emergencies (TEE), relative eye emergencies (REE), and non-emergency eyes (NEE). The classification of TEE, REE and NEE was made considering the classification of the American Academy of Ophthalmology, [10] which can be considered an authority on this subject, and by evaluatingthe patient using our clinic’s daily practice approach.

TEE refers to conditions that could lead to vision loss or disability if individuals do not intervene within hours or even minutes. REE includes conditions that require faster and uncomplicated recovery when diagnosed and treated within days. NEE encompasses patients with no urgent signs requiring immediate attention, patients who should have scheduled elective eye examinations, and those who, after appropriate consultation by a general practitioner, do not need referral to the Eye Emergency Department.The percentages in Tables 1, 2, 3 and 4 were calculated as the ratio of eye emergencies in the relevant row to the total number of eye emergencies.

Statistical analyses

The mean, standard deviation, median minimum, maximum, frequency and ratio values were used for descriptive statistics. The distribution of variables was measured via the Kolmogorov‒Smirnov test or Shapiro‒Wilk test. The Mann‒Whitney U test was used to analyse quantitative independent data. The chi-square test was used in the analysis of qualitative independent data, and the Fisher test was used when the chi-square test conditions were not met. The SPSS 27.0 program was used in the analyses.

Results

In 2022, a total of 652,224 individuals sought care at the general emergency department, with 285,355 being adults and 366,869 being children. Among these, approximately 325,000 were males, and 327,224 were females. Amid all presentations, 9,982 individuals (1.5%) were referred to the Eye Emergency Clinic. Twelve patients who could not be diagnosed, 42 patients for whom nothing was written about the diagnosis and treatment in the registration file, and 35 patients who were diagnosed and treated but did not attend the follow-up examination were not included in the study.

Table 1 shows the demographic characteristics of the patients admitted to the Eye Emergency Clinic and the time of presentation. The age distribution shows that the youngest patient was a newborn (Day 1), and the oldest patient was 98 years old. The mean age was 32 years, and the median age was 33 years. In terms of sex distribution, 72.1% of the patients were male, and 27.9% were female. Thepatients were distributed throughout the year, with the highest number in November (10.5%) and the lowest number in February (6.8%). According to the time of arrival, 50.5% of the applications were made between 08:00 and 17:30, 36.9% between 17:30 and 24:00, and 12.6% between 00:00 and 08:00.(Fig. 1).

Fig. 1
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Bar graphs illustrating the age distribution, sex distribution, arrival month, and arrival time of patients presenting with eye complaints to the emergency department

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Table 1 Patient demographic data and the time of presentation to the eye emergency clinic
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Table 2 shows the numbers and rates of various eye emergencies among patients presenting to the Eye Emergency Clinic. The most common emergencies included keratitis and preseptal cellulitis, whereas some conditions, such as retinal artery occlusions and giant cell arteritis, were rare.

Table 2 The number of patients belonging to the True Eye emergencies group and their percentage to all patients examined in the Eye Emergency Clinic. (n=9,982)
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Table 3 presents the number of patients belonging to the relative eye emergency group and their ratio to all patients presenting to the eye emergency clinic. The three most common conditions were corneal foreign bodies, conjunctivitis and corneal disorders.

Table 3 The number of patients belonging to the relative Eye Emergency group and their percentageto all patients examined in the Eye Emergency Clinic. (n=9,982)
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Table 4 shows the number of patients in the nonemergency ophthalmological conditions group and their proportion of all patients attending the Eye Emergency Clinic. The most common conditions included subconjunctival haemorrhage and dry eye.

Table 4 The number of patients belonging to the nonemergency eye disease group and their percentagescompared with those of all patients examined Atthe Eye Emergency Clinic. (n=9,982)
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The proportion of male patients was significantly (p < 0.05) greater in the > 30 years group than in the ≤ 30 years group (Table 5).

Table 5 Comparison of patients aged ≤ 30 years and >30 yearsin terms of sex and time of arrival
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Analysis of true eye emergencies by age group shows that the rates of retinal artery occlusion, rhegmatogenous retinal detachment, keratitis, glaucoma crisis, endophthalmitis and chemical injury were significantly greater in individuals older than 30 years. However, no significant difference was found between the two age groups in terms of the incidence of open globe injuries or orbital fractures.(Table 6).

