Consultant ophthalmologist Dr Nick Jacobs explains how to translate an optician’s recommendation for assessment into an effective referral
GPs often get letters from opticians asking to refer the patient on for specialist assessment. But there are issues over whether the patient really needs referral and, if so, how quickly. This article will advise on how to manage four typical clinical scenarios.
GPs may also not always be sure what information to send with the referral but in my experience there is no need to summarise or try to interpret the optician’s findings – but don’t forget to include a copy of the optician’s report. Medical history is especially useful to the ophthalmologist. You may find it easier to include a printout from the notes even though it is a little less personal than a letter. Cataract referrals should include the optician’s referral.
Cupped discs are often identified by opticians either unilaterally or bilaterally. Asymmetry in disc cupping is significant.
Some visual fields are definitely abnormal in appearance and compatible with a diagnosis of glaucoma. Laser retinal scanning technology is used nowadays to assess and monitor the layer thickness of optic discs and retinal-nerve fibres in glaucoma patients.
Visual fields and driving
There is a certain amount of confusion around this topic. By law, the DVLA must be informed if both eyes have a true defect of the field of vision. Also, if there is a visual-field defect in one eye or both eyes, the car insurer must be informed as the insurance may become invalid if the information is not passed on.
A nuclear cataract, which is a dense brown cataract where the centre of the lens hardens gradually, will cause a change in refraction. The eye will become gradually more myopic.
Following cataract surgery some patients will develop thickening of the posterior capsule, which will then be referred by the optician for possible YAG laser capsulotomy.
3. Retinal abnormalities
Opticians usually carry out a very thorough examination of the patient’s retina, particularly the periphery. This leads to the discovery of all sorts of mild abnormalities.
It is necessary to obtain a reasonable photograph of the lesion via the optician or in the hospital and arrange for the patient to be reviewed on a regular basis, usually annually, with this photograph to hand. It does not matter whether this is done in a hospital setting or by the optician as long as change can be recognised.
4. Age-related macular degeneration (ARMD)
Just a few years ago, ARMD was essentially an untreatable condition, although focal laser treatment was sometimes used in a bid to ameliorate early wet macular problems.
Dry macular change can take the form of discreet or confluent cream-coloured drusen or little bumps, pigment alteration giving a salt-and-pepper appearance or straightforward thinning and atrophy. These changes can cause gradual reduction and some distortion of central vision.
Dr Nick Jacobs is consultant ophthalmologist and clinical lead for The Practice Ophthalmology Service.
The Practice Ophthalmology Service is an Intermediate care provider of ophthalmology and manages around 20,000 new referrals per year, running approximately 90 community-based clinics a week.
The full version of this article is available by contacting Dr Jacobs at firstname.lastname@example.org
Cupped disc Neurological field loss Cataract Pigmented lesions Ocular migraine Posterior vitreous detachment Dry macular change Wet macular change Cupped discs are a frequent optician’s finding Cupped discs are a frequent optician’s finding