Download Protocol for cataract referral refinement and patient Choice

Nov 2009
Ophthalmic Referral Guidance
Optometrist and GP notes
General advice on urgency of referrals
The average wait for routine first appointment can be up to 8-10 weeks. Where there is a level of urgency,
referrals should include a detailed history and full clinical findings in order in order to support the case.
CATARACT
Just because a patient has a cataract (which can be considered as part of the ageing process) does not mean
that they need to be seen by the hospital. It is most important that patients are only referred for cataract if they
are having problems caused by their cataracts bad enough for them to want to have surgery. A number
of patients are being referred with relatively good VA’s who decline to have the operation when the risks are
fully explained to them. It may be that these patients are having symptoms from their cataract, but if these are
not bad enough for them to wish to accept the risk (albeit small) of surgery then they should not be referred.
Please can you ensure that you make it clear to the patient that there is a risk that they may be left worse off
after the operation. The risk of losing one's vision completely, from infection or haemorrhage at the time of
surgery, is rare, affecting about 1 case per 1000 procedures. If minor complications are included ,the recent UK
National Cataract Surgery Survey found an overall complication rate of 7.5% although these minor issues can
often be managed by the clinician. Those patients with better VA’s may be referred if they meet the criteria
below BUT there needs to be full supporting history and symptoms documented in the referral letter.
A Cataract Assessment enables accredited optometrists to perform an anterior eye and dilated fundal
examination to exclude other pathology. NB only Tropicamide to be used for dilation. If a patient is found to
have other minor pathology, this should be highlighted on the referral form. The assessment enables discussion
of cataract surgery with the patient and explanation of the risks involved. This can then be weighed up by the
patient and they can decide whether or not they wish to be referred for surgery depending on their degree of
visual difficulty and their attitude to the surgery.
Patients with some cataract present, but symptoms not being caused by the cataract should be
examined ( and referred for other co-morbidity if necessary) in the normal way.
Patients should only receive an assessment if a decision to refer is being considered and then should
only be referred following assessment if they are:
•
•
•
symptomatic of cataract AND
have some impairment of lifestyle (typically involving a reduction in visual acuity) AND
willing to have surgery (following counseling and discussion with the optometrist).
Patients with uncomplicated cataract are to be referred through the Choose and Book (C&B) pathway
after assessment by an accredited Optometrist. When possible, non-accredited Optometrists should refer
patients for assessment to accredited practitioners within the same practice.
Patients with co-morbidity found during the assessment which then forms the major reason for referral
should be referred in the normal way and NOT through the C&B pathway. However, patients with Dry
AMD may be referred on the cataract pathway if it is considered that their removal would be beneficial.
Patients meeting the above criteria who are unable to make an informed decision (eg Alzheimer’s)
should NOT be referred through the C&B pathway.
If patients are taking Flomax or Tamsulosin (for prostrate problems) or similar drugs, please can you highlight
this on the referral form? This can cause Floppy Iris Syndrome, which makes cataract surgery more
complicated.
Patients requiring second eye procedures will normally discuss options and be counseled by their consultant.
However, if a patient was treated for their first eye and discharged, they can be regarded as a new referral
under the scheme.
DIABETES
A community based retinal camera screening scheme is in place for Bexley, Bromley and Greenwich
Patients with diabetes should be regularly screened and be encouraged to attend their screening. However, it
needs to be reinforced that this does not replace the need for regular eye examinations as they can be more
prone to ocular complications.

If patients are not under regular screening review or attending a HES diabetic clinic, the patients GP
should be informed if any retinopathy is found during an eye examination. This is useful even if the retinopathy
does not require referral to the HES to enable the management of the condition to be reassessed. However, it
should be clearly stated when referral to the HES is NOT required. At present, Optometrists who see diabetic
patients under the GOS have a duty to notify the GP of their findings.
Non sight threatening (Mild and Moderate Non-Proliferative) retinopathy does not require referral.
New gradings for camera scheme
No retinopathy R0
-
-
-
-
require annual screening
Mild and Moderate Non- proliferative retinopathy R1 require annual screening, inform diabetes care team

The National Screening Committee has made recommendations for how quickly patients with referable
retinopathy should be seen by the Ophthalmologist.

The minimum time recommended between screen positive and consultation with an Ophthalmologist is:
1 Maculopathy M1 ie clinically significant macular oedema, ischaemic maculopathy - less than 13 weeks.
NB outside the camera screening scheme and in the absence of any other adverse signs, referral for a few
microaneurysms within one disc diameter does not constitute maculopathy.
