A suggested Guidance Protocol for Direct Referral by Optometrists



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A Suggested Guidance Protocol for Direct Referral by Optometrists
Following the introduction of the new General Ophthalmic Services Contract on the 1st April 2006, optometrists will be referring direct to Hospital Eye Units (with a copy being sent to the patients GP). The following is intended as a guide to optometrists when considering referral into an eye unit.
The following protocol has assumed that there is no established community triage (Level 2 / GIES scheme) or Care Pathway established.

This guidance has been produced as a basic referral template to be considered and adapted for local use.


It is important to establish a point of contact within the hospital to receive referrals.
This guidance is intended to help support ophthalmologists when they are vetting referrals received from optometrists by ensuring that as much relevant information is included on the referral form.

It is vital that this guidance is agreed either in this form or a modified version between the Area Optometric Committee and the Hospital Eye Department


To help improve efficiency and for the convenience of the HES the referral criteria have been divided into three categories: ‘urgent’, ‘soon’ and ‘routine’. Ocular emergencies have been considered within the urgent category.

These categories fit with the priorities defined on the new draft referral form designed by Optometry Scotland.


The final category described within the guidance looks at a range of common conditions that can be managed in the community by optometrists.

It is important to state that Optometrists should always work within their own personal scope of practice and expertise.

The new GOS contract allows for intra and inter referral of patients between clinicians to help maintain high levels of patient safety.
Optometrists should try to ensure, as far as possible, that all referrals are supported by a full ocular & medical history and the patients CHI number.
There are additional notes at the end of the document for certain common conditions such as cataract, glaucoma and AMD.
It is suggested that this document be considered in conjunction with the Ophthalmology Care Pathways published by the Centre for Change and Innovation (see appendix).
IMPORTANT CONTACT INFORMATION

Hospital Contact Address

Telephone Contact Number

Fax Contact Number








This guidance should be read in conjunction with the Ophthalmology Pathways produced by the Centre for Change and innovation that can be found at:

http://www.pathways.scot.nhs.uk/ophthalmology.htm


REFERRAL PROTOCOLS
The following list provides guidance for optometrists when considering referral to the HES.
URGENT REFERRALS

OCULAR EMERGENCIES

There are very few genuine ocular emergencies; the following list describes most of them. In the absence of a dedicated ocular casualty service it would be sensible to contact the eye unit before referring the patient so that the receiving clinician is prepared.




Condition

Description

Optometric action

Microbial keratitis

Bacterial, protozoa, fungal

Same day referral, no intervention

Chemical injury

Alkali, acid

First aid - washout with sterile saline + same day referral

Penetrating injury

Globe ruptured / Eyelid laceration

Immediate referral

Cellulitis

Orbital / preseptal

Same day referral

Scleritis

Blurred vision, severe deep pain, h/a, photophobia, red eye, A/C –flare & cells

Immediate referral

Flashburn

Welder’s arc eye – severe pain

Same day

Embedded corneal f.b.




Same day

Anterior Uveitis

Ocular pain, blurring, photophobia. Peri-limbal injection, flare a/c, KPs, irregular pupil.

Dilate with Cyclopentolate Hyd. (1%).

Refer same day to eye unit.



Hyphaema

Blood in anterior chamber

Refer immediately to exclude contusional injury to the interior eye

Orbital blow out fracture

Pain on restricted eye movement, bony tenderness, diplopia, tingling over the maxilla

Same day referral

Cellulitis

Orbital / Peri orbital

Same day referral

Ophthalmia neonatorum

Bacterial / viral

Same day referral

Central retinal artery occlusion (CRAO)

Painless loss of vision, afferent pupil defect.

Immediate referral

Posterior uveitis

Floaters, blurred vision, vitreous debris, retinal exudates/infiltrates, retinal vasculitis

Immediate referral

Papilloedema

Intracranial space occupying lesion. Severe headaches on waking, nausea, poor coordination

Immediate referral for neurological assessment.

