Ophthalmic Emergency Department Visits at a Tertiary Medical Center in Israel: Demographics and Clinical Characteristics Over a Six-Month Period

Introduction

The Emergency Department (ED) is responsible for treating emergent cases that require immediate attention. However, many patients present to the ED with urgent conditions that require care but could wait. As a result, ED overcrowding is a global problem that has a direct negative impact on patients, ED staff, and hospital finances.¹ Studies show that preventable non-urgent cases account for 30–40% of all ED visits in the United States and Canada.^2–4

Ophthalmic diseases and injuries represent a significant portion of the daily workload in EDs, with nearly 2 million eye-related cases presenting annually in the United States alone.^5,6 The estimated prevalence rate of patients referred to general emergency with ocular complaints ranges between 1–6% of the total visits.⁷

Ophthalmic emergencies are generally defined as conditions requiring immediate intervention to prevent permanent vision loss, such as retinal detachment, acute glaucoma, or ocular trauma, whereas urgent or non-emergent ophthalmic complaints include conditions that are symptomatic but can often be managed safely in outpatient or community-based settings.^8,9

Previous studies have demonstrated that non-emergent ophthalmic conditions constitute a substantial proportion of emergency department visits, accounting for nearly half of all ophthalmic presentations in some high-volume centers.⁵ Similar findings have been reported in European tertiary care settings, underscoring the need for improved triage systems to differentiate true emergencies from conditions appropriate for outpatient management.^8,10–12

In Israel, Ministry of Health records from 2015 indicate that ocular and adnexal conditions accounted for 1.5% of all emergency department visits.¹³ Furthermore, data from various urgent care centers estimate that the prevalence of conjunctivitis is 0.84%, while conjunctival and corneal injuries account for 0.8% in smaller healthcare facilities across the country.^14,15

The Jerusalem metropolitan area, with a population of 1,183,000 as of 2020,¹⁶ has two tertiary healthcare centers, one of which is the Hadassah Medical Center (HMC). Serving approximately 1 million patients annually, the center recorded an estimated 144,855 ED admissions in 2020.¹⁷

Given Israel’s growing population, it is essential to define the epidemiological characteristics of ophthalmic ED admissions to manage patient load, optimize resources, and develop appropriate solutions for non-emergency cases. Optimizing ophthalmic triage pathways is increasingly recognized as essential for improving emergency department efficiency and resource utilization, particularly in healthcare systems facing growing demand and workforce constraints.⁹

Therefore, this study aimed to characterize the demographic and clinical features of patients presenting to a tertiary ophthalmic emergency department in Israel, quantify diagnostic distributions, and identify patterns suggestive of potentially non-urgent care utilization. We also examined demographic and clinical predictors of follow-up referral using regression modeling to inform triage optimization and community ophthalmic care planning, rather than to estimate the true incidence of ophthalmic emergencies. These data, although collected in 2018, provide a valuable pre–COVID-19 baseline for ophthalmic emergency department utilization. Given the substantial changes in healthcare access and patient behavior following the COVID-19 pandemic, this study offers important context for interpreting more recent trends. Unlike prior Israeli reports from general emergency or urgent care settings, this study focuses specifically on a tertiary ophthalmic emergency service.

Materials and Methods

This retrospective study covered a six-month period, from January to June 2018. Data were gathered from the electronic medical records (EMR) of patients examined at the ophthalmic ED of HMC in Jerusalem, Israel, and anonymized prior to analysis, with a total of 1,406 patients included. Patients could only present at the ophthalmic ED after being referred from the general ED at HMC. The EMR data collected included, among other details, age, gender, medical and ocular history, chief complaint, and the final diagnosis after examination. Follow-up recommendations, such as referrals to the Hadassah Ophthalmology Clinic or a local community ophthalmology clinic, were also recorded.

