Rational referrals: Ophthalmology

In the latest article in our series on navigating referral pathways, Ophthalmologists Dr Ali Al-Gilgawi, Mr Nikhil Cascone and Mr M Ashwin Reddy advise on how to approach referral for this busy outpatient specialty

Introduction
Ophthalmology is the busiest outpatient specialty in the NHS, with more than seven million attendances in 2021/2022.¹ Between 2019 and 2022, while overall surgical backlogs rose by 14%, ophthalmology saw an increase more than four times higher, at 59%.¹ Ophthalmology makes up 10% of the total waiting lists in the NHS, so teamwork between GPs and ophthalmologists is important in controlling the influx into the specialty, while maintaining excellent standards of care.² Many referrals from our GP colleagues follow a request from an optometrist. 

Advice and guidance
Advice and guidance (A&G) has reduced referrals into the system, but response times can vary significantly and this can affect the effectiveness of the process. Use A&G for management plan advice for:

• Patients with diagnosed chronic ophthalmic conditions who are experiencing a deterioration in symptoms between clinic appointments.
• Questions regarding the availability of eye drops already prescribed, and suitable alternatives.
• To discuss optician referral requests that you are not sure need onward referral.
• Patients with persistent symptoms of known diagnoses, or recurrent problems managed in primary care (e.g. persistent conjunctivitis).

Same-day referrals
Speak to the on-call ophthalmologist in the area for the following conditions:

• White reflex in an infant/child. If you can see something white within the pupil or behind the pupil, an urgent referral needs to be made. The parents may notice this in the dark and you may have difficulty identifying it. Still a referral needs to be made. Diagnoses include congenital cataract and retinoblastoma. Perform a fundal reflex (previously described as red reflex) using an ophthalmoscope.
• Orbital cellulitis. These patients will usually be children, but anyone with signs of periorbital cellulitis with associated ophthalmoplegia (reduction in eye movement), loss of vision or systemic compromise should be referred into secondary care immediately.³ Any concerns can be discussed with the on-call ophthalmologist in the area. These patients are usually jointly managed by ENT and ophthalmology.
• Keratitis (cornea involvement). If you suspect keratitis, the patients requires prompt treatment. Clues would include corneal oedema (haziness in the cornea), contact lens wear, drop in vision and acute ocular pain.
• Sudden drop in vision. Any patient who has had a sudden (within 48 hours) severe drop in vision should be referred acutely to a secondary service for a full ocular assessment. Differentials here would include retinal artery/vein occlusions, retinal detachments or amaurosis fugax. All require prompt review. Always check the fundal reflex in case of a vitreous haemorrhage, which will show a reduction compared to the other side.
• Acute closed-angle glaucoma (ACAG). Suspicion should be high in patients who have pain, corneal oedema and a mid-dilated pupil that is not reacting to light. These patients require prompt pressure-control that is potentially sight saving. It is always helpful to know if patients have had cataract surgery or if their pupil is reacting to light as this makes a diagnosis of ACAG very unlikely.
• Pupil-involving nerve palsies. Patients with new ocular motility syndromes (such as third nerve palsies) that involve the pupil could be experiencing symptoms of cerebral lesions such as tumours or aneurysms. These patients should be referred to their local A&E for prompt imaging.
• Anterior uveitis. Clues here would be recent surgery where the steroid drops have been stopped, or systemic associations with a red, painful eye associated with photophobia (pain in the light) and small pupil. The vision will be reduced. The fundal reflex will be reduced compared with the other eye.
• Endophthalmitis. This can be difficult to diagnose but suspicion should trigger a same-day referral into the local service. Clues could be recent surgery or intraocular injections, a very painful red eye and a drop in vision. You may also find the cornea will be hazy, with hypopyon (pus/inflammatory deposits) in the anterior chamber, which can sometimes be seen macroscopically.
• Temporal arteritis. Consider this in patients who come in with a unilateral headache and ipsilateral tenderness to the scalp or jaw claudication. These patients will also be aged over 50, as GCA in patients younger than this is vanishingly rare. Any ocular involvement should only heighten the urgency, prompting an A&E referral immediately.

Urgent outpatient referrals
Refer urgently to the local ophthalmology service if you suspect the following conditions:

• Wet AMD. These patients will have an acute or sub-acute drop in vision with distortions to the images they see. They may already have a diagnosis of dry AMD. Alternatively, they may come after an optical coherence tomography (OCT) scan performed by their optometrist. Refer these patients in within two weeks for assessment and initiation of treatment.
• Eyelid malignancy. The most common are lid-related malignancies (basal cell carcinomas, squamous cell carcinomas, melanomas). Refer to ophthalmology in the first instance for lesions involving the lid margin, all the way up to the orbital rims. Any lesions on the conjunctiva that are worrying should be referred using the two-week pathway. Concerns should be raised for any new lesions, or any that change characteristics within a short timeframe.
• New nerve palsies, pupil-sparing. Patients with a new ophthalmoplegia where the pupil is spared should be referred promptly to secondary care. These are most commonly microvascular in aetiology, but space occupying lesions should be ruled out.
• Blurred optic disc margins. This may be seen on fundoscopy in the GP clinic, or referred from an optometrist. Patients should be reviewed by a specialist within two weeks. If they have any associated headache or cerebral signs, they should be sent to A&E.⁵
• Loss of red reflex (now termed fundal reflex). The fundal reflex with an ophthalmoscope varies with different ethnic background so always assess the parents to know what can be expected for their child. Non-white children are often referred unnecessarily.
• Sudden-onset nystagmus in a child. Nystagmus in children can have causes related to the brain such as brain tumours so it is important these children are seen promptly. If the fundal reflex is abnormal, the cause may be related to cataracts or retinoblastoma.
• Optic neuritis. In patients with a suspicion of optic neuritis (a short history of blurred vision in one eye, blurred optic disc margins, pain on ocular movements), a two-week referral is usually appropriate. If patients have a known demyelinating condition, a relapse should trigger same-day referral into A&E.

Routine referrals
These are appropriate for patients where the following diagnoses are considered:

• Dry eye. Where copious ocular lubrication with lid hygiene measures have not helped, refer these patients routinely into the service.
• Ptosis and other eyelid concerns. The majority of eyelid concerns (unless previously mentioned) can be referred routinely into your local service.
• Chronic glaucoma. It can be difficult to see any signs of this disease, and these patients are commonly picked up by optometrists and referred in. However, patients with a family history, with a gradual loss of vision or field defect should be referred in for screening.
• Cataract. These patients will have a gradual blurring of vision and may come with a letter from the optometrist. This will be painless, gradual and to varying degrees of severity. Fundal reflex with an ophthalmoscope will detect this. Refer these patients routinely into the local cataract service – do make sure they have not already had cataract surgery!
• Squint. In adults ensure full eye movements (to exclude a cranial nerve palsy (above). In children, perform a fundal reflex (including the parents) to exclude cataract and retinoblastoma.

Dr Ali Al-Gilgawi is a specialty registrar in ophthalmology, Mr Nikhil Cascone and Mr M. Ashwin Reddy are consultant ophthalmologists at Barts Eye Services, The Royal London Hospital, London. 

References

1. Royal College of Ophthalmologists. NHS England publishes guidance on reducing ‘did not attends’ in Outpatient Services. 2023. Link
2. NHS England. New NHS measures to improve eye care and cut waiting times. Link
3. Amin N et al. Assessment and management of orbital cellulitis. Br J Hosp Med 2016;77(4):216-20. 
4. NICE NG12. Suspected cancer: recognition and referral. 2023. Link
5. NHS Scotland. Papilloedema. 2022. Link