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OP10.1-7 | Miscellaneous Skills, Emergencies and Community Ophthalmology — PBL Case

CLINICAL SETTING

A district general hospital eye casualty, Saturday morning. Dr Priya, a final-year MBBS intern, is the only doctor available. Two emergencies arrive simultaneously. Emergency 1 — Ramu, 42 years, a sugarcane farmer: he was mixing lime (calcium hydroxide) solution to whitewash his house walls when a large splash entered his left eye. He presented 40 minutes after the injury. His wife says he rubbed his eye vigorously after the splash. On examination: VA right eye 6/6, left eye hand movements only. Left eye shows severe blepharospasm, white ischaemic conjunctiva from limbus to equator, and a ground-glass opaque cornea. Emergency 2 — Shanthi, 34 years, a field labourer: she was struck by a sugarcane stalk tip in her right eye while harvesting. On examination: the right eye is soft (low IOP), there is a full-thickness limbal wound 4 mm in length with iris tissue prolapsing through the wound, and vitreous is visible in the wound. VA right eye = light perception only. Left eye is normal. Later that day, Dr Priya joins a NPCBVI outreach blindness camp in a nearby village where 400 adults and 60 children are screened.

Trigger 1: The Chemical Burn — Assessment and First Response

Ramu is brought in crying, holding his left eye tightly shut. He is in severe pain. His wife is panicking. Dr Priya notes the severely ischaemic conjunctiva and opaque cornea on the left side. She also notices that 40 minutes have already passed since the injury. A junior nurse asks: 'Should I call the specialist first before we do anything?'

DISCUSSION POINTS

  • What is the FIRST action Dr Priya must take, and should she wait for a specialist? Explain the time-criticality of chemical burns versus other ocular emergencies.
  • Why is lime (calcium hydroxide — an alkali) more dangerous to the eye than sulphuric acid? Explain the molecular mechanism of tissue damage and why it is self-perpetuating.
  • Describe the step-by-step irrigation protocol: what fluid to use, how to overcome blepharospasm, how long to irrigate, and what endpoint confirms irrigation is complete.
  • Using the Roper-Hall grading system, classify the left eye injury from the findings described. What does the limbal ischaemia specifically predict about the long-term prognosis?
  • What is the correct position of the patient during irrigation, and why should the right (unaffected) eye also be checked?
Click to reveal Trigger 2: The Open Globe Injury — Management and Referral (discuss previous trigger first!)

Trigger 2: The Open Globe Injury — Management and Referral

Shanthi is assessed next. On examination, iris tissue is prolapsing through the limbal wound and vitreous is visible. There is no Fox shield in the casualty tray. The nearest tertiary eye unit is 3 hours away by road. A medical student with Dr Priya suggests: 'Should we try to push the iris back in and close the wound here? The patient can't travel 3 hours like this.' The patient is also nauseous and is retching.

DISCUSSION POINTS

  • Classify Shanthi's injury using the BETT (Birmingham Eye Trauma Terminology) classification. Is this a penetrating or perforating injury, and what is the significance of the visible vitreous?
  • Why is the medical student's suggestion to reduce the prolapsed iris and close the wound at the district hospital potentially harmful? What are the risks of attempting repair at a non-specialist centre?
  • There is no Fox shield available. What improvised measure can Dr Priya use to protect the eye during transport, and what must she specifically avoid doing to the eye?
  • The patient is retching. Why is this clinically significant in open globe management, and how should it be addressed before transport?
  • List the five immediate management steps Dr Priya should complete before arranging transfer, and what information she should communicate to the receiving tertiary centre.
Click to reveal Trigger 3: The NPCBVI Blindness Camp — Community Ophthalmology in Action (discuss previous trigger first!)

Trigger 3: The NPCBVI Blindness Camp — Community Ophthalmology in Action

At the afternoon blindness camp in the village, Dr Priya and a team screen 400 adults and 60 children. Findings: adults — 60 with VA <6/18 (better eye, best correction), 28 with VA <6/60, 10 with VA <3/60, predominantly from dense cataracts; children — 4 with Bitot's spots, 6 with night blindness, and 1 with a hazy softening cornea in one eye. A local village elder tells Dr Priya: 'We know about the free cataract surgery at the district hospital but people are afraid — they say one man became completely blind after the operation and now nobody goes.' The village has no supplementary feeding programme.

DISCUSSION POINTS

  • Using WHO ICD-11 (2018) definitions, classify the adult patients screened into the correct visual impairment and blindness categories. How does India's NPCBVI operational definition of blindness differ from WHO ICD-11?
  • Stage each group of children using the WHO xerophthalmia classification. Which child requires immediate treatment before they leave the camp, and what is the correct treatment protocol to administer on the spot?
  • What is the Cataract Surgical Rate (CSR)? If this block of 150,000 population performed 450 cataract operations last year, calculate the CSR and compare it to the Vision 2020 target. What does the elder's story about a bad surgical outcome represent in terms of the NPCBVI cataract backlog?
  • List the four leading causes of blindness in India in order of prevalence, and distinguish between 'avoidable blindness' and 'unavoidable blindness' with examples from this camp.
  • Propose a structured plan Dr Priya could submit to the District Health Officer to address the demand-side barriers at this camp, referencing specific NPCBVI programme components.

Learning Issues

Research these questions and bring your findings to the discussion.

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