Ophthalmic diagnoses were classified according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9). Similar but not identical diagnoses were grouped into eleven main categories for statistical analysis (based on ICD-9 classifications): eyelid and orbital disorders, ocular surface and corneal disorders, uveitis and scleral disorders, vitreous and retinal disorders, optic nerve and neuro-ophthalmic disorders, neurological and head trauma related complains, lens disorders, trauma, glaucoma, eye trauma and foreign bodies, strabismus and nystagmus and systemic and miscellaneous conditions (Table 1).

Table 1 Categorization of Ocular Complaints and Diagnosis

Given the potential for overlap between diagnostic categories, a hierarchical approach was used to assign each case to a single primary diagnostic category. Classification was based on the principal diagnosis documented at the conclusion of the ophthalmic emergency department evaluation and the primary anatomical structure or pathology driving clinical management. Trauma-related presentations were categorized according to the main site of injury (eg., eyelid or orbital trauma classified under eyelid and orbital disorders), whereas the “eye trauma and foreign bodies” category was reserved for isolated ocular surface or globe injuries without associated adnexal involvement. Each visit was assigned to only one diagnostic category to avoid duplication.

Although formal urgency triage scores were not available, presentations resulting in a final diagnosis of no ocular pathology or conditions typically manageable in outpatient or primary care settings (eg., uncomplicated anterior segment disorders) were considered proxies for non-urgent ED utilization, consistent with prior ophthalmic ED literature.

Inclusion/Exclusion Criteria

All patients who presented to the ophthalmic emergency department at Hadassah Medical Center between January and June 2018 were eligible for inclusion. Visits were included if the patient underwent a complete ophthalmic evaluation and had a documented final diagnosis. Records with missing key demographic or diagnostic data were excluded.

Due to anonymization of electronic medical records, repeat visits by the same patient could not be reliably identified; therefore, each emergency department visit was considered a single independent entry. Also, the six-month study period (January–June) may not fully capture seasonal variation in ophthalmic presentations, particularly trauma- and ocular surface–related conditions.

Patients were evaluated in the ophthalmic emergency department by ophthalmology residents under the supervision of attending ophthalmologists. All patients were initially assessed in the general emergency department and referred to the ophthalmic ED according to institutional triage protocols, reflecting the standard emergency care pathway in Israel.

Patients were stratified into four age groups (0–14, 15–34, 35–49, and ≥50 years) to reflect clinically meaningful life stages and differences in ophthalmic disease patterns. This age categorization is consistent with prior epidemiologic studies of ophthalmic emergency department utilization and facilitates comparison with national demographic data.

Follow-up recommendations were categorized into primary follow-up (FU1), defined as the initial referral decision made at discharge from the ophthalmic emergency department, and secondary follow-up (FU2), defined as additional follow-up recommendations documented after the initial evaluation. These categories were used to assess patterns of care utilization and follow-up needs. Due to limitations inherent to retrospective documentation, routine follow-up visits and urgent subspecialty follow-up referrals could not be reliably distinguished and were therefore analyzed together.

The study was approved by the Institutional Helsinki committee of Hadassah-Hebrew University Medical Center (Study number: HMO-19-0677). The committee exempts retrospective research from informed consent by the participants. Data was collected from the Ophthalmology Department database and anonymized before analysis.

Statistical Analysis

Categorical variables were expressed as frequencies and proportions, while continuous variables were presented as means and standard deviation (SD). Descriptive statistics were performed. The chi-square test was used to compare categorical variables, while the Z-proportion test was applied to evaluate proportions between study groups. A logistic regression model was utilized to assess the association between age, gender, and diagnostic category and the need for follow-up after visiting the ED. Logistic regression models were used to evaluate factors associated with the need for follow-up after ophthalmic emergency department visits. Two dependent variables were analyzed: (1) primary follow-up (FU1), defined as any follow-up referral recommended at the time of emergency department discharge, and (2) secondary follow-up (FU2), defined as documented follow-up recommendations recorded after the initial visit. Independent variables included age, sex, diagnostic category, and chief complaint. Given the descriptive, retrospective design, the analyses were intended to identify overall patterns and associations rather than to detect small subgroup differences. Bonferroni correction was applied for post-hoc analysis and multiple comparisons. Results were considered statistically significant at p<0.05. Statistical analyses were performed using SPSS software (IBM SPSS Statistics, Version 27.0, Chicago. Armonk, NY: IBM Corp).

