the modern management of ocular emergencies requires growing fields of expertise to implement appropriate triage of patients [ 16 ] . a correlation between final visual outcome and prompt access to specialized care has been reported [ 710 ] . one of the most popular tools in emergency eye clinics ( eec ) relies on the first level of decision made by an ophthalmic nurse practitioner ( onp ) [ 5 , 11 , 12 ] . the patient referred to eec may eventually be oriented to an ophthalmologist within an arbitrary defined time frame . the new south wales ( nsw ) health and state and the nsw statewide ophthalmology service of sydney have released recommendations to manage ocular emergency , aiming at implementing some consensual procedures and care . the first formal eye - dedicated triaging system , the rescue system , was proposed in 2007 by rossi et al . . it consists of a color - coding scheme discriminating cases through three grades of severity and promptly identifies those who eventually might require hospitalization . however , patients are also commonly referred to eec for ocular emergencies by a first - line health care practitioner for further specialized eye care and appropriate treatment . at that time point , an identification of the ocular condition is usually tentatively proposed or at least suspected . thereafter , the triage efficiency would dramatically benefit from a basic but consensual tool scoring severity for each possible ocular emergency item presenting at emergency room . finally , a consensus tool scoring severity of eye emergency items would eventually serve for research purposes to weigh the severity of rather heterogeneous items in clinical trials . we were therefore driven to reach a consensus based on the severity of the most common ocular conditions seen at eec , aiming at attributing to each of them a simple clinical score for severity . we built the basic severity score for common ocular emergencies [ base score ] on the basis of a comprehensive survey conducted with a panel of experts in the field of ophthalmology and/or emergency eye care . the delphi method was used to synthesize expert opinions and achieve consensus [ 14 , 15 ] . briefly , it entailed a panel of experts who answered the base score survey and subsequently received feedback on the  group response ,  after which the process was repeated again to reach a majority agreement . the delphi consensus relies on an iterative , anonymous method with controlled feedback and statistical aggregation of group responses [ 16 , 17 ] . a steering committee including three ophthalmologists ( m.d . , ( jean - louis bourges , dominique monnet , and antoine p. brzin ) , one epidemiologist ( m.d . , ph.d . ) ( isabelle boutron ) , and two nurses ( catherine issad and michel alvarez ) participating in the ocular emergency health care system was built . ocular emergency items were listed on the basis of the relevant literature to be further proposed in the survey . the first author reviewed the literature published before august 2012 and available on pubmed , cochrane library , and google scholar websites . the urls http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed , http://www.thecochranelibrary.com/view/0/index.html , and http://scholar.google.fr/schhp?hl=fr were visited using the following keywords : eye and ( emergenc or trauma)/ocular and ( emergenc or trauma ) and ( french [ language ] or english [ language ] ) . the relevant literature was selected on the basis of paper titles and abstracts . every generic term pointing to an ocular condition related to emergency care was considered a possible item , captured and sorted into four main categories : anterior segment items , posterior segment items , traumatic items , and items linked to complications following ocular surgery . the list of items was completed , amended , and eventually validated by the steering committee . finally , the steering committee approved a list of 86 items , classified as 21 anterior segment items , 26 posterior segment items , 25 traumatic items , and 14 items related to complications after ocular surgery . the formulation of items was open to free comments from participating experts to ensure the relevance and reliability of the final scoring and to strengthen the consensus . we systematically selected all the email addresses of the corresponding authors of the original articles available in full text and obtained as described above . further , we systematically selected all corresponding authors with an email address available from an original article published between 2011 and 2012 in six scientific journals ( ophthalmology , investigative ophthalmology and visual science , archives of ophthalmology , british journal of ophthalmology , american journal of ophthalmology , and journal of cataract and refractive surgery ) , rated within the top ten journals for their impact on the field of ophthalmology . , o.d . , or nonclinician health care practitioners in the panel of experts if they were involved in the field of ocular emergency , referring patients to eec or participating in dedicated research . we planned to conduct at least two iterative rounds by email , using the surveymonkey tool . email addresses for the selected experts were extracted from their publications , and they were invited to participate online in the delphi process . they were sent a standardized information package , including a synopsis of the study and a description of the delphi process . experts who did not respond were solicited again by an email reminder sent four days , two weeks , and four weeks after the initial invitation , before being considered permanently unwilling to participate . experts who declined our invitation the purpose and the methodology of the survey were further detailed for the experts who agreed to participate by providing remote access to a dedicated website . the opportunity to decline to participate permanently was offered to the experts . in our first delphi round , each member of the panel evaluated the severity of the 86 items based on a 7-point scale ( supplementary material available online at http://dx.doi.org/10.1155/2015/576983 ) . for each event , experts were asked the following question :  according to your personal expertise , please rate the severity of the following ocular conditions seen in the emergency room , using the following seven - point ordinal scale . the 7-point scale was used to collect responses with the anchors  not severe at all  at 0 and  maximal ( currently untreatable )  at 6 . severity was left to each expert 's own understanding . within the survey , a dedicated email address and some free writing space thus , the experts could comment or suggest items freely and possibly modify items in the next round with the approval of the steering committee . at the end of the first round , , the experts were informed of each median rating ( q1q3 ) collected from the first round . considering the same event , the same question , and the same rating scale , the experts were asked to rate each event again by confirming their first rating or modifying it in the light of the first - round results . the answers were collected , reviewed , and analyzed by the steering committee ( jean - louis bourges , isabelle boutron , dominique monnet , antoine p. brzin , catherine issad , and michel alvarez ) . we applied a last observation carried forward ( locf ) strategy for missing data after the first round . thus , if an expert did not answer the second round , we considered his / her first - round answer . the concept of consensus within a group was defined as homogeneity or consistency opinion among the experts . assuming that each item was characterized by a constant but unknown severity the median rating and the first quartile  third quartile [ q1q3 ] ) were established considering each individual item for the whole group . the final weight for each event was the median rating obtained during the last delphi round . all analyses were performed on the r statistics system ( version 2.10.0 ; https://www.r-project.org/ ) . a fifth took the first round of the survey ( n = 80 ) , answering from 18 different countries . the other reported professional degrees were optometrist ( o.d . ) and various other scientific degrees . fifty - six experts scored all 86 items in the first round and all experts scored all items in round 2 . table 2 reports the consensus reached by the experts who ranked the global severity of each item within the four proposed categories . for anterior segment items , the experts considered noninfectious conjunctivitis as the less severe event ( median = 1 [ q1 = 1 ; q3 = 1 ] ) , whereas perforating ulcer of the cornea was ranked as the most concerning item ( median = 5 [ q1 = 5 ; q3 = 5 ] ) . subconjunctival hemorrhage , classified as a posttraumatic event , was considered the least severe item ( median = 1 [ q1 = 0 ; q3 = 1 ] ) . for items involving the posterior segment , ophthalmic migraine and vitreous floaters were both ranked as the least severe items ( median = 1 [ q1 = 1 ; q3 = 2 ] ) , although they were considered slightly more severe than noninfectious conjunctivitis . retinal artery occlusion was considered the most severe item ( median = 5 [ q1 = 4 ; q3 = 6 ] ) , ahead of retinal detachment and acute binocular diplopia with neurological symptoms ( median = 5 [ q1 = 4 ; q3 = 5 ] ) . among traumatic items , penetrating eye injuries either with intraocular foreign body ( median = 5 [ q1 = 5 ; q3 = 6 ] ) or without intraocular foreign body ( median = 5 [ q1 = 5 ; q3 = 5 ] ) were ranked highest like panophthalmitis from items following intraocular surgery . the second round only modified 3 median scores with quartiles remaining unaltered : subconjunctival hemorrhage ( 0.0 to 1.0 ) , retinal detachment ( macula off ) ( 5.0 to 4.0 ) , and ophthalmic migraine ( 2.0 to 1.0 ) . figure 2 illustrates how the severity ranking was distributed among the four main categories of items . the basic severity score for common ocular emergencies [ base score ] is , to our knowledge , the first attempt obtained by expert consensus to rate ocular emergency items for severity . actually , consensual scores obtained from the delphi method faithfully transpose the reality of a day - to - day ophthalmological practice which includes eye emergencies . it seems obvious to every ophthalmologist that , regarding severity , conjunctivitis should be less rated than any acute anterior uveitis . yet , there had been so far no tool to approach the difference between these two items quantitatively . the present score offers the opportunity to ophthalmological staff members , health care practitioners , or researchers to quantify ocular severity of frequent emergency conditions reproducibly , reliably , and most probably accurately . we foresee the core utility of the base score both for emergency room staff to triage patients who are suspected to have a specific ocular condition and to standardize research in ocular emergencies . the way this score . it may be also extremely difficult to discriminate severity among miscellaneous items , such as branch retinal vein occlusion ( brvo ) and perforating but self - sealing laceration of the cornea . not only are such