Anterior ischaemic optic neuropathy (AION)

Arteritic (Giant Cell Arteritis) & non-arteritic.


Immediate referral of arteritic AION and referral of non-arteritic to exclude arteritic form.

Acute glaucoma

Narrow angle, Rubeosis, Raised IOP, Pupil fixed & part dilated, Bulbar redness, Pain, Corneal oedema

First aid – instil pilocarpine and same day referral to eye unit


Malignant Hypertension

H/A – typically occipital, blurring. Retinal cotton wool spots, haemorrhages, optic disc swelling, raised BP

Immediate referral for admission to hospital for medical treatment.



URGENT REFERRALS.. cont (Within 30 DAYS)

Condition

Description

Optometric Action

Dacryocystitis

Painful swelling lower eyelid due to naso-lacrimal duct obstruction. Risk of secondary infection of lacrimal sac.

If hot compresses do not resolve problem, refer for systemic antibiotic treatment. Incision and drainage may be indicated.

Herpes Zoster Ophthalmicus

Skin lesions across ophthalmic division of trigeminal. Can involve the eye

Same day referral to GP for oral anti viral treatment. If eye involved refer next day to eye department

Marginal keratitis

Red eye, pain, blepharitis, marginal infiltrates.

Lid hygiene, Fusidic Acid. Urgent referral for topical steroid

Herpes Simplex Keratitis

Skin vesicles, red eye, dendrites, anterior uveitis

Refer for topical anti viral agents

Vitreous haemorrhage

Breakthrough haemorrhage into vitreous body.

Refer for further investigation of cause / laser treatment when retina visible.

ARMD (exudative)

Sudden onset central scotoma, distortion, macropsia, reduced vision.

Macular subretinal fluid, exudates, blood, drusen.

Thickening of sensory tissue.


Contact eye unit for urgent referral to a medical retina specialist, especially if vision still 6/24 or better - for PDT or Argon laser Tx.

Retrobulbar neuritis

Painless visual loss / desaturation of rd targets / dullness of vision

Urgent referral for diagnosis of exclusion – exclude other causes.

Acute diplopia

Third, fourth, sixth nerve palsy. Trauma.

Urgent referral for investigation – see Diplopia Pathway.

Retinal Detachment

Obvious retinal tear/hole, tobacco dust, increasing flashes & floaters

Urgent referral – contact eye unit same day by telephone for advice from vitreo retinal specialist

Third, fourth, sixth nerve palsy

See above –acute diplopia

Urgent referral

New macular hole

Circinate separation of sensory retinal layers at fovea.

Confirm diagnosis with slit lamp bio. Urgent referral if recent presentation (< 4 weeks) for consideration of gas bubble repair.

Proliferative diabetic retinopathy

NVD / NVE, maculopathy, Hard exudates within 1DD of fovea, pre-retinal haemorrhage.

Urgent referral to a medical retina specialist


Symptomatic blunt trauma




Urgent referral

Optic disc pallor

Suspected compressive lesion associated with history and field loss

Urgent referral



Vitritis




Urgent referral


SOON REFERRALS (Less than 60 days)


Condition

Description

Optometric Action

Glaucoma with IOP over 30mmHg

(preferably confirmed by pachymetry)



High IOP with or without other glaucoma findings. Repeat tonometry, fundoscopy and automated perimetry.

Repeat all findings to confirm results. Tonometry by contact applanation. Disc assessment by dilated fundus biomicroscopy.

Suspected Neoplasia of the lids or conjunctiva

Suspected Carcinoma or melanoma.

Refer for biopsy

Amaurosis Fugax

Intermittent monocular visual loss.

Full examination. Refer to exclude Giant Cell Arteritis, and cardiac & carotid auscultation

Optic disc haemorrhage

Splinter haemorrhage within the retinal nerve fibre layer at the disc margin
Dot / blot haemorrhage

Assess for normal tension glaucoma and refer as appropriate
GP referral for urine & BP










Maculopathy – recent drop in VA

Unexplained central visual loss. Central scotoma?