Patient and Public Involvement

Patients and the public were not directly involved in the development of the research questions, study design, or outcome measures, as this was a retrospective study based on existing medical records. However, the findings of this study highlight key patient care issues, and its results will be shared through publications and professional forums to support healthcare improvements.

Results

Demographics

This study included a total of 1,406 patients, with a mean age of 37.1 ± 23.1 years at the time of ED presentation. Of these, 796 were males (56.6%) and 610 were females (43.4%), compared to the national population distribution of 50.4% males and 49.6% females during the same period.

The study population was categorized into four age groups: 0–14, 15–34, 35–49, and 50+ years. The largest two groups were those aged 15–34 years, accounting for 35% of the study population, and those aged 50+ years, making up 32%. The representation of both the 15–34 and 50+ age groups in the study was significantly higher compared to their proportion in the general population (p < 0.001). According to 2019 data from the Israel Central Bureau of Statistics,¹⁸ these two age groups made up 29% and 25% of the general population, respectively. Interestingly, while the 0–14 age group constitutes 28% of the general population, they only represented 18% of ED admissions, indicating a significantly lower proportion of ophthalmic ED visits among young children. A summary of age group representation in the study cohort versus the general population is shown in supplementary Table S1.

Chief Ocular Complaint at Presentation

The main reasons for admission or referral to the ophthalmic ED were categorized into eight groups based on similarity or anatomical correlation (Table 2). Among patients aged 50 years and older, 43.6% presented with visual disturbances (eg., decreased vision, double vision, or loss of visual field). Additionally, 75% of patients with floaters or flashes belonged to this age group. These complaints were significantly less common among patients under 34 years (p<0.001, Table 2). Eye trauma was most frequently observed in the 15–34 age group (41.4%), followed by the 0–14 age group (34.9%), while the 50+ group had the lowest incidence (12%, Table 2). When analyzing the distribution of ocular complaints by sex, 22.1% of males presented with ocular trauma (Table 3).

Table 2 Chief Complaint Categories by Age Group

Table 3 Symptoms and Ocular Complaints at Presentation by Sex

Ophthalmic Diagnosis Given (Final Diagnosis)

Anterior segment disorders were the most common diagnosis accounting for 42.4% of cases (596 patients). Retinal disorders were identified in 13.7% of cases (193 patients), while 15.6% (219 patients) had no ocular pathology, and ocular trauma was diagnosed in only in 2.1% of cases (Table 4). When stratified by sex, male patients were more frequently diagnosed with anterior segment disorders (46.5% vs. female 37%), whereas glaucoma diagnosis were more common in females (15.4% vs. 11.7% in males, p < 0.05). Additionally, females were more likely to receive no ocular pathology diagnosis (18.5% vs. 13.3% in males, p < 0.05, Table 4).

Table 4 Ophthalmic Diagnosis by Sex

Stratification by age group revealed that 22.4% of patients aged 0–14 years had no ocular pathology, a significantly higher proportion compared to 10.5% among patients aged 50 years and older. The majority of patients diagnosed with orbit and eyelid disorders were in the 0–14 age group (17.6%), while anterior segment disorders were most commonly diagnosed among 15–34-year-olds (51%). A significantly greater proportion of patients aged 50 years and older were diagnosed with retinal disorders compared to younger age groups (26.3%) (Table 5).

Table 5 Ophthalmic Diagnosis by Age Group

Although trauma-related symptoms constituted a substantial proportion of presenting complaints, only a limited number of cases were classified under the trauma diagnostic category. This reflects the study’s classification framework, in which corneal and conjunctival foreign bodies and superficial injuries were categorized as anterior segment disorders rather than trauma. Accordingly, the trauma diagnosis category represents more severe or anatomically distinct injuries.

