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3tournal of Epidemiology and Community Health 1993; 47:
382-387
Pattern of ophthalmological accidents andemergencies presenting
to hospitals
R S Bhopal, D W Parkin, R F Gillie, K H Han
AbstractStudy objective To investigate the numbersand
characteristics of patients with oph-thalmological accidents and
emergenciespresenting to hospitals.Design-Prospective survey over
eightweeks.Setting-Two general and one ophthalmicaccident and
emergency departments, twogeneral outpatient departments, and an
eyehospital ward consulting room (all in twoteaching hospitals) in
Newcastle upon Tyne.Measurements and main results-Consultation
numbers by age, sex, healthdistrict ofresidence, source ofreferral,
diag-nosis, and disposal were determined. Anaverage of 37
ophthalmological emergencypatients were seen daily. The all cause
con-sultation rate per 1000 population forNewcastle residents was
2*64 (17-2 per year);for injuries it was 110 (7.2 per year) and
forinflammations the rate was 0*91 (5.9 peryear). Consultation
rates per 1000 were 3-5for males and 1-8 for females, the
excessbeing explained by the higher risk ofinjury tomen. Most
patients were self-referred (58%),consulted during office hours
(79-6%), wereattended by senior house officers workingalone
(83-9%), and were asked to return forfollow up (66.1%). Patients in
an accidentand emergency department seldom saw aconsultant in their
initial management. Thediagnoses ofpatients from outside
Newcastlewere little different from those who livedwithin the city.
The 10 commonest problemsaccounted for 68% of all cases. Injuries
werethe commonest problem (40.9% of
alldiagnoses).Conclusion-Ophthalmological accident andemergencies
are an important component ofan accident and emergency
departmentworkload. These patients are usually seen byjunior
doctors, some untrained in oph-thalmology. The wide range of
presentingproblems poses a challenge for training andthe
organisation of effective referral chains,while the gender
difference in injury ratespoints to the potential for
prevention.
_ Epidemiol Community Health 1993; 47: 382-387
Acute ophthalmological problems are common,constituting a
substantial proportion of the workof general practitioners1 2 and
hospital accidentand emergency (A&E) departments. 3 Initialcare
is provided variously by ophthalmologicalnurses,5 6 doctors working
in specialist clinics,8 9
and doctors in general A&E departments.'Information on the
number of patients, theirdemographic characteristics, sources of
referral,management, and disease patterns is required forinformed
discussions on health needs and appro-priate care.8 9 Table I
summarises the main char-acteristics of the few British studies
that providesuch information. With the exception of thesurvey by
Sheldrick et al,2 previous studies eachreported the experience of
one centre but did notrelate it to a defined population, and hence
couldnot be used to calculate disease rates.Our survey adds to
previous observations in
four ways: by comparing ophthalmic and generalcasualty
departments,3 by recording informationon accident and emergencies
which go directly tooutpatient clinics or their equivalent, by
per-mitting the calculation of incidence rates for adistrict health
authority, and by providing data onup to three diagnoses, rather
than one. The studyaddresses the following principal questions.
Howmany ophthalmological accidents and emer-gencies are there and
when do they present? Whatare the age and gender of patients? Where
dopatients come from? Whom do they consult?What is the pattern of
presenting disease?
Data and methodsSEtTINGIn Newcastle, ophthalmological services
are pro-vided on a subregional basis in two teachinghospitals, the
Royal Victoria Infirmary (RVI) andthe Newcastle General Hospital
(NGH). At theRVI, patients may be seen at the A&E departmentby
non-specialist staff, or by specialist staff eitherat the
ophthalmology outpatient department orthe inpatient ward side-room.