2 Severe Non-Proliferative R2 or loops - less than 13 weeks.
microaneurysms, hard exudates, blot hemorrhages, CWS, venous beeding
3 Proliferative Retinopathy/Advanced Diabetic Eye Disease R3 - new vessels on the disc (NVD) high risk or
elsewhere (NVE) less risk, pre-retinal hemorrhage, vitreous haemorrhage – 2 weeks.

Referral decisions will depend on whether the patient has been seen for regular screening or is already
under the HES. It will also depend on the time since the last screening or examination along with any history
and symptoms. Again, please avoid referring patients unnecessarily to the hospital when they are already being
seen.
EXAMPLES OF CONDITIONS NOT REQUIRING REFERRAL TO THE EYE CLINIC –
Optometrist / GP managed. (Letter to GP to inform or if required to recommend further treatment)
Asymptomatic dry ARMD
Asymptomatic Fuch’s Dystrophy
Asymptomatic map-dot fingerprint dystrophy
Asymptomatic peripheral retinal degeneration
Asymptomatic flat retinal lesions
Asymptomatic hypertensive retinopathy (refer to
GP only)
Vertigo
Headaches
Blackouts
Mild Blepharitis
Contact lens problems not involving corneal
infections
Contact lens fitting problems
Dry eye
Keratoconus improvable with spectacles
Meibomium Gland Dysfunction - hot compress etc
Non-specific field defects – can use refinement
scheme.
Pterygium not Threatening Visual Axis
Sub-Conjunctival Haemorrhage – Normal BP
(letter to GP if suspect BP)
GLAUCOMA
Acute glaucoma should be referred direct to QMS rapid access eye clinic
All chronic glaucoma’s should be by referral letter NOT direct to eye casualty. The decision to refer
should be based on all your clinical finding’s and the patient’s risk factors and these should be
recorded in the referral letter.
Following NICE guidance, all cases of suspect OHT should be investigated using the following scheme
before referral. Unrefined cases of OHT will be seen by the community eyecare team.
Glaucoma and ocular hypertension referral refinement protocol (May 2009)
Introduction
False positive referrals cause unnecessary anxiety to the patient, paperwork for the practitioner and a waste of
hospital resources. The aim of this referral refinement scheme is to enable optometrists/OMPs to refine their
own referrals for glaucoma prior to deciding whether or not a patient should be referred. This can be done by
repeating IOP measurements, using an applanation method (Perkins or Goldmann), and/or repeating visual field
tests on a separate occasion. This scheme will also help optometrists/OMPs to ensure that they are complying
with the NICE guidance (Clinical Guideline 85, April 2009) on the diagnosis and management of chronic open
angle glaucoma (COAG) and ocular hypertension (OHT).
This document does not include every instance in which the patient should be referred and is
not intended to be a substitute for professional judgement. Consideration should be given to
inter-eye symmetry and changes from previous clinical findings. If in doubt refer.
Criteria for repeating fields and/or pressures
Please note that the scheme only applies to patients who are registered with a Bexley Care Trust or
Greenwich tPCT GP and payment will not be made for patients who are registered outside this area.
The following criteria is evidenced based and should be considered as the main guidance when repeating
fields/IOP under this scheme.
IOP
NICE guidance states that patients with IOP that is consistently or recurrently >21mmHg should have a
definitive diagnosis of OHT involving applanation tonometry (Goldmann), gonioscopy and pachymetry by a
specialist healthcare practitioner. see NICE Guideline for full details, available at www.nice.org.uk).
If the IOP measured at the patient’s eye examination is >21mmHg, in order to avoid unnecessary false positive
referrals it is desirable if optometrists/OMPs repeat this measurement using Goldmann or Perkins tonometry.
This can be done at the same appointment as the patient’s eye examination. A fee may be claimed from the
PCT for this. If the IOP is still only slightly above 21 and discs and fields are normal, optometrists are
encouraged to ask the patient to return on a second occasion to repeat the applanation tonometry again to
determine whether this IOP is still above 21mmHg. Only if the IOP is consistently or recurrently above 21 (discs
and fields normal) should the patient be referred for a diagnosis of OHT as per the NICE guidance.
