A Case of Painful Visual Loss- Managing Orbital Compartment Syndrome in the Emergency Department

Audience: Emergency medicine (EM) residents. This simulation curriculum may also be utilized for senior medical students conducting EM rotations. Background: Ophthalmologic education represents only a small portion of medical school curriculums and continues to decrease over time, leaving physicians poorly equipped to diagnose and manage eye complaints.1 Of emergency physicians (EPs) surveyed, 72.5% felt that they could diagnose orbital compartment syndrome (OCS), yet only 40.3% felt comfortable performing a necessary lateral canthotomy and cantholysis (LCC).2 These survey results demonstrate the urgent need for improved ophthalmology education in EM residency to help us diagnose and manage potentially vision-threatening pathology. Educational Objectives: By the end of this simulation, learners will be able to: 1) demonstrate the major components and a systematic approach to the emergency ophthalmologic examination, 2) develop a differential diagnosis of sight-threatening etiologies that could cause eye pain or vision loss, 3) demonstrate proficiency in performing potentially vision-saving procedures within the scope of EM practice. Educational Methods: Low-fidelity simulation was conducted using a novel model adapted from that used by Phillips et al. during their ophthalmology day in the Department of Emergency Medicine at Vanderbilt University.3 The simulation case was developed by an interdepartmental team of ophthalmologists and EPs at our institution. Research Objectives: To evaluate for statistically significant changes in self-efficacy, knowledge, and performance after an educational intervention. Our primary outcome was defined as a checklist-based performance on a simulated case of orbital compartment syndrome necessitating LCC. Research Methods: We conducted a single-center prospective pre- and post-interventional study evaluating the impact of an educational intervention on EM resident management of a simulated case of OCS. Our two-part study intervention consisted of a lecture on OCS followed by a four and a half hour ophthalmology education day (OED). Residents were evaluated using self-efficacy scales (SES), multiple-choice questions (MCQ), and a performance checklist (developed via a modified Delphi process) at three timepoints: Pre-intervention, immediate post-intervention, and three months post-intervention. Post-graduate year (PGY)-1 through PGY-4 EM residents at an Urban Level 1 Trauma Center participated. Results: Initial recruitment consisted of 18 residents (PGY-1 through PGY-4), and 16 residents (PGY-1 through PGY-3) completed the study. Nine residents participated in the OED and seven residents did not. There were no pre-existing differences in median checklist-based performance, MCQ, or SES scores prior to the intervention. At three months post-OED, the OED attendees scored statistically significantly higher on checklist-based performance than non-attendees (lecture only). Discussion: Ophthalmology education in physician training is limited, and EP comfort with performing vision-saving procedures is poor. We developed a simulation case involving such a vision-saving procedure as well as an ophthalmology curriculum that increased skill retention surrounding management of ophthalmologic emergencies. Topics: Emergency medicine (EM), ophthalmology, orbital compartment syndrome (OCS), retrobulbar hematoma, vision loss, eye pain.