A&E staff andgeneral practitioners both refer patients to
thelatter.At the NGH patients may be seen during office
hours at an ophthalmic A&E department or theophthalmology
outpatient department. Out ofhours patients are seen at the general
A&E depart-ment, where an ophthalmic nurse is usuallyavailable,
and are often referred for follow up tothe ophthalmic A&E
department or ophthalm-ology outpatient department.These hospitals
draw patients from a wide
catchment area with a population of about1 100 000, of which
about 25% resides in theNewcastle Health Authority area.8 The
nearestalternative specialist facilities in the northernhealth
region are in Sunderland, Darlington, andSouth Tees. There are no
other A&E departmentsin Newcastle, the nearest being in
Gateshead andNorth Shields. Newcastle residents would beunlikely to
be referred or to refer themselves to
Division ofEpidemiology andPublic HealthMedicine, Universityof
Newcastle uponTyne, The MedicalSchool, FramlingtonPlace, Newcastle
uponTyne NE2 4HHR S BhopalD W ParkinDepartment
ofOphthalmology,Newcastle GeneralHospitalR F GillieAccident
andEmergencyDepartment,MiddlesbroughGeneral HospitalK H Han
Correspondence to:Dr R S Bhopal
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383Ophthalmological accidents and enmergencies
Table I Characterstlics of six studies of ophthalmological
accident and emergency services in relation to the present
studyPlace
Varnable Bristol6 Leicester7 Souithamptonz5 Canterbury/Kent?
Worcester' Nottingham2 Newcastle upon TyneSetting Eye clinic Eye
clinic Eye casualtv General casualty Eye casualty 7 of 25 general
Eye casualty, eye
practices in clinics, and generalNottingham and eye
casualtycasualty
Population served Urban/rural Urban/rural Urbanirural Largely
rural Urban/rural Mainly urban Urban/rural(about 835 000) (about
410 000) (about 240 575) (about 36 018) (about 1 100 000)
Access to service - - Open Open Open Open Open to casualtiesand
by referral toclinics
Consulting Doctors Doctors Ophthalmic Doctors Ophthalmic GPs
& eye Doctorsprofessionals nurses doctors nurses/doctors
casualty staff (few by nurses)Timing of study Feb-Julv 1981 Sept
1981-Aug Feb-July 1983 May 1983-Apnrl May & June 1989 March
1989-Feb April-June 1989
1982 1984 1990No. of new 7113 6576 8092 1870 1629 1771 GP
2068patients or consultations, 816 eyeconsultations casualty
consultationsDiagnostic coding Ad hoc ICD Ad hoc Ad hoc Ad hoc Ad
hoc Ad hocNo. of diagnoses 1 1 1 1 1 Not stated 3recorded
hospitals outside the city, though patients whowere outside the
city at the time of illness may nothave consulted doctors in
Newcastle.
DEFINITION
An ophthalmological accident and emergency wasdefined as "an eye
problem, which, in the opinionof patients or their professional
advisers, needsimmediate (same day) consultation in either
anaccident and emergency department or anophthalmology outpatient
department". Patientsadmitted directly as inpatients, that is
bypassingoutpatient and A&E departments, were excluded.
DATA COLLECTION
For eight weeks starting on 10 April 1989, aproforma was
completed for every patient. Thefirst part was completed by
reception staff and thesecond by the consulting doctor, except for
thediagnostic code which was sometimes entered byone ofthe research
group. These codes were basedon an ad hoc disease classification.
(Proforma andclassification are available from the authors.) Upto
three diagnoses could be recorded for eachpatient. We did not
record the cause of theunderlying disease, for example the reason
for theinjury.The data were analysed using the Statistical
Package for the Social Sciences. For calculatingdiagnosis
specific rates (as in table V) informationon up to three diagnoses
was used. Diagnoses werecategorised as injury, inflammation, and
other.Diagnoses were also grouped as "serious" or"non-serious",
based on whether an expert oph-thalmological opinion on first
presentation wouldusually be required for example hyphema,
iritis,and cyclitis were in the "serious" category (a fulllist of
"serious" conditions is available from theauthors).The health
district of residence was identified
from the postcode for 1398 patients, using acomputerised
postcode directory, and from thetown of residence for 487, using an
index of townnames and local authority districts. The districtwas
not identified for 183 (8 8%) patients. Dis-tricts were further
categorised as being inNewcastle Health Authority, surrounding
healthauthorities, more distant health authorities withinthe
Northern Regional Health Authority area, andthose outside the
northern region. Age, sex, anddisease specific rates were
calculated for
Newcastle Health Authority using 1988 OPCSpopulation
estimates.