Visual fields
If the examining optometrist decides that there is a clinical indication to perform a visual field test and the
resulting visual fields are ‘suspicious’ or ‘defect’ on the Humphreys, Henson or equivalent visual field screener,
or there is a significant defect on the FDT (without a known cause), a fee can be claimed from the PCT for
repeating the visual field test with the aim of avoiding a referral. This applies even if the visual field defect is not
thought to be due to glaucoma but due to other pathology. The repeated field test must be done using a
suprathreshold or full threshold technique (not FDT) and be supervised by an optometrist. The aim of this is to
determine whether the patient has a repeatable visual field defect which may be due to glaucoma or other
pathology, or whether the patient is simply performing badly at the test on the day. Repeat field tests must be
done on a different day from the eye examination to reduce the effects of patient fatigue.
The additional fee is not payable for repeating visual field tests using the FDT machine.
When applanation pressure readings >21 prompt a decision to refer, a fee for repeating fields cannot be
claimed as the management will still be the same.
Referral refinement fees
The fees, payable per patient, are:



£11 for performing/repeating applanation tonometry (1st and 2nd time),
£16 for repeating (full or supra-threshold) fields, or
£22 for repeating applanation tonometry and fields
If the patient is referred to hospital it is important to put all the clinical information on the referral letter and
include a copy of the repeated visual field plot, so that the ophthalmologist can prioritise the referral. Failure to
adequately complete a full and legible referral letter may result in non-payment of the additional fee.
Referral criteria include
1.
2.
3.
4.
5.
6.
IOP alone: IOP consistently or recurrently >21mmHg by applanation tonometry (not NCT)
Visual field alone – consistent glaucomatous-type defect
Optic disc appearance alone – pathological cupping must be unequivocal. Disc size should be
considered when deciding whether or not discs are suspicious – large cups on large discs are less likely
to be suspicious than large cups on small discs.
Suspicious cup asymmetry of 0.2 or greater.
Discs and fields – if both show glaucomatous change, regardless of IOP.
Change in optic disc – documented change in disc appearance (i.e. cup size, neuroretinal rim
configuration, new haemorrhage or change in cup/disc ratio of 0.2 or greater).
Payment
Practitioners should ask patients to sign the payment form to consent to audit and the transfer of their
information to the Care Trust/PCT. These should be sent, along with the payment summary form to Christine
Pearson at KPCA, Station Road, Maidstone. These forms can be photocopied as required or are available as
pdf or Word files. Please can you send these forms in monthly for payment, rather than individually.
Please also make sure patients are included on the correct Care Trust/PCT summary which should
relate to whether the GP is Bexley or Greenwich based.
This scheme will be carefully audited so practitioners should carefully document why they have repeated fields
or pressures so this information is available to the PCT upon request. The aim of the scheme is to reduce the
numbers of inappropriate glaucoma and OHT referrals and it will be evaluated according to this aim. A fee for
repeat fields can only be claimed once per patient per year. This scheme is designed to reduce the number of
inappropriate NHS referrals and so can be used for both NHS and private patients.
GLAUCOMA REFERRAL REFINEMENT CLAIM FORM
Patient’s details
Previous surname
First
name
Surname
(if changed within past
12 months)
GP name
Date of birth
Postcode
Surgery address
Bexley / Greenwich PCT(delete)
Age group and Ethnicity (not compulsory)
Under 18
46-60
18-30
61-75
31-45
Over 75
Ethnicity Code
refer to information sheet
Consultation outcome
Reason for repeat
IOP readings
Visual Fields
by NCT
R
L
R
L
1st
App IOP
R
L
2nd
Defect
App IOP
Visual Fields
R
I confirm I have conducted the repeat tests in accordance
with the protocol. I understand that the Care Trust/PCT will
monitor all referrals and may from time to time ask to see
the records of patients examined under the scheme.
L
Referred?
Yes
No
Yes / No
Practice stamp
Optometrist’s
signature
Print name
Patient’s declaration and consent
I confirm I have had the inside of my eyes examined, a repeat fields test by the optometrist
and/or the pressure test with drops (delete as appropriate).
I consent to the results of these tests being collected for the purpose of audit and ensuring
best practice amongst optometrists.
Patient’s
Signature
Fee Claimed (please circle)
Date
IOP £11
VF £16
Both £22
,Please send completed forms with summary form to:
Christine Pearson,
Kent Primary Care Agency,
Revised May 09
11 Station Road, Maidstone, ME14 1QH
AGE RELATED MACULAR DISEASE
Early age related macular degeneration (AMD) is characterised by drusen (small and large) and focal
pigmentary changes. Patients with early AMD but no distortion do NOT usually require referral, except for other
reasons e.g. partial sight registration, LVA’s or cataract. These patients can be referred via the usual route
(NOT fast track). However, patients may just require increased reading additions, advice on lighting, diet and to
stop smoking. If appropriate. AREDS preparations should be recommended to patients with large drusen and /
or pigmentary changes.
