Triage of six patients in a four-hour village screening camp

Ranking (most urgent first): iii, ii, i, iv, v, vi. The logic is: how many hours of delay convert a treatable eye into a lost eye.

1. Chemical splash (iii) - tissue destruction is continuing while the chemical sits in the fornices. This is the only case where the correct action is taken by me, immediately, without waiting for any doctor: copious irrigation now (topical anaesthetic if available, lids held open, 20–30 minutes of saline or clean running water, sweeping the fornices). Then transfer.
2. Painful red eye, hazy cornea, halos, vomiting (ii) - this reads as acute angle closure with a very high pressure. Optic nerve damage accrues over hours to a day or two; the patient needs pressure-lowering treatment and a specialist today. Do not dilate, do not lie the patient flat, keep her in the shade and send her on the 14:00 vehicle or earlier.
3. Sudden painless loss of vision that morning (i) - retinal artery occlusion, dense vitreous haemorrhage or retinal detachment. Time of onset matters and should be written down. Arteritic occlusion is sight-threatening to the second eye within days; this patient must be seen the same day, but unlike (iii) there is nothing useful I can do on the spot.
4. Leukocoria in a 7-year-old (iv) - a white pupillary reflex in a child must be treated as possible retinoblastoma until excluded. It is not a minutes-emergency, but it is a life-threatening diagnosis, so the referral should be same-week at the latest and preferably today with the ambulance, with the finding written plainly.
5. Mature cataract (v) - gradual, painless, no red flag. List for the camp's surgical schedule.
6. Refraction only (vi) - do it while the queue moves; it needs no doctor.

Act first, ask later. Caustic injury is the one eye condition where a technician's immediate action changes the outcome more than anything the consultant will do an hour later.

• Anaesthetise the eye if a topical anaesthetic is in the box (for comfort and to allow lid retraction), then irrigate immediately with whatever sterile or clean fluid is at hand - normal saline is ideal, Ringer's or clean running water is acceptable. Do not delay irrigation to search for the perfect fluid.
• Technique: patient sitting or lying with the affected eye down and the head turned so the irrigant runs away from the good eye; hold the lids open (a lid speculum if available, otherwise fingers or a bent paper clip is not acceptable - use gloved fingers), and sweep the upper and lower fornices, especially the upper, where lime and particulate matter lodge. Evert the upper lid to check for particles and remove them with a moistened cotton bud.
• Volume and duration: at least 20–30 minutes, or until the pH of the lower fornix is neutral (litmus paper if available). Check pH after stopping; if still abnormal, resume. Alkali (lime, cement, plaster, drain cleaner) penetrates and needs longer than acid.
• After irrigation: record what was used, how long, the pH before and after, and visual acuity as best as can be measured; instil nothing else unless protocol or the doctor orders it; pad loosely only if advised; and transfer urgently - this patient needs slit lamp examination, fluorescein and specialist care regardless of how well the eye looks.
• Warn the patient: the eye may look quiet and still be severely damaged; do not judge severity by comfort.

Explanation, in plain language and without a lecture: say what you found, why it cannot wait, and what will happen next. For the farmer: "The vision in this eye dropped suddenly today. That can happen when a blood vessel or the retina at the back of the eye is affected, and the chance of saving sight is best if a specialist sees it today. We do not have the machine here to look inside the eye. The ambulance leaves at two o'clock; go straight to the eye OPD at the district hospital and show them this paper." Then check he has understood, that he has someone with him, and that he has money or a scheme card for the journey - practical barriers are the commonest reason referrals fail.

If he refuses, I do not argue indefinitely; I explain the risk once more, record that referral was advised and declined, and get a witness or thumb impression.

On the referral slip:

• Name, age, sex, village and mobile number; date and time of examination.
• Presenting complaint with time of onset and laterality.
• Visual acuity each eye as measured, with the method used, and torch examination findings.
• Working impression written as a suspicion ("sudden painless loss of vision right eye - needs fundus and pressure assessment"), not as a confirmed diagnosis.
• First aid given (irrigant, volume, duration, pH), drops instilled, and time.
• "Referred same day - please assess urgently", with the referring technician's name and the camp's contact number so the hospital can send back findings.