Table 6 Comparison of true eye emergencies in the age ≤ 30 years and age >30 years groups
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Table 7 shows that there are certain differences between eye emergency cases according to age group. Individuals older than 30 years have significantly higher rates of corneal foreign bodies, conjunctivitis and corneal disorders. The rates of retinal vein occlusion and ocular cranial nerve palsies were also significantly higher in the group older than 30 years. However, no significant difference was observed between age groups in terms of uveitis, optic neuropathy or sudden visual loss.

Table 7 Comparison of relative eye emergencies in the age ≤ 30 years and age>30 years groups
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As shown in Table 8, the rates of subconjunctival haemorrhage, cataracts, diabetic retinopathy, vitreous diseases and refractive error were significantly greater in the group aged > 30 years than in the group aged ≤ 30 years.

Table 8 Comparison of nonemergency eye patients between the age ≤ 30 years and age>30 years groups
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Visual acuity was significantly (p < 0.05) greater in the > 30 years age group than in the ≤ 30 years age group.(Table 9).

Table 9 Comparison of visual acuity between the age ≤ 30 years and age> 30 years groups
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The age of the male patients was significantly (p < 0.05) greater than that of the female patients (Table 10).

Table 10 Comparison of age and time of arrival according to sex
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As shown in Table 11, the rates of rhegmatogenous retinal detachment and microbial keratitis were significantly lower in males than in females, whereas the rate of orbital fracture was greater in females.

Table 11 Comparison of top eye emergencies according to sex
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As shown in Table 12, the rates of corneal foreign bodies and corneal disorders were significantly greater in male patients than in female patients, whereas the rate of sudden loss of observation was significantly lower in female patients.

Table 12 Comparison of relative eye energy levels according to sex
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As shown in Table 13, the rates of subconjunctival haemorrhage, cataracts, diabetic retinopathy, vitreous diseases and refractive error were significantly lower in male patients than in female patients.

Table 13 Comparison of nonemergency eyes according to sex
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Visual acuity did not differ significantly (p > 0.05) between male and female patients (Table 14).

Table 14 Comparison of visual acuity according to sex
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The cause of arrival, management and outcome of cases are detailed below by diagnosis. (Table 15)

Table 15 Follow-up and prognosis of eye emergencies
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Corneal foreign body

Patients complained of foreign bodies in the cornea. All patients were discharged with medical treatment. Good visual outcomes (mean visual acuity: 0.86) were observed.

Conjunctivitis

Patients complained of eye redness and discharge.All patients were discharged with medical treatment. Minimal visual impact (mean visual acuity: 0.64).

Uveitis

Patients complained of eye pain and blurred vision. Patients were referred for medical treatment. Moderate visual impairment (mean visual acuity: 0.52).

Subconjunctival haemorrhage

Patients complained of a red spot in the eye. All patients were discharged with medical treatment. Almost normal vision (mean visual acuity: 0.98) was observed.

Optic neuropathy

Patients complained of sudden vision loss. Medical treatment and follow-up were performed. Significant visual impact (mean visual acuity: 0.55).

Retinal artery occlusion

Patients complained of sudden, severe vision loss. Medical treatment, hyperbaric oxygen, and retinal follow-up were performed. Severe visual impairment (range: LP to 0.1).

Retinal vein occlusion

Patients complained of blurred or distorted vision. Medical treatment and retinal follow-up were performed. Variable vision outcomes (range: HM to 0.5).

Retinal detachment

Patients complained of flashes of light and floaters. Vitreoretinal surgery and retinal follow-upwas conducted.Vision ranged from LP to 0.7.

Nerve paralysis

Patients complained of double vision and eye movement problems. Follow-up and consultation were given. Moderate visual impairment (mean visual acuity: 0.55).

Keratitis

Patients complained of eye pain, redness, and blurred vision. Medical treatment, hospitalization, and referral to the cornea department were performed. Severe visual impairment (range: HM to 1.0).