Late AMD can be divided in late dry and late wet AMD. The late dry AMD is geographic atrophy involving the
fovea. The ’wet’ AMD is characterized by the development of new blood vessels beneath the retina (choroidal
neovascularisation). The sub-classification is no longer relevant in Lucentis therapy. This requires urgent
referral for consideration on Lucentis therapy (subject to referral guidelines).
Which patients to refer?
Use of this form is only for patients registered with GP’s in LAMBETH, SOUTHWARK,
LEWISHAM, BEXLEY, BROMELY & GREENWICH.
Patient’s symptoms are very important – a recent onset of symptoms such as distortion scotoma, shadow or
patch in the central vision is more likely to represent wet AMD, than simply a gradual worsening, blurring or
difficulty with vision which is more likely to be related to the dry form, or cataract etc. If the VA is unchanged, it is
unlikely that the patient will have wet AMD.
Fluorescein angiography and OCT are the mainstay for the diagnosis of wet AMD, the Amsler grid has a
significant high false positive rate and has limited value.
NICE FAD on Lucentis states that treatment should be available to patients who have a VA of 6/96 or better in
the affected eye without permanent structural damage to the fovea.
Local Referral Guidelines for Wet AMD (urgent – 2 weeks to treatment)
Visual loss and VA in affected eye – 6/96 or better
Recent sudden onset of central distortion (usually less than 6 months)
Fundal appearance suggestive of choroidal neovascularisation, such as haemorrhages and exudation.
Patients should be advised that treatment may not appropriate in every case.
If VA <6/96 - non-urgent referral to local eye department for consideration of LVA assessment.
Referrals using either the fax reporting form or the wet amd rapid access referral form to include the following
information:Patient’s details and telephone number
Affected eye and duration in weeks
Patient’s refraction and VA
Referring Optometrist or GP name and address
These referral notes have been devised for general GUIDANCE
only. They do not remove from practitioners their professional
responsibility to each patient, who should all be dealt with on an
individual basis.
PATIENTS WHO ARE MONOCULAR OR HAVE OTHER RISK
FACTORS MAY CONSTITUTE A HIGHER RISK
NHS
SOUTH EAST LONDON
URGENT
WET AMD DIRECT
REFERRAL PATHWAY
URGENT FAX REFERRAL FORM for patients registered with GP’s in LAMBETH,
SOUTHWARK, LEWISHAM, BEXLEY, BROMLEY & GREENWICH.
Referral Guidelines: (one answer must be 'yes')
Visual loss and VA in affected eye – 6/96 or better
Recent sudden onset of central distortion (usually less than 6 months)
Fundal appearance suggestive of choroidal neovascularisation, such as haemorrhage, exudation
Patient’s name and address:
Optometrist/GP name and address:
Telephone Number:
Telephone Number:
Patient’s refraction & visual acuity
R
VA
N
L
VA
N
Which eye is affected and duration in weeks
Right/Left
Duration of symptoms:
Past history of AMD in either eye
weeks
Y/N
FINDINGS:
In the AFFECTED EYE ONLY, presence of:
Macular haemorrhage (preretinal, retinal. subretinal)
Subretinal fluid
Exudate
King’s College Hospital
Ophthalmology Dept
Denmark Hill, London SE5 9RS
FAX: 020 3299 3012
Tel: 020 3299 1522
Queen Mary’s Hospital
Ophthalmology Dept,
Frognal Avenue, Sidcup, Kent DA14 6LT
FAX: 020 8308 5430
Tel: 08452 707727 (call centre new appts)
Princess Royal University Hospital
Farnborough Common
Bromley BR6 8ND
FAX: 01689 863329
Tel: 01689 865779
Y/N
Y/N
Y/N
St Thomas’ Hospital
Eye clinic, Ground Floor, South Wing
Lambeth Place Road, London SE1 7EH
FAX: 020 7188 4318
Tel: 020 7188 4329
Moorfields Eye Hospital - Retinal Treatment Unit
162 City Road
London EC1V 2PD
FAX 020 7253 3411 ext 2311
Tel: 020 7566 2583
Optometrist: Send original to GP for information
Patient will be contacted within 1 week. However, please give the patient the telephone number
to call the chosen centre should this not happen.