Title : Visual acuity assessment for eye presentations to the emergency department a retrospective audit across a London NHS Trust
Abstract:
Background: In the UK, eye-related complaints account for up to 6% of Emergency Department (ED) attendances, with an estimated annual incidence of 20–30 ophthalmic emergencies per 1,000 population. Approximately two-thirds of these presentations are managed entirely within the ED. As per clinical guidelines, visual acuity (VA) assessment is a core component in initial assessment of patients presenting with ocular symptoms. In the ED setting, VA provides an objective baseline of visual function, supports risk stratification and diagnostic decision-making, and facilitates early identification of potentially sight-threatening emergencies.
Aim: To evaluate the completeness and quality of visual acuity (VA) assessment and documentation for compos mentis adult patients presenting to the Emergency Department (ED) with eye-related complaints across Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT).
Methods: A retrospective, cross-site clinical audit of ED attendances at Queen’s Hospital (QH) and King George Hospital (KGH) was conducted. Adult patients (≥18 years) presenting with an eye-related concern were identified from electronic ED clerking records. Data was extracted for 150 consecutive patient attendances between 14 August 2025 to 30 September 2025. The primary outcome was the proportion of eligible patients with VA assessed and documented in ED clerking records. Secondary outcomes included quality indicators of assessment and documentation: monocular VA recording, notation accuracy in a standard format, and reassessment using a pinhole occluder when VA is <6/6.
Results: Among 150 patients, 91 (60.7%) were female and 59 (39.3%) male. Presenting complaints were predominantly blurred vision 76/150 (50.7%), followed by ocular pain 29/150 (19.3%), red eye 27/150 (18.0%), and trauma 21/150 (14.0%). VA assessment was clinically feasible in 146/150 (97.3%) of attendances, and was not indicated in four cases due to clinical instability or cognitive impairment. The assessing practitioner was a doctor in 121/150 (80.7%) cases, with other clinician groups accounting for 29/150 (19.3%). VA was documented in 12/146 (8.2%) of eligible attendances, indicating that for 134/146 (91.8%) of eye-related presentations to ED, there was no documentation of VA assessment. Where documented, VA was recorded monocularly in 10/12 cases. Reduced VA (<6/6) was recorded for 9/12 examined patients, none of whom had a documented reassessment using a pinhole occluder. VA notation errors were identified in three records, reflecting non-standard or incorrect formats. Ophthalmology follow-up was arranged in 39/150 (26.0%) attendances; however, 33/39 of these referrals lacked documented VA to inform downstream triage and prioritisation.
Conclusions: Despite near-universal clinical eligibility, VA assessment and documentation in ED eye-related presentations were infrequent and often incomplete with respect to key quality standards, including reassessment using a pinhole occluder for reduced VA. The high proportion of ophthalmology follow-up referrals without supporting VA documentation underscores a system-level gap with potential implications for clinical decision-making, referral quality, service efficiency and medico-legal liability. These findings support implementation of targeted training, standardised documentation prompts, and point-of-care tools to improve VA assessment and adherence to best-practice assessment pathways.
