Tara McSwigan, MPAS, PA-C, on Treating Ocular Emergencies in Primary Care

In this podcast, Tara McSwigan, MPAS, PA-C, discusses her session “Foresight: 5 Ocular Emergencies Not to Miss” at the American Academy of Physician Assistants 2021 Conference, including how primary care providers should approach patients presenting with ocular concerns. 

Additional resource:

• McSwigan T. Foresight: 5 ocular emergencies not to miss. Talk presented at: American Academy of Physician Assistants; May 20-26, 2021; Virtual. https://ww3.aievolution.com/aap2101/index.cfm?do=ev.viewEV&ev=1015

Tara McSwigan, MPAS, PA-C, is an assistant professor in the Department of Physician Assistant Studies at the University of Pittsburgh. 

TRANSCRIPT:

Leigh Precopio:  Hello everyone, and welcome to another installment of Podcasts360, your go‑to resource for medical news and clinical updates. I'm your moderator Leigh Precopio with Consultant360 Specialty Network.

Ocular presentations are common in primary care settings, but not all primary care providers feel equipped to deal with these cases. However daunting it may seem, with a systematic approach and a bit of confidence, the management of these patients is possible in a primary care setting.

This was among the topics of discussion at the 2021 American Academy of Physician Assistants conference. Today I'm joined by session presenter, Tara McSwigan, MPAS, PA-C who is an assistant professor in the department of physician assistant studies at the University of Pittsburgh.

Thank you for joining me today, Tara. To begin, could you give us a brief overview of your session?

Tara McSwigan:  Absolutely. My session is called, "Foresight: 5 Ocular Emergencies Not to Miss." The reason I got to this is because after so many years of emergency medicine, I came to find that so many clinicians in primary medicine, internal medicine, even some of us in the ER, are very frankly uncomfortable with the idea of ophthalmology and the different types of cases that can present.

The idea of the session is to first of all walk the primary care provider who are many - actually, a full host of different types of providers - through the history and the physical associated with the ocular exam. Then, to be followed up with five specific ocular emergencies.

Essentially, with the history everybody says, "OK, that's the easy part" and it is, but what's so great about eye history is that you can very quickly narrow that differential diagnosis. In other words, if somebody presents with a painful eye condition, I already know. I can already deduce that the problem is in the anterior portion of the eye.

To counter that, if somebody has no pain, no discomfort and they say, "Hey, yeah, I have this change in my visual acuity" or "loss of acuity," then that also directs my differential to the posterior eye, and I know right away that it's a bad thing. The history says so much.

Also then with the physical exam, that's what really puts a lot of us on edge. Again, what I walk the participant through is if you execute a systematic exam of the eye every single time, anterior to posterior, front to back, that it is very easy to navigate. The first part of my lecture is that very discussion.

The latter half, the bigger portion of it therefore does go through five, not every single ocular emergency, but just the five most common that I have personally encountered. In the form of starting, again, most anteriorly with issues on the cornea. Namely, a corneal ulceration associated with contact lens. How to identify it. How to treat it. Herpetic keratitis from herpes zoster versus herpes simplex virus. Going a little bit deeper then would be an acute glaucoma picture. Orbital cellulitis is number four, and then the fifth of those ocular emergencies is the description and evaluation of a retinal detachment. Essentially, trying to lay some groundwork about how to evaluate the eye, and then to walk through those five ocular emergencies.

Leigh Precopio:  What are some common pitfalls when it comes to treating patients who present with ocular emergencies in a primary care setting?

Tara McSwigan:  I would say that the pitfalls fall under the idea of a lack of confidence when it comes to ocular care, and therein a lack of ability to communicate with the appropriate discipline. Unless we are ophthalmologists, none of us are experts in this field.

I've noticed so many primary clinicians, myself included early on, really wanted to avoid...We would avert ourselves when an ocular issue came up. It's not necessarily specific to ocular emergencies as we are discussing today, but eye care in general. There's something very daunting about it.

I would say that the first pitfall is that we as clinicians, we don't feel confident enough in ourselves. The problem with that is we have been trained sufficiently to have that skill set. We have the competence to at least get the ball rolling with so much of this care. Confidence is so important, and a lot of us are lacking it.

The second pitfall is the more we avert involvement with eye care, the less we have the skill to communicate what needs to be done or what our findings are. So much of ophthalmology care is me, as a primary clinician, doing the evaluation and then being able to process it and punt it forward. I need to be able to say, "Hey doctor so and so, this is Tara McSwigan. This is what I find." To you as the ophthalmologist, I need to be able to adequately describe what I am finding to make sure that I ensure that right follow‑up, or initiate the proper care right then and there. It's so crucial that we can describe what we are visually seeing to somebody who is receiving our information on the other end.

Leigh Precopio:  That brings me to my next question. At what point in the treatment continuum would a primary care provider refer their patient to an optometrist or ophthalmologist?

