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Best Practice for Ophthalmic Referrals Contents Best Practice for Ophthalmic Referrals ................................................................................................... 1 General Referral Best Practice ............................................................................................................ 1 Cataract Referrals ............................................................................................................................... 2 Glaucoma Referrals ............................................................................................................................. 3 Wet AMD Referrals ............................................................................................................................. 3 General Referral Best Practice The organisation for booking NHS appointments across Devon is Devon Referral Support Services (DRSS). This covers TRAC (Tamar Referral and Appointments Centre) and DART (Devon Access and Referral Team). The advantages of using the referral forms are that it: Ensures the referral form is legible: Ensures the patient is placed in the correct clinic Ensures a timely referral. Delays in referrals through the DRSS have been reported due to missing information and the form being illegible. Please fill out the form completely. Please choose 1 clinic on the referral form. For patients with multiple co-morbidities— pick the clinic that is most important and in the free text comments explain other relevant history and symptoms. Patient and GP Details Ensure all patient details including the current GP name and address are correct and up to date before referral. It is important to ask the patient if their details are correct at the point of referral. This will ensure that there is no delay in referral for the patient. Non-Ocular referrals Any referrals for non-ocular conditions such as skin lesions on the cheek must be first referred to the patients GP. Referral conditions When referring patients for Ophthalmic Conditions please choose one condition for referral and put other relevant information in the free text. Consider which is the most important condition and which clinic is the best clinic to treat that condition. For example, if a patient presents with cataract and blepharitis, choose cataract as the reason for referral and place blepharitis in the free text. Lesions around the eye When referring lesions around the eye please state: How long the lesion has been present and the size of the lesion. Blepharoplasty Blepharoplasty (eyelid surgery) and brow lift is regarded as a low priority procedure and is therefore not routinely funded by the NHS. Blepharoplasty with and without brow lift will be funded when the following criteria are met: • • Impairment of visual fields in the relaxed, non-compensated state: Evidence will be required that eyelids impinge on visual fields, reducing field to 120 degrees laterally and 40 degrees vertically (20 above and 20 below). Correction of ectropion (eyelid turns outwards) or entropion (eyelid turns inwards towards the eye) with ocular irritation and causing functional implications. All referrals for low priority procedures are to be made via the GP . Cataract Referrals Please note that this information is not essential but classified as best practice for cataract referrals in Devon. Criteria for surgical referrals: There should be sufficient cataract to account for the visual symptoms Is the Cataract affecting the patients quality of life? Have the risks of the surgery been explained to the patient? Is the patient available for the next 18 weeks Is there any other pathology especially any macula changes? report from a recent sight test The patient should be informed of the risks and benefits of surgery: 80-90% of patients report a benefit from surgery including improved clarity of vision and improved colour vision. Surgery in the second eye may allow significant additional gains in visual function in everyday activities and QoL above and beyond what is achieved after surgery in the first eye [1]: functional improvement in visual symptoms ability to meet the DVLA driving standard The risks include: Common: bruising of the eye or eyelids , cystoid macular oedema, refractive surprise, dropped nucleus or fragments, capsule tear, dislocation of the implant lens. Rare: further loss of visual function (about 0.1% of surgical patients lose vision in operated eye), infective endophthalmitis (1 in 1000 operations), corneal decompensation, post-operative raised intraocular pressure, glaucoma, retinal detachment, postoperative infection, in one