What to do with referrals from optometrists
In his seventh article on eye problems, Dr Scott Fraser offers advice on referral pathways
offers advice on referral pathways
Most patients who are referred to the hospital eye service (HES) have this referral initiated by a high street optometrist. Many optometrists now use their considerable skills and training not only to prescribe glasses for patients, but also to diagnose and monitor eye diseases. As many serious eye diseases such as glaucoma and diabetic retinopathy are asymptomatic until late in the disease, optometrists play a vital role in picking up these conditions when treatment is most efficacious.
Although direct optometry to hospital referral is likely to increase in the future, the current system involves – unless in an emergency situation – referral by the optometrist to the patient's GP. This can often mean you are faced with either an incomprehensible letter, a confused patient or both and it is therefore important:
lfor the referring optometrist to make clear the reason for the referral
lfor you to read the referral letter/form to see what the optometrist actually wants.
In practice most referral letters fit broadly into three categories.
1 Potentially significant eye disease has been diagnosed
This involves a definite or presumptive diagnosis from an optometrist and will usually be suggesting referral to the HES. Certain diagnoses need direct onward referral:
lAll forms of glaucoma
lAge-related macular degeneration
lCorneal disorders with sight-threatening potential such as keratoconus, symptomatic pterygia, significant dry eye
lPeripheral retinal abnormalities
Other diagnoses may or may not need referral, such as:
lMild dry eye
lCataract – this should only be referred if the cataract is affecting the patient's day-to-day functioning such as driving, watching TV, reading, shopping. If the patient does not want surgery they should not be referred.
A patient in whom referral to the HES is made on an optometrist's recommendation will still gain from their GP's input. Although it is not always necessary for you to see the patient prior to referral, it is very useful for the ophthalmologist to know:
lCurrent and significant past medical history
lPast ophthalmic history
lAny personal/social circumstances that may be pertinent to the consultation.
There is usually space on the optometrists referral form for this to be added.
2 Informing of findings
Some optometrists will let the patient's GP know of anything abnormal they find – but do not recommend referral to the HES. It can be difficult in these circumstances and without specialist knowledge/experience to decide what is the most appropriate course of action. Examples include:
l A few drusen at the macula
l A single cotton-wool spot
l Longstanding floaters
l Peripheral corneal vascularisation
Many of these findings are not discussed in textbooks as they are not diseases in themselves and, as isolated findings, are generally of no significance. But unless you are confident that the optometrist's findings are of no significance, the best course of action is to either contact the referring optometrist for more details or to ring up your local eye department for guidance
Once you have a better idea of the condition and its significance it is important to ensure the patient understands the findings and whether referral is necessary.
3 Request for systemic evaluation
A small number of optometrists' referrals are direct requests for further medical management, based on their findings. This is usually for further non-ophthalmic examinations or investigations, such as:
lBlood pressure measurements in a patient with recurrent sub-conjunctival haemorrhages
lBlood sugar in a young patient with asymptomatic lens opacities
lLipid profile in a patient with arcus
Generally speaking these patients do not need onward referral, but again if there is an element of doubt, contact the referring optometrist or ask advice from an ophthalmologist.
Who does what?
l Optometrists (old name ophthalmic opticians) examine for and prescribe glasses – during sight tests they also screen for the presence of common eye diseases, such as glaucoma, cataract
l Dispensing opticians – they fit patients for glasses and contact lenses but do not do any ocular examination
l Orthoptic – experts in the treatment of eye movement disorders
lIn the current system, most patients are referred to the
hospital from their
own GP but with the referral initiated by
a high street optometrist
lThe majority, but not all, patients referred to you by an optometrist need onward referral
lIsolated abnormal findings – often not in textbooks – may well be of no significance
lIf in doubt ask the optometrist for clarification or speak
to a local ophthalmologist
Scott Fraser is consultant ophthalmologist at Sunderland Eye Infirmary and
Eye Know How
(BMJ Books, 2000)