Examine with dilated slit lamp bio. Urgent referral to a medical retinal specialist for FA and assessment for treatment if exudative/wet.

Other ‘dry’ causes - monitor or consider low vision support.

See AMD Pathway


Neurological visual field loss

Bitemporal or Homonymous

Urgent referral to eye unit

Iris & Retinal melanoma -suspected




Urgent referral


ROUTINE REFERRALS


Condition

Description

Optometric Action

Lid / conjunctival cysts

E.g. Chalazion – Meibomian cyst – painful or non-painful swelling of the lid.

Check for acne rosacea



Hot compresses and blepharitis treatment, but might require routine referral for incision and curettage.
Refer to GP for treatment.

Persistent epiphora

Blocked tear drainage

Routine referral for sac washout and to consider surgical options

Pterygium affecting visual axis

If visual symptoms troublesome consider surgical repair

Refer for surgical treatment or monitor

Keratoconus - Symptomatic

Vision reduced with spectacles, requiring RGP contact lens or keratoplasty

Refer for contact lens assessment

Corneal dystrophy - symptomatic

Stable appearance. Asymptomatic

Annual review


Anisocoria - new

Risk of recent blunt trauma, Adies, IIIrd nerve palsy, Horners.

Urgent referral of suspected neurological cases.

Afferent pupil defect - new

Neurological / optic nerve damage

Refer if new finding.










Retinitis pigmentosa

Primary pigmentary degeneration of the retina. Progressive visual loss. Untreatable

Refer once condition has progressed. Counselling required to assist with the management of progressive visual loss

Abnormal optic disc - new

Abnormal disc appearance

If field loss present monitor or consider routine referral

Unexplained gradual visual loss

No obvious aetiology

Refer for second opinion

Entropion / Ectropion

- severe


Risk of ocular surface damage

Refer for possible lid repair

Altered melanosis of the lids or conjunctiva

Risk of malignancy

Refer – with pre and post photographs if possible


Exophthalmous / Proptosis

- new findings



Risk of surface disease and global compression of the optic nerve. Might also be evidence of space occupying lesion in the globe.

Colour vision assessment, visual fields & motility. Refer all abnormal findings or evidence of recent change in proptosis


Strabismus - childhood

New finding / amblyopia

Full examination, including cyclo refraction and prescribe full plus Rx before referral for orthoptic assessment.

See Squint & Amblyopia Pathway



Visual field defects – repeatable, non-specific




Repeat fields before referral


Cataract - symptomatic

Blurred vision (eg less than 6/12), disability glare, photophobia. Interfering with lifestyle.

Patient wishes surgery.



Full eye examination including dilated slit lamp bio to exclude co-morbidity. Advise Px on procedure.

Consider blepharitis treatment if appropriate. See Cataract Pathway



Glaucoma

IOP over 28mmHg, lower IOP with pathological cupping, repeatable visual field loss (automated perimeter).

Repeat all findings to confirm results. IOP by contact applanation tonometry. Disc assessment by slit lamp bio (60D / 78D). See Glaucoma Pathway.

Pre-proliferative diabetic retinopathy

Hard exudates 2DD of macula, retinal haemorrhage, IRMA

Full dilated fundus examination by slit lamp bio before referral

Retinal haemorrhage




Obtain BP/Urine check before referral

Retinal macroaneurisms




Obtain BP/Urine check before referral

ARMD

Dry or stable with reduced VA

Full eye examination. Refer for registration or to LVA service.


COMMUNITY CARE
There are a number of common eye conditions that could be managed within the community by optometrists in conjunction with General Practitioners.

When managing common eye disorders optometrists should always ensure that they are working within their sphere of expertise and experience.