ResultsTable II summarises data on the main variables,while
table III gives the age and sex specific ratesand ratios for the
Newcastle Health AuthorityArea. These data are discussed below in
thecontext of some subgroup analyses (nottabulated).
NUMBER, TIME OF ARRIVAL, AND PLACE OFRESIDENCE OF PATIENTSThere
were 2068 new patients-by extrapolation,an estimated 13 416
patients per year. Most wereseen in the NGH eye casualty
department(63 1%), the NGH A&E department (13-6%), orthe RVI
A&E department (19-1%), and few inoutpatient clinics or the
hospital ward (4 2%).
Table II Patients' characteristicsCharactenrstic (nzo of
patients) No. (%)Gender (2061)Male 1385 67-2Female 676 32.7
Age group (2068) (y)0-4 43 2 15-15 126 6 116-64 1577 76-365+ 322
15-6
Source of referral (1990)Self 1160 58-2GP 409 20-5Hospital 107
5-4Work/school 227 11-4Optician 22 1.1Other 69 3.5
Time of arrival (2026) (h)09-12 1000 49-413-17 610 30 118-21 272
13422-08 144 7 1
Diagnoses categorised as (2068)Injury 913 44-1Inflammation 667
32-3Other 488 23-6
Diagnoses grouped as (2068)Senrous 453 21 9Non-serious 1615
78-1
Action taken (2054)Discharged 754 36-7Asked to return 548
26-7Referred to outpatients 393 19-1Admitted 58 2-8Other 301
14-7
Grade of staff seeing patients (n=2052)Senior house officer
(SHO) 1722 83-9SHO and registrar 79 3-8Registrar or senior
registrar 80 3-9Junior and consultant 32 1-6Consultant 73 3
6Clinical assistant 66 3-2
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R S Bhopal, D W Parkin, R F Gillie, KH Han
Table III Consultation rates and ratios by age and sex for
Newcastle Health Authorityresidents
Males Females MalelFemale Ratio All casesPop Ratel Ratel Ratel
Estimated
Age group (y) Cases (000's) 1000 Cases Pop 1000 Ratio 95% CI
1000 annual rate0-4 12 7 7 1 56 10 6-8 1 47 1 06 (0-46, 2 45) 1 52
9 865-9 17 8-7 1 95 4 8-1 0-49 3 96 (1-33, 11 8) 1 25 8 1310-14 13
7-8 1 67 5 7-4 0-68 2 47 (0-88, 6 92) 1 18 7 7015-19 27 10 5 2-57
22 10-4 2 12 1 22 (0-69, 2-13) 2 34 15 2420-24 37 13-1 2-82 24 12 2
1-97 1 44 (0 86, 2 40) 2 41 15 6725-29 54 11-5 4 70 21 11-2 1-88
2-50 (1 51, 4 14) 3 30 21 4830-34 41 9-8 4 18 17 9 5 1 79 2-34 (1
33, 4-11) 3 01 19 5335-39 47 9 3 5 05 17 8-8 1 93 2-62 (1 50, 4 55)
3 54 22 9840-44 41 93 441 13 90 1-44 305 (1 64, 5-69) 295 19
1845-49 42 7-3 5-75 11 7-1 1-55 3 71 (1-91, 7 21) 3-68 23 9250-54
29 7-0 4 14 16 7-3 2-19 1 89 (1-03, 3 48) 3 15 20 4555-59 32 7 0 4
57 17 7 5 2-27 2 02 (1-12, 3 63) 3-38 21-9760-64 27 7 0 3 86 15 7 8
1 92 2-01 (1 07, 3 77) 2-84 18 4565-69 17 6-6 2 58 16 8 2 1 95 1-32
(0 67, 2-61) 2 23 144970-74 8 4-7 1 70 11 6 7 1 64 1-04 (0 42, 2
58) 1 67 10-8375-79 9 3 6 2 50 15 6 3 2 38 1-05 (046, 240) 242 15
7680-84 8 1 9 421 17 45 378 1 11 (048, 258) 391 25 3985+ 10 1-0
1000 8 3 5 2 29 4-38 (1 73, 11-1) 400 2600Total 471 133-8 352 259
1423 1 82 1-93 (1 67, 225) 264 17 19
Weekly counts of completed forms indicated con-sistency for the
A&E departments and the eyecasualty department, but not the
other sites wheresome cases were clearly not recorded. We
estimatethat about 90 (5%) patients seen at the outpatientclinics
were not recorded.There were more patients on weekdays (daily
average=40) than weekend days (Sundayaverage=21, Saturday
average=25). About onefifth (20 5%) of all patients were seen
in"unsocial" hours-that is between 6 pm and 9 am(table II). By
comparison, 12-8% of patients withconditions in the "serious" group
presentedduring these hours; 14-3% of patients withinflammations
and 26% of patients with injuriespresented between 6 pm and 9
am.
Thirty nine per cent of patients were NewcastleHealth Authority
residents, 50% came from sur-rounding districts, 10% came from
distant dis-tricts, and less than 1% came from districts outsidethe
northern health region.
AGE AND SEX DISTRIBUTION OF CASES AND INCI-DENCE RATESThe mean
age was 41 years (range 0-94, median39). Those of working age were
most likely toconsult, and overall, men were almost twice aslikely
to consult as women; this gender differentialalso applied to
children. The male excess was seen
overwhelmingly in the "injury" category, in whichmales accounted
for 84% ofcases. The age and sexdistribution summarised above is
reflected in theconsultation rates for Newcastle residents, shownin
table III and the figure. Overall, there were 2.6consultations per
1000 population over the studyperiod, an estimated 17-2 per 1000
per year.
Older people were more likely to haveinflammatory conditions and
problems which fellinto the "serious" group, while younger
patientswere. more likely to have injuries. For example,those over
60 years formed 20-1 % of all patients,29-6% of patients with
problems in the "serious"group, 27-9% of those with inflammatory
prob-lems, and 4 9% of those with injuries.
SOURCE OF REFERRAL, GRADE OF CONSULTINGDOCTOR, AND ARRANGEMENTS
FOR REVIEW OFPATIENTMost patients referred themselves to both the
RVI(77-1 %) andNGH (73 3%) A&E departments. Atthe NGH
ophthalmic A&E department, 51% ofpatients were self referred.
Overall, self referralaccounted for 58-1% of cases. Other sources
ofreferral were general practitioner (20 5%), workor school (11
4%), and hospitals (5-4%).
Patients were most likely to see a senior houseofficer alone (83
9%), or a senior house officerwith a registrar (3 8%). At the NGH
A&E, whichhad the highest rate for out of hours presentation,97
3% of patients saw a senior house officeralone. There, 96% of
patients in our "serious"group of conditions were also seen by a
seniorhouse officer alone though most of these patientswould also
have been seen by the ophthalmicnurse.Only 104 patients (5-1%) were
seen by a
consultant, and of these 72 (3 5%) saw only aconsultant. There
were few (4 (0.6%)) con-sultations with consultant ophthalmologists
in thetwo A&E departments; the remaining 68 tookplace in the
other three sites. Twenty two condi-tions were listed by one of us
(Mr R F Gillie) asusually warranting specialist advice (for
example,orbital injury, venous obstruction, glaucoma,
etc).Altogether 67-8% of patients (160 of 236) withthese diagnoses
were seen by senior house officersalone. Seventeen (9%) of these
patients were
10
9 *Males8 Females
8
7
0)
3
2
0
Age group (y)Figure Consultation ratesby age and sex
forNewcastle residents
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Ophthalmizological accidetnts anid emergencies
discharged, 14 (8 2%) ofwhom had, on discharge,been seen by a
senior house officer alone.Most patients were either asked to
return
(26-7%), referred to outpatients (19-1 %), or weredischarged to
general practitioner care (36 7%).Few were admitted to
hopsital.
PATTERN OF DISEASETable IV shows the diagnostic pattern,
arrangedanatomically. The 10 commonest diagnoses,which accounted
for 68% ofthe total, were cornealinjury, acute conjunctivitis,
superficial keratitis,conjunctival injury, iritis, subconjunctival
haem-orrhage, lid injury, chronic conjunctivitis, cornealulcer and
tarsal cyst. A total of 163 diagnoses wereadded by recording more
than one diagnosis.Table V gives total and gender specific
disease
rates for selected diagnoses and categories of
CHARACTERISTICS OF PATIENTS W'ITH INJURY, ANDCONDITIONS GROUPED
AS "SERIOUS"Patients with injury, compared with those withother
conditions, were more likely to be male(84-5% v 53-5%), younger
(mean age 34 v 46years), to be referred from work or school (19 -
3%v 5-1%), and less likely to be referred on to theoutpatient
department (5 5% v 29-9%).
Patients with diagnoses categorised as "serious"were more likely
to be referred by a generalpractitioner (37-6% v 15 7%), to be seen
by adoctor other than a senior house officer (25-2% v13-5%), and to
be admitted to hospital (8-7% v1-2%) than those with other
conditions. There-fore, patients with conditions in the
"serious"group seem to be managed differently fromothers.
disease for residents in the Newcastle Health COMPARISON OF
PATIENTS FROM NEWCASTLE,Authority area. The male to female ratio
for SURROUNDING, AND DISTANT DISTRICT HEALTHinjuries was 5-5:1.
AUTHORITIES
Patients from the three geographical areas weresimilar with
regard to time of arrival, grade of
Table IV Diagniostic pattern of conslultationi: aniatomical
categonres doctor seeing patient, and action on discharge..irst
Second Third Total There were three substantive and
statisticallydiagnlosis (%,) diagnosis (%) di'agnlosis ( I,(
significant differences. Firstly, fewer patients from
Lids 183 (9 0) 11 (7-6) 3 (16-7) 197 (8-8) distant districts
than from Newcastle were child-Lacrimal 15 (0-7) 2 (1-4) 0 17 (0 8)
ren (3-7% v 9-8%) (x2=8-54, df=l, p
-
R S Bhopal, D W Parkin, R F Gillie, K H Han
diagnosis, we recorded three. As 171 diagnoseswere added in this
way, past studies have slightlyunderestimated the problem of
ophthalmologicalaccidents and emergencies.
INTERPRETATION OF THE RESULTSHealth services research such as
this is intended tohelp plan local services and appraise the need
forand the nature of existing services. It is importantto consider
critically whether patterns of care areappropriate to population
needs. We now assessour findings in the light of those of
otherresearchers, summarised in table VI.As these surveys show, the
workload created by
ophthalmological accidents and emergencies issubstantial. The
consultation rates in tables III andV offer an opportunity to
estimate the workload ingiven populations by applying the given age
and sexspecific rates. The annual consultation rates here(overall
17-2) are a little lower than those fromNottingham (22 7) but,
given the relatively smallnumbers on which they are calculated (730
and 816respectively), the two figures are mutually support-ing. The
age and sex pattems in the Nottinghamand Newcastle studies are
similar.
Information on consultation patterns could intime allow for the
rational planning of rotas. It isnotable that patients with more
serious oph-thalmological problems in our "serious" groupwere not,
contrary to expectation, more likely topresent during unsocial
hours. As with a previousreport,5 we found that out of hours cases
were asmall proportion of the total, and were mainlyinjuries.Most
cases were self referred (58 1%), particu-
larly injuries. Three other studies3 5 found thatnearly 90% of
patients were self referred. Oph-thalmological conditions are
commonly treated ingeneral practice. In one study only 15%
werereferred to hospital,' and in another2 about twothirds of
consultations were in general practice. Itis clear, however, that
patients view hospitals as animportant source of primary care for
such prob-lems, particularly injuries. The pattern of prob-lems
seen in general practice and hospital isdifferent. This is
illustrated by McDonnell'sstudy, where bacterial conjunctivitis was
10 timescommoner than comeal abrasion and foreignbody, ' while in
our study corneal injury was nearlythree times as common as acute
and chronicconjunctivitis.The few referrals from
optometrists/opticians,
confirming other findings,2 4 6 indicate that theirrole in the
primary care of acute ophthalmological
problems is small. Yet their premises are oftenbetter equipped
for identifying, if not dealingwith, simple problems such as
foreign bodies(which are best identified using a slit lamp)
thangeneral practitioners' surgeries and some generalcasualty
departments.
Referrals from doctors, in contrast to selfreferrals, were more
likely to be to outpatientdepartments, the ward, or the ophthalmic
A&Edepartment than to the general A&E depart-ments.
Clearly, doctors do distinguish betweenthe need for general
hospital advice and oph-thalmological hospital advice. Further,
profes-sionally referred patients were more likely to be inthe
"serious" group. Patients were likely to be seenby a senior house
officer alone, however, almostirrespective of their place of
residence, time ofarrival, diagnosis, and referral source. A
con-sultant opinion was rare, except in outpatientclinics or wards,
a generalisation supported byother studies.4The service for
ophthalmological accidents and
emergencies was led by senior house officers,particularly in the
two general accident andemergency departments. This may be the
mostappropriate grade of doctor to provide care butclearly he or
she may need ready access to anopinion from a senior colleague or
consultant.Few senior house officers, however, saw a
patienttogether with a senior colleague. In our study,discharge to
general practitioner care was lesslikely than in several others
(see table VI). The lowdischarge rates indicate that the doctors
did notperceive the presenting problems as minor.While diagnoses
relating to injuries and con-
junctivitis predominated, there was an extremelydiverse mix of
cases at each site. Thus senior houseofficers, and ophthalmic
nurses if appropriate, inA&E departments must be adept at
distinguishingpatients with easily diagnosed and minor prob-lems
from those with such diagnoses as comealulcer, vitreous
haemorrhage, iritis, and glaucoma.There is a wide range of problems
about whichboth ophthalmological and general senior houseofficers
need training. If GPs are to provide firstline care, further
training is likely to be neces-sary.'0 Those who have studied the
role of oph-thalmic nurses in first line care seem satisfied
withthe service provided.4 5 Medical audit is required,in the face
of the diversity nationally and inNewcastle alone, to study the
quality of careprovided by various models of care. Thoughtneeds to
be given to the nature, costs, andeffectiveness of training.
Place
Characteristics Bristol6
Modal age range (y)Sex ratio (M:F)Estimated No. of new
patients daily 39Out of hours (%)Referral:
SelfGP 7.
(GIOptician NS
Discharged 60Diagnosis (%):Trauma 45'Inflammation 35*
NS=not stated
Leicester7
20-292-4:1
19
56-03 300P or optician)
1-0*0 78-0
0.0 29-0
Southanzpton-5
M>F
4418 1
89-97.3
CanterbiKetit'20-293:1
5
89-7NS
0-7 -77-8 68-9
436
Newcastle1fl upon Tvne
Worcester4 (present stutyv)20-29 21-30
2:1
27
86 89 2
NS53-8
65-621 7
3720 5
58-220 5
1-136-7
44-132-3
Table VI Summary ofselected results from fivestudies of
ophthalmologicalaccidents and emergencies
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Ophthalmiiological accidenits anid emiiergenicies
Injury, which is a major cause of serious eyedisease, including
blindness, constitutes a highproportion of the emergency cases
presenting tohospital. The fivefold difference in injury
ratesbetween men and women is similar to that shownin Nottingham,2
a US population study, I and in astudy of ocular trauma cases at a
hospital. 12Interestingly, the injury excess also occurs
amongchildren in the age groups 5-14 years, as is alsoreported
elsewhere.2 4 This excess is not, there-fore, solely due to an
occupation related risk, butreflects differences in behaviour and
social cir-cumstances. This inequality deserves furtherstudy.
Meanwhile, the use of safety glasses orgoggles during activities
that can lead to eye injuryneeds to be more widely
emphasised.'3
In conclusion, this survey portrays a seniorhouse officer led
service that provides a mix ofprimary and secondary care to a large
geographicalarea. Some patients travel from afar to seek
aconsultation, and many return for review. Patientsfrom distant
districts were no more likely to bedischarged to general
practitioner care than thosefrom Newcastle; clearly geographical
considera-tions do not loom large in the consultation.Among the
fundamental policies of the NHSreforms9 are that money should
follow the patient,and that patients' views on care should be
con-sidered. The effect of implementation of policieswhich might
involve the reorganisation ofophthalmological services so that
patients travelmoderate distances only for a specialist opinionbut
local services deal with most common prob-lems needs monitoring.
Whether such local firstline care should be provided by
generalpractitioners, ophthalmic nurses, specially trained
hospital junior staff, or general hospital A&E staffrequires
wider discussion.
Many nurses, doctors, and clerical staff diverted theirenergy to
help collect the data. Detailed advice orassistance was provided by
ProfessorA L Crombie, Mr AK Maitra, Dr H G Pledger (who instigated
the study),Mr K Stannard, Dr G Sanders, Mr D D Milne, Mr G ABarnes,
Mr S White, Mrs P Bignall, Ms J Hastie, Mrs LOrmond, and Ms J
Seddon. Mr L Hutchinson patientlyand ably prepared the manuscript.
The anonymousreferee provided helpful comment. Our thanks to
all.
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in the community? Br] Ophthalmiiol 1988; 72: 733-6.
2 Sheldrick JH, Vernon SA, Wilson A, Read SJ. Demandincidence
and episode rates of ophthalmic disease in adefined urban
population. BMJ 1992; 305: 933-6.
3 Edwards RS. Ophthalmic emergencies in a district
generalhospital casualty department. Br .7 Ophthalmol 1987;
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4 Burton RC. Ani auidit of Worcester Eye Hospital
CasualtyDepartmlenit. May and June 1989. Worcester: 9.
(Availablethrough authors.)
5 Jones NP, Hayward JM, Khaw PT, Claoue CMP, ElkingtonAR.
Function of an ophthalmic "accident and emergency"department:
results of a six month survey. BMJ 1986; 292:188-90.
6 Vernon SA. Analysis of all new cases seen in a busy
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7 Chiapella P, Rosenthal AR. One year in an eye casualtyclinic.
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plan1985-1994. Newcastle, Northem Regional HealthAuthority
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9 Secretaries of State for England and Wales, Scotland
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10 Wilson A. The red eye: a general practice survey. _7 Roy,
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11 Glynn RJ, Seddon JM, Berlin BM. The incidence of eyeinjuries
in New England adults. Arch ophthalnmol 1988; 106:785-789.
12 Liggett PE, Pince KJ, Barlow W, Ragen M, Ryan S. Oculartrauma
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