Follow-Up After ED Visit

Out of the 1,406 patients included in the study, 1,176 (83.6%) were referred for follow-up, either at the Hadassah Ophthalmology Clinic or with a community-based ophthalmologist. The need for follow-up at the Hadassah Ophthalmology Clinic varied by age, with 36% of patients aged 50 years and older, 27% of those aged 15–34, and 22.4% of those aged 0–14 requiring follow-up (p<0.001). In contrast, follow-up with community-based ophthalmologists was most common among younger patients, occurring in 46.8% of those aged 0–14, 38.7% of those aged 15–34, 35.4% of those aged 35–49, and 39% of those aged 50 and older (p<0.001, (Supplementary Table S2).

A multivariable logistic regression analysis was performed to assess factors associated with the likelihood of requiring follow-up after ophthalmic emergency department admission. Patients aged ≥50 years showed higher odds of requiring follow-up compared with those aged 15–34 years (OR = 1.5, p = 0.098). In addition, patients diagnosed with orbit and eyelid disorders had significantly higher odds of follow-up referral (OR = 2.6, p = 0.005), as did patients with retinal disorders (OR = 2.0, p = 0.022), compared with those with no ocular pathology. After adjustment, orbit and eyelid disorders and retinal disorders remained significantly associated with follow-up referral. Detailed regression coefficients and p-values for follow-up predictors are presented in Supplementary Table S3. Post-hoc pairwise comparisons were adjusted using Bonferroni correction, and statistically significant differences are indicated by alphabetical subscripts in the tables.

Discussion

This study evaluated the epidemiologic characteristics of ophthalmic emergency department admissions at an Israeli tertiary medical center. The number of admissions to the emergency department continues to increase as the population grows. Evaluating baseline, pre–COVID-19 pandemic patterns of ophthalmic emergency department visits at a tertiary medical center in Israel is vital for enabling the healthcare system to provide better, faster, and more efficient emergency care.

During the six-month period examined in this study, the majority of patients assessed in the ophthalmology emergency department were aged 15–34 years, with the second-largest group comprising adults aged ≥50 years. Both groups demonstrated higher admission rates compared with their relative proportions in the general population. Stagg et al¹⁹ attempted to define risk factors associated with ED presentation for non-urgent ocular conditions. In line with our findings, they showed that younger individuals were more likely to seek care in the ED for non-urgent eye problems compared with older adults. Although the classification of urgent vs. non-urgent presentations was not performed in this study, future research should focus on the younger cohort to better characterize the urgency of presentations and to propose potential alternatives for managing non-urgent conditions outside the hospital setting. Elucidating definitions or gradations of complaint types addressed in the ED, while simultaneously expanding access to appropriate community-based care for this population group, has the potential to reduce non-urgent admissions.

This study did not apply a standardized urgency classification; therefore, inferences regarding potentially non-urgent emergency department utilization are based on indirect indicators, including the proportion of visits without ocular pathology and the high rate of referrals for community-based follow-up. In this context, the observed diagnostic patterns still provide clinically meaningful insight into emergency department utilization and help identify opportunities to improve triage processes and community-based eye care services. The finding in the current study that males accounted for a higher proportion of ED admission than females (56.6% n=796 vs. 43.3% n=610) is consistent with other studies reporting predominantly male presentations to the ophthalmic emergency room. Yehezkeli et al²⁰ compared a one-month period during the COVID-19 pandemic in 2020 with the corresponding period in 2019 and found that the majority of patients admitted to the ED were male in both years (60.58% in 2020 and 56% in 2019). Other reports confirm this distribution,^5,21,22 even when accounting for the national population distribution of 50.4% males and 49.6% for females. Furthermore, the proportion of patients aged 0–14 years in the total population is 28.1%, but they represented only 17.7% of all ED admissions in the cohort. This indicates that the rate of ED presentation in this age group is lower compared to their representation in the population.

In the current study population, 42.4% of patients (596 patients) presented with anterior segment disorders, followed in prevalence by no ocular pathology (15.6%) and retinal disorders (13.7%). Most of the pathology-free group were toddlers and children (0–14 years); possibly explained by (1) that younger patients tend to be involved in minor trauma incidents, (2) and the fact this range includes children at a developmental stage preceding the ability to precisely describe symptoms and (3) how this can lead anxious parents to seek prompt examination, especially after normal work hours, when most community care is no longer available.^23,24 Nevertheless, the fact that the second most common diagnosis in the ophthalmic ED was “no ocular pathology” is eye-opening. This finding should be further addressed to reduce unnecessary and non-urgent admissions as out-patients, thus easing the burden on the ED.

Complaints related to ocular trauma comprised 17.7% of all ED presentations evaluated. A notable finding within this group was the male-to-female ratio, which was approximately 11:6, corresponding to 22.1% and 12% respectively (P<0.0001). This proportion is significantly lower than that reported in other duties worldwide. For example, Channa et al⁵ reported an incidence of 36.3% for all ED visits related to ophthalmic trauma, such a major discrepancy can be attributed to differences in diagnostic categorization- superficial injuries, burns, and bone fracture, for example, were not categorized as ocular trauma in our study. Additionally, the fact that there was no predominance by gender or age group, as was previously reported to be higher among men of working age,^17,25 may be related to the relatively small cohort size. Alternatively, this finding may reflect our classification approach as corneal and conjunctival foreign bodies were enumerated under “anterior segment disorders”, within which a male predominance was observed in the 15–34 age group (51%). Another possible explanation is the seasonal nature of our data collection, which was limited to winter months, as opposed to spring and summer when increased outdoor and recreational activities may lead to a higher incidence of ocular trauma.

Overall, 83% (1,176 patients) were referred to ophthalmic follow-up at the Hadassah Ophthalmology Clinic or with a community-based ophthalmologist. The majority of these patients were males aged ≥50 years. To date, no data exist on the rate of patients who complied with follow-up. A previous study reported a follow-up rates of 60%²⁶ with some authors attributing poor compliance to limited medical insurance coverage or insufficient financial resources to obtain follow-up care. In contrast, Israeli law provides citizens with universal health insurance and prioritizes easily accessible health care (ie., including direct access to secondary specialist care without the need for referral, including ophthalmology). Therefore, we hypothesize that the proportion of patients “lost to follow-up” in our study may be smaller. Chen et al²⁷ reported that 25.2% of patients did not complete follow-up and found that those who failed to do so were significantly more likely to revisit the ED. Whatever advantages are accrued by follow-up after ED examination, such as monitoring complications or receiving a precise diagnosis, appropriate follow-up after ED evaluation may also reduce the number of potentially non-urgent ED presentations.²⁸

We observed that patients aged ≥50 years had 1.5 times higher odds of receiving a follow-up referral than patients aged 15–34 years. We contend that raising awareness of routine ophthalmic examinations among the older age group would contribute to early diagnosis of ophthalmic pathology, help prevent ocular morbidity, and reduce the number of admissions to the ED. Carvalho et al²⁹ showed that 69.0% of cases presenting in the ED were diagnosed as requiring simple treatment, which could have been performed in primary or secondary care units. Rai et al³⁰ showed that the majority of eye-related complaints presented to the ED were potentially non-urgent presentations. Community urgent care centers are available across Israel. We suggest that raising public awareness about the importance of routine ophthalmic examinations, along with increasing the availability of first-line community treatment, can also reduce the ED burden.

Healthcare systems, including those in Israel, require streamlining to improve efficiency and the quality of care. The service recommendations proposed in this study are directly supported by the observed patterns of ophthalmic emergency department utilization. Specifically, anterior segment disorders constituted the most common diagnostic category, suggesting that many presentations could be managed effectively in community or urgent care settings. In addition, a substantial proportion of pediatric patients were discharged without an ocular pathology, indicating opportunities for improved triage and parental guidance. The high rate of follow-up referrals underscores the need for streamlined referral pathways and improved continuity of care between emergency and outpatient services. This study identifies three recommendations to reduce unnecessary ED admissions: (1) patient education promoting the prevention and early detection of ophthalmic symptoms, (2) providing routine eye exams and screening for potential issues across different age groups, and (3) ensuring that general practitioners receive training in managing common ophthalmic problems in urgent care settings, thereby reducing the need for patients to seek emergency care. Careful planning is essential for implementing these recommendations, improving patient outcomes, and lowering ED admissions. Our study also highlights the importance of follow-up care for patients with orbit and eyelid pathology and retinal disorders after receiving initial management in the ED. The regression findings indicate that older patients and those presenting with retinal disorders are more likely to require follow-up, supporting the need for expedited assessment pathways for visual disturbance presentations in the emergency department. In contrast, the high prevalence of anterior segment conditions suggests that strengthening community-based ophthalmic services may help reduce emergency department burden. Collectively, these findings underscore the importance of incorporating resilient ophthalmic emergency check-in and triage pathways into healthcare planning, particularly during pandemics and other systemic disruptions, to preserve access for sight-threatening conditions while directing minor complaints to alternative care pathways.^31–33

The findings of this study have broad implications for global health, underscoring the importance of proactive healthcare strategies to alleviate pressure on emergency services worldwide. Many countries, especially those with rapidly aging populations or strained healthcare infrastructures, face challenges similar to those identified in this study, such as increasing rates of non-urgent ED admissions. However, the study has some limitations, including its retrospective nature and single-center design, which may limit its generalizability. Seasonal variation may have influenced the observed distribution of diagnoses, especially trauma and ocular surface disorders, and should be considered when interpreting these findings. Future studies could address the timing of ED presentations, fluctuations in admission rates, as well as longer data collection periods and larger cohorts to clarify the epidemiology of ED admissions. Our findings should be interpreted as descriptive of utilization patterns within a single tertiary ophthalmic emergency department, rather than as estimates of the true incidence of ophthalmic emergencies.

Emergency department utilization patterns are known to change substantially during public health crises. During the COVID-19 pandemic, multiple studies reported a marked reduction in ophthalmic emergency visits, accompanied by delayed presentations and increased disease severity for sight-threatening conditions. Multicenter data from Italy demonstrated significant alterations in ophthalmology emergency utilization during lockdown periods, highlighting the need for robust and adaptable emergency access pathways during systemic disruptions.³¹ Condition-specific analyses have further shown modified emergency presentations for acute vitreoretinal symptoms, such as spontaneous posterior vitreous detachment, underscoring the importance of preserving direct access pathways for patients with visual disturbances during pandemics.³² Beyond pandemic settings, limitations in emergency access and triage capacity represent a global health challenge, as evidenced by low treatment rates for ocular emergencies in resource-limited regions, reinforcing the need for equitable emergency check-in models worldwide.³³

Future studies should validate structured ophthalmic triage classification systems in similar clinical settings and evaluate re-attendance rates and follow-up completion, as these outcomes are directly linked to healthcare utilization patterns and system burden.

Conclusions

This study provides a baseline, pre-COVID-19 pandemic characterization of ophthalmic emergency department visits at a tertiary medical center in Israel. In addition to anterior segment disorders being the most prevalent diagnosis, the second-most common discharge diagnosis was the absence of ocular pathology, a finding that was predominantly observed among younger patients. The majority of patients admitted to the ophthalmic ED were males aged 15–34 or 50 years and above. This data can be used to assess the current state of ophthalmic emergency care in Israel and support the development of more effective strategies for delivering ophthalmic healthcare.