COMMUNITY CARE – OPTOMETRY & GP

Condition

Description

Optometric Action

Sub conjunctival haemorrhage

Suspect mild trauma or hypertension

Examine to exclude surface damage and refer for BP check

Xanthelasma




Routine referral for cosmetic surgery as necessary.

Blepharitis

Lid crusting mild discomfort

Lid scrubs / Fucidic acid. Monitor.

Allergic conjunctivitis

Conjunctival inflammation, lid swelling with papillae, watery discharge/mucus strands – no corneal involvement

Topical mast cell stabilisers or anti histamines

Hordeola

Tender lid swelling due to Staphylococcal infection of the lash follicle.

Can resolve spontaneously. Hot compresses and topical antibiotic might aid recovery. Systemic antibiotic needed on occasion - then refer.

Mild entropion & ectropion

Asymptomatic

Monitor & advise. Watch for trichiasis with entropion and exposure keratoconjunctivitis with ectropion

Trichiasis

Gritty discomfort due to misalignment of eyelashes. Due to blepharitis, entropion.

Epilate and monitor. If recurring consider referral for electrolysis or Cryotherapy.

Superficial foreign bodies

Loose foreign bodies

Remove with moist cotton bud and check for ocular surface damage. Consider prophylactic topical antibiotic.

Episcleritis

Diffuse, sectoral or nodular redness. Can recur. Most cases idiopathic and recover spontaneously.

Consider ocular lubricants. Moderate / severe / nodular cases might require topical NSAIDs or topical steroids – then refer.

Corneal dystrophy - stable

Asymptomatic

Monitor annually

Dry eye

Lacrimal insufficiency, Meibomian dysfunction. Mucus deficiency.

Hot compresses, lid massage, lid scrubs, ocular lubricants, punctum plugs


Pterygium - stable

Not threatening the visual axis

Monitor annually


Corneal abrasions

Superficial

Examine with slit lamp. Tx with topical antibiotic as prophylactic if concerned. Check that cornea has recovered. Refer if not resolving within 48 hours.

Holmes Adie pupil – known diagnosis

Tonic uni/bilateral, dilated, poor reaction to light reflex, reduced accommodation.

Monitor.


Cataract - asymptomatic

Acceptable VA. Patient coping well. Good view of fundus. Px does not wish surgery

Review every 6 months or annually depending on VA. Full dilated fundus biomicroscopy examination with 60D or 78D lens.

See Cataract Pathway



Flashes & floaters

Vitreous floaters, PVD. No retinal breaks or tears.

No tobacco dust or progressive symptoms indicative of vitreo-retinal disease.



Detailed dilated peripheral fundus examination by slit lamp bio. Check for retinal tears/breaks, pre-retinal blood or ‘tobacco dust’ in anterior vitreous.

Check that symptoms regress or stabilise after two months, if so, PVD will most probably not progress to RD.

Review 6 months (and issue written advice on RD symptoms) or refer for indented indirect ophthalmoscopy if concerned.

See Flashes & Floaters Pathway



Ocular Hypertension

(preferably confirmed by pachymetry)



IOP less than 28mmHg, no field loss, normal disc appearance.
* see note on relative risk of OH leading to OAG

Carefully record disc appearance, repeat IOP by applanation, repeat field result (automated perimeter).

Review 6 monthly.



AMD – dry / stable vision

No macropsia. Vision can vary. Hard drusen. RPE degeneration.

Monitor. Full eye examination every 6-12 months, including refraction.

Refer for LVA assessment if VA drops. Consider social work support if patient is considered visually disabled ie normally when VA drops below 6/18.



Choroidal naevus

Flat pigmented lesion

Carefully record and monitor any changes.

Macular hole / cysts

– longstanding

(Confirmed diagnosis and discharged from HES)


Px reports narrow slit distorted or missing in centre

Monitor for change in VA or increased distortion / macropsia. Slit lamp bio. Surgical treatment might be an option

Maculopathy – stable.