items medically highly unrelated , but the actual severity of ocular conditions could at best be approached at the subspecialty level . according to the base score consensus , the brvo and the corneal perforation would both fall into the same quartile range , but the former would be given a median score of 3 , while the latter would score 4 . thus , the global approach of the consensus demonstrates the ability to weigh the severity of items in situations where physicians would encounter difficulties assessing it . throughout the survey , some clinical items were purposely vaguely or rather imprecisely described . the deliberate choice to define each item in one way or another was made to best approach each situation encountered in emergency room . similarly , we chose not to define the word  severity  precisely during the consensus process . severity is a broad term that encompasses several concepts , including the decisive role of immediate care , every foreseeable outcome , invasiveness of treatments , room for worsening , contagiousness , pain , or associated injuries . by taking the survey , each expert had the opportunity to consider every relevant notion , selecting his or her own score . by scoring ocular emergency items in relation to each other and by using severity as a term with a wide meaning we believe it generates optimal results for clinical classification , rendering it more relevant in real - life practice and more realistic to implement the base score at eec . managing an ocular emergency , just like managing other emergencies , usually requires following three main steps : immediate triage , patient examination , and downstream orientation . the first - line triage mainly relies on patient 's medical history and presenting symptoms . the anamnesis is collected widely by nonmedical staff , who optionally refer patients to the specialist , usually using a formalized protocol . in 2006 in florida , less than half of the ophthalmologists answered emergency department calls . consequently , patients are oriented within a preset deadline by various health practitioners , who may have a medical degree or simply belong to the paramedic staff with various levels of experience . we postulate that the different health care providers would interact in a rationalized , secured , and even more coherent fashion by using a standard score for severity . communication is now strongly increased by the use of smartphones , tablets , and laptops through medical applications . using mobile devices , the base score could improve the efficiency of triage by giving health care practitioners a consensual tool to standardize their decision making process . the eye - dedicated rescue triage   used color coding to identify the acceptable delay for patients to have access to eye care . the triaging system does not integrate a quantified tool to evaluate the severity of ocular items . to be implemented reproducibly worldwide , this system as well as other ocular emergency triage systems could be fine - tuned by integrating the quantitative rating for severity of common emergency items generated by the base score . the large number of experts willing to participate in the process makes the mean scores fairly reliable . the extended range of the experts ' affiliations and participating countries adds to the robustness of the base score , which might fit every eec worldwide , independently of inherent specificity of local health care systems . this could indicate that the base score items and groups of items were accurate and meaningful to a wide range of eye care professionals from various countries . on the other hand , this could have resulted from the experts ' agreement to the first - round results , provided at the time of the second survey . at that point , the experts might have felt no need to contribute further to the process by completing the second round , arguing that they would not change their minds on the basis of the knowledge of the first - round mean scores . it may also have resulted from experts ' weariness in taking time from their busy schedules to complete surveys . finally , the base score still needs to be validated in eec actual practice with a test sample of patients to assess its clinical accuracy by correlating the scores with the real clinical outcomes .
purpose . to weigh ocular emergency events according to their severity 
 . methods . 
 a group of ophthalmologists and researchers rated the severity of 86 common ocular emergencies using a delphi consensus method . 
 the ratings were attributed on a 7-point scale throughout a first - round survey . 
 then , the experts were provided with the median and quartiles of the ratings of each item to reevaluate the severity levels being aware of the group 's first - round responses . 
 the final severity rating for each item corresponded to the median rating provided by the last delphi round . 
 results . 
 we invited 398 experts , and 80 ( 20% ) of them , from 18 different countries , agreed to participate . 
 a consensus was reached in the second round , completed by 24 experts ( 43% ) . 
 the severity ranged from subconjunctival hemorrhages ( median = 1 , q1 = 0 ; q3 = 1 ) to penetrating eye injuries collapsing the eyeball with intraocular foreign body or panophthalmitis with infection following surgery ( median = 5 , q1 = 5 ; q3 = 6 ) . 
 the ratings did not differ according to the practice of the experts . 
 conclusion . 
 these ratings could be used to assess the severity of ocular emergency events , to serve in composite algorithms for emergency triage and standardizing research in ocular emergencies .