Tara McSwigan:  That is a great question. The first thing I would say is, not necessarily too quickly. Again, bridging on that subject of, we need to take some ownership of these patients. Part of that ownership is our having the ability to recognize what is truly emergent, what is urgent, and what can be handled in a primary setting, perhaps not getting the other discipline involved.

As we are talking about ocular emergencies today, part of my job, part of all of our jobs, in the primary setting is being able to identify, "Yes, this is an ocular emergency." Even among ocular emergencies, there's different levels of that. There are certain things that I discuss in my lecture such as, somebody who has an acute glaucoma. Someone who has an orbital cellulitis. Those need to be dealt with right this second. Those do not wait 24 or 36 hours.

I, in the primary setting, need to be able to recognize and say, "Hey, this one needs to go actually to the emergency room. This one needs to go to see an ophthalmologist right this second."

I also need to be able to discern then, "OK, this is an emergency. This person has an corneal ulcer." That's emergent, but it might hinge on the idea of urgent. In that, do they need to see ophthalmology right this second? No. But as a primary clinician, it is very much my responsibility to reach out to ophthalmology to myself and initiate that care on the appropriate medication in terms of a Quinolone drop for the ulcer, for instance. Initiating the care, and then getting them in the right hands of the ophthalmologist. One other big hindrance that those of us in primary medicine could have is not having access to all of the right equipment. That, unfortunately, can prompt somebody being sent to ophthalmology even sooner.

In other words, if I'm highly suspicious that somebody may have an acute glaucoma, but my only means to evaluate their intraocular pressure...Remember that pressure that is building up in the anterior chamber is gross palpation with my own hands. That is, as implied, a gross evaluation. I don't have access necessarily to a Tono‑Pen for tonometry. I might not have access to a slit lamp to have a more thorough evaluation of the anterior chambers. So some of my need to send to the appropriate specialist or discipline is my lack of equipment to thoroughly evaluate that patient in a primary setting.

Leigh Precopio:  What key messages do you hope primary care providers take away from your session?

Tara McSwigan:  I want primary care providers to hear what they need to hear to encourage them to become more confident on the first end of the discussion say, "Hey, you can ask this history, and then you can execute this exam”, because if we approach it in this X Y Z manner, it is actually very reasonable to navigate. I want to encourage people and instill confidence in people that this is within our scope of practice. It is very much our responsibility to care for these our patients and not necessarily flood a referral system. It's very easy to say, "I'm just going to punt this one out or that one out." That is not good medicine in so many scenarios. We need to take ownership of what we can manage in a primary setting. But then, on the back end of that, to be able to identify what really is an ocular emergency.

If I can identify what the problem is, again, the dichotomy of that is what needs to go right this second or what can I initiate and have prompt follow‑up. This is about empowering the primary clinicians to say, "Hey, yes, I can do this, but I can also recognize what is outside of my scope of practice and what warrants care by ophthalmology."

Leigh Precopio:  What other knowledge gaps exist among primary care providers regarding the management and treatment of ocular emergencies?

Tara McSwigan:  I wouldn't say so much that it is a gap in knowledge. It has been very much, and I've already alluded to this, but it has been the lack of implementation of that knowledge. When we don't use something, it doesn't work that well. That is so true when it comes to ocular medicine. Part of us being confident in primary medicine is being able to say, "Hey, I'm going to go ahead, and I'm going to put this type of medicine into practice." For those of us that have shied back and stepped away from it and said, "Oh gosh, I'm too far gone. I need to send this to ophthalmology." That's not true. If you were listening to this podcast today, it is because you have come around to the point of saying, "You know what? I owe this to my patients. This is in my scope of practice. There should not be a gap in what I can provide to my patients in a primary setting." Taking ownership of this is bridging that potential knowledge gap by listening to podcasts, doing different types of skill sessions. I would say if you listened to my lecture, part of it is knowing how to implement certain hands‑on techniques as well. So much of medicine is we listen to the patient, we come up with our diagnosis.

But when it comes to ocular medicine, we need to have a hands‑on skills as well to know how to introduce fluorescein to stain an eye to look for that ulceration, or to look for that dendritic lesion. To know how to use the Tono‑Pen to access pressure. There's so many parameters that come into the involvement and the care of the eye that I would just challenge us to fill in those gaps by taking the extra measures to further educate ourselves, to refine our hands‑on skills, to take care of our patient. Again, to learn how to best communicate what we are finding, what we are evaluating with the receiving clinician, be it optometry, ophthalmology, whomever that is, or emergency departments depending on the scenario.We need to refine our skills to assess the problem, have the right skills with the hands‑on part of it, and then to refer it outright.

Leigh Precopio:  Great. Thank you again for taking the time to answer all my questions today.

Tara McSwigan:  Absolutely, Leigh. I really appreciate this invitation and this opportunity. This is a subject I hope you can tell I'm very passionate about, and I welcome anybody out in the audience to take a listen to the lecture. Hopefully you will find it helpful. Thank you so much.