Open globe Injury

Patients complained of severe eye trauma and vision loss. Hospitalization, emergency surgery, and follow-up were performed. Severe visual impairment (range: LP to 0.3).

Glaucoma crisis

Patients complained of severe eye pain and blurred vision. Medical treatment and referral to the glaucoma department were performed. Variable vision outcomes (range: HM to 0.8).

Endophthalmitis

Patients complained of eye pain, redness, and vision loss. Medical and surgical treatment were performed. Severe visual impairment (range: LP to 0.3).

Chemical injury

Patients complained of eye pain and vision problems following chemical exposure. Mostly medical treatment was performed. Moderate visual impairment (mean visual acuity: 0.46).

Cellulitis

Patients complained of swollen, red, and painful eyelids. Mostly medical treatment was performed. Moderate visual impairment (mean visual acuity: 0.70).

Corneal disorders

Patients complained of eye pain and vision problems. Mostly medical treatment was performed. Moderate visual impairment (mean visual acuity: 0.68).

Cataract

Patients complained of blurred vision. All patients were referred to the cataract department. Moderate visual impairment (mean visual acuity: 0.46).

Diabetic retinopathy

Patients complained of vision changes and floaters. The patient was referred to the retinal department. Variable vision outcomes (range: HM to 1.0).

Orbital fractures

Patients complained of facial trauma and vision problems. Follow-up or consultation. Significant visual impact (mean visual acuity: 0.22).

Eyelid incision (in the absence of ocular complications)

Patients complained of eyelid cuts. This was followed or primarily repaired. Moderate visual impairment (mean visual acuity: 0.57).

Vitreous diseases

Patients complained of floaters and vision changes. Follow-up was conducted. Variable vision outcomes (range: LP to 1.0).

Sudden vision loss

Patients complained of sudden vision loss. Consultation and follow-up occurred. Variable vision outcomes (range: 0.3 to 1.0).

Refraction errors

Patients complained of blurred vision. The patient was referred to the eye clinic. Moderate visual impairment (mean visual acuity: 0.43).

Discussion

This study aimed to evaluate the profile of patients attending eye emergency clinics, with an emphasis on differentiating between true ocular emergencies (TEEs) and nonemergency eye conditions (NEEs). Our findings highlight several significant aspects that warrant detailed discussion.

A very small proportion of patients presented to the emergency department with eye complaints, which includedcentral retinal artery and central retinal artery branch occlusions, [11]giant cell arteritis, open globe injuries, [11,12,13] Cavernous sinus thrombosis, acute angle-closure glaucoma,13 endophthalmitis, orbital cellulitis,13 alkali chemical eye injuries, [11,12,13] retinal detachment without macular involvement, [11,12,13] and various types of keratitis, constitute conditions associated with urgent eye conditions [14, 15]. The rates reported in the literatureare similar to those reported in this study [2, 3]. In our study, 13% of the cases were classified as true ocular emergencies. In comparison, previous studies reported that approximately 12% and 14% of cases, respectively, were true ocular emergencies. However, patients were not classified according to the order of urgency, as was done in our study. When looking at the subcategories, true ocular emergencies were very rare compared with all ocular emergencies in the study.The rate of true ocular emergencies among all patients examined in the emergency department was 0.2%. To help differentiate nonurgent eye complaints from genuine complaints, it is important to establish robust protocols for triage and coding systems, as well as the implementation of adequate training platforms. These measures can improve patient care by providing health care workers with the knowledge and skills necessary for accurate diagnosis and treatment [6,7,8].

The annual incidence of retinal detachment is reported to be between 6.3 and 17.9 cases per 100,000 [16]. In this study, this rate was 19 cases per 100,000. Studies have indicated that retinal detachment without macular involvement is considered an urgent condition, whereas retinal detachment with macular involvement is relatively urgent [17]. The reason for the slightly higher retinal detachment rate in thisstudy than in other studies may be that the hospital is a tertiary care hospital and allows more trauma patients to be admitted.

Giant cell arteritis can cause optic neuropathy leading to blindness and occurs in approximately 15–25 cases per 100,000 people [18]. No cases of giant cell arteritis were encountered in our study over the course of a year. The disease can sometimes have a subclinical course, leading to either an undiagnosed state or patients not presenting to the emergency department with primary eye complaints.

Central retinal artery and branch occlusions are among the most urgent conditions in ophthalmology practice. The incidence is reported tobe 1 in 100,000, and among ophthalmology referrals, it is found to be 1 in 10,000 [19]. In our study, central retinal artery occlusion was diagnosed in 3 patients, and central retinal artery branch occlusion was diagnosed in 3 patients. A higher incidence rate than that reported in the literature was observed; this could be attributed to the development of new diagnostic methods, such as optical coherence tomography angiography (OCTA), fluorescein angiography (FA), and enhanced depth imaging optical coherence tomography (EDI-OCT).

Open globe injury is the most common cause of unilateral visual blindness worldwide; [20]its incidence ranges from 2 to 6 cases per 100,000 annually [21]. In this study, the incidence was 10.7 cases per 100,000. Among patients with ophthalmic complaints, the rate was 0.7%. Owing to its poor prognosis, open globe injury is the most common cause of unilateral visual loss worldwide, as observed in our study.

Microbial keratitis is an urgent condition that results in blindness if not treated early; it has varying frequencies in different regions worldwide, with an incidence ranging from 6.6 to 40.3 cases per 100,000 [14, 22]. In this study, the rate was 15.3 cases per 100,000. As one moves towards rural areas in Turkey, this rate might be even higher. Among true ophthalmic emergencies, acute angle-closure glaucoma is frequently encountered. In Europe, the incidence of acute angle-closure glaucoma ranges from 3.9 to 4.1 cases per 100,000 people. [22, 23] In this study, the incidence was 4.7 cases per 100,000. In addition to acute angle-closure glaucoma, open-angle glaucoma and congenital glaucoma have also presented to our emergency department. Endophthalmitis has varying incidences depending on the causative agent but is a common reason for emergency eye visits [24]. In the literature, the reported incidence of endophthalmitis ranges from 0.1 to 4 cases per 100,000 people [25]. In this study, the incidence was 2.6 cases per 100,000.Chemical substance exposure to the eye, especially alkali chemical exposure, is one of the most critical eye emergencies [26]. A total of 10–12% of patients present to the emergency department with eye complaints [27]. In this study, chemical injuries accounted for 3.3% of all injuries. This value was lower than that reported in the literature. The lower incidence in our study could be due to differences in regional industrial exposures or safety practices.

The incidence of orbital cellulitis ranges from 1.6 to 6 per 100,000 in those under 18 years of age and from 0.6 to 2.4 per 100,000 in adults [28, 29]. In this study, the incidence of orbital cellulitis was 2.45 per 100,000, constituting 0.2% of those presenting with eye complaints. Cases of preseptal cellulitis, dacryocystitis, and cellulitis due to other causes were also included in the true eye emergencies category because of the potential progression to orbital cellulitis. Overall, the incidence of eye and periocular cellulitis was 48.3 per 100,000, constituting 3.1% of all eye emergencies.

Orbital wall fractures also require a multidisciplinary approach and referral to the Eye Emergency Clinic. In a study conducted in Korea, the incidence was 46.9 per 100,000, and 26.8% of these patients underwent surgery [30]. In a study conducted in America, the incidence ranged from 7.7 to 11 per 100,000 people [31]. A study with 500 patients reported muscle entrapment in 3 patients [32]. In our study, the incidence of orbital fractures was 35.5 per 100,000, constituting 2.3% of all ocular emergencies. The percentage of patients with muscle entrapment among all orbital fractures was 5.4%. Overall, the incidence of true eye emergencies in the present study was generally in line with the literature.

A corneal foreign body is one of the most common reasons for seeking emergency care for the eye. It is often seen among industrial workers dealing with materials, construction workers, and motorcycle riders who do not wear protective eyewear. In some studies, it has been identified as the most frequent cause of emergency visits. In a study focusing on patients with ocular trauma presenting to the emergency department, corneal foreign bodies accounted for 58.2%, followed by corneal erosion at 24.9% and blunt eye trauma at 12.6% [33]. In this study, similar to this research, the proportion of patients presenting with ocular trauma among all ophthalmic emergencies was 56.8%. Among patients with ocular trauma, 45.1% had corneal foreign bodies, 29.1% had corneal erosion, and 9.9% had blunt eye trauma, ranking second and third, respectively. In this study, patients with corneal foreign bodies and corneal erosion were classified into the relative emergency group. Some patients present to the emergency department immediately, and some present a few days after the trauma, suggesting the urgency of the situation. In another study, among patients presenting to the emergency department with eye complaints, the highest rate was 40.9% for ocular trauma, 29% for ocular infections, and approximately 45% for conditions they did not consider urgent [34]. In this study, ocular infections were identified in 18.4% of patients with ocular complaints, of which 12.2% were cases of conjunctivitis, which aligns with findings from the same cohort.

The primary objective of this study was to assess the prevalence of urgent eye pathologies among patients visiting the general emergency department. Compared with the literature, our cohort’s percentage of ocular infections was lower. This prompts an exploration of the potential reasons behind this variation, and raises questions about health care-seeking behaviour, access to services, and possibly differing diagnostic practices between regions or urban versus rural settings. For example, could a higher utilization of general practitioners for minor conditions such as conjunctivitis contribute to this discrepancy?

Astudy conducted in the UK reported that 37% of patients presenting with eye complaints did not require urgent care [35]. Similarly, another study reported that 50.4% of patients who presented to the emergency department with eye complaints did not have an urgent condition [36]. The findings contribute to this understanding, indicating that 27.3% of patients presenting with eye complaints in the emergency department do not have urgent conditions. Among these patients, the largest subset (10.2%) comprised patients reporting eye irritation and foreign body sensation, often attributed to dry eyes [37].

Analysing the comparatively lower proportion of urgent cases in our cohort can offer valuable insights into service provision and potentially guide improvements. Understanding why cohort figures differ from those in the literature may reveal opportunities for optimizing pathways to care, enhancing service accessibility, and refining diagnostic protocols within the health care system.

The proportion of patients who presented to the emergency department for refractive errors was 1.1%. These groups consisted of individuals who were unable to find an appointment at any clinic for dry eye issues and eyeglass prescriptions. In our study, the proportion of patients who presented with no sequelae or subconjunctival haemorrhage (SCH) was 4%. A similar study with a comparable patient count reported an incidence of SCH of 2.9% [38]. In our study, owing to its predominantly benign course, SCH was included in the nonurgent eye conditions group. However, it should be carefully evaluated, as sometimes it can be a precursor symptom of an underlying condition.

A study in the United States found that emergency physicians often feel uncomfortable examining patients with eye complaints [39]. There is a similar situation in Turkey. Another study showed that there was a high level of agreement when patients whose initial examination in the emergency department was performed by emergency medicine residents trained in ophthalmology triage were re-evaluated by ophthalmologists [40]. This finding indicates that, both globally and in Turkey, when evaluating patients with eye complaints in the emergency department, doctors, who are the first point of contact with patients, should receive additional training in the field of ophthalmology in addition to basic medical education.

Limitations

In this study, diseases were not categorized via any scoring system. Additionally, detailed distinctions between paediatric and adult conditions were not made. These can be considered limitations of our study.

Conclusion

In conclusion, timely intervention is crucial in preventing visual and functional impairment resulting from top eye emergencies (TEEs). This study found that 13% of eye emergencies were classified as TEEs, 60% as relative eye emergencies (REEs), and 27% as nonemergency eye (NEE) conditions. Although the prevalence of TEEs is not excessively high, a significant proportion of patients presenting to the emergency department with eye concerns are referred for eye consultation by doctors with limited expertise in ophthalmology. This burdens the Eye Clinic, leading to extended waiting times and compromising examination thoroughness. To address this issue, it is imperative to enhance the training of general emergency department staff, particularly in tertiary hospitals, in recognizing and managing eye emergencies. This will streamline patient care pathways, optimize resource allocation, and ensure timely intervention for TEE patients, minimizing adverse outcomes.