Stable VA

Monitor

Epiretinal membrane

If VA stable and no macular damage

Monitor for change.


Optic disc abnormalities

Stable. Long term. Tilted disc, unusual cupping but normal IOP and fields

Monitor 6 monthly initially. Consider annual review thereafter.

Diabetes

No retinopathy or background DR.

Examine with slit lamp bio. Review as required depending on presenting signs.

Dysthyroid Disease

Exophthalmous. Pain on eye movement. Dry eye symptoms.

Monitor. Review as required. Consider ocular lubricants. Refer if proptosis causes concern or if optic nerve is threatened.

Peri-orbital haematoma (black eye)

Blow to orbital area

Check VA & fundi. Check globe for lacerations and abrasion and hyphema in the a/c. Check for afferent pupil defect. Check for normal ocular motility. Review 3 days.


Additional Referral Notes for Certain Common Conditions

Cataract

The Optometric examination when examining a cataract patient should include the following:



  • Detailed history & symptoms

  • Record a full ocular a medical history

  • Refraction & Visual Acuity & Pupils

  • Slit Lamp – anterior segment

  • Tonometry & Visual Field

  • Fundus exam – dilated slit lamp biomicroscopy

  • Detect / exclude co-morbidity

  • Discuss risks & benefits of surgery with patient

  • Issue information leaflet to patient

  • Agree desire for surgery with patient

  • Refer on standardised referral form as per local protocol

(See CCI Cataract Pathway)

Routine Referral



Glaucoma

The Optometric examination of a glaucoma suspect should include a full examination to include:



  • Detailed history & symptoms

  • Record a full ocular a medical history

  • Refraction & Visual Acuity & Pupils

  • Slit Lamp – anterior segment – by gonioscopy if possible

  • Contact applanation tonometry & automated visual field assessment

  • Fundus exam – dilated slit lamp biomicroscopy

  • Detailed examination and assessment of the optic nerve head

  • Digital imaging if available

  • Detect / exclude co-morbidity

Repeat applanation tonometry, visual field assessment and optic disc slit lamp bio examination to ensure findings are consistent before referring.

(see Glaucoma CCI Pathway)


* OHT & OAG & Vascular Occlusion

Several studies of OHT’s over a 5-year period describe the risk of OHT leading to OAG. The relative risk ratios vary with increasing IOP measurement as follows:

2.6-3% with IOP between 21-25mmHg; 12-26% with IOP between 26-30mmHg; 42% with IOP over 30mmHg.

In addition, patients with vascular disease may be at a greater risk – either because of the disease process itself or their medication.

Other studies show that OHT over 30mmHg are at a greater risk of ocular vascular occlusions – approximately 3%. For this reason some ophthalmologists may choose to reduce IOPs of certain patients e.g. those over 65’s to less than 25mmHg because of this risk.
Optometric monitoring if IOP less that 28mmHg and there are no other glaucomatous findings.

Routine referral for OAG.

Emergency referral for Acute Closed Angle Glaucoma.

Age Related Macular Degeneration

The examination should include:



  • A full eye examination

  • A detailed record of history and symptoms. ‘Wet’ exudative symptoms of distortion, central scotoma, micropsia or macropsia will be of recent onset if relevant. With some cases of ‘dry’ AMD the patient might describe distortion but this does not warrant an urgent referral as there is no credible treatment option.

  • Examination of the posterior pole using the slit lamp bio technique with a 60-78D lens. Patients with exudative changes will exhibit some thickening of the sensory retina, sub retinal fluid, blood, exudates.

  • A full refraction is indicated with pinhole VA recorded. A recorded VA of 6/24 or better is indicative of a more optimistic prognosis and a very urgent referral is indicated for further investigation including flourescein angiography. It is suggested that telephone contact be made with the HES for the convenience of the receiving physician.

(See AMD CCI Pathway)
Frank Munro - Optometry Scotland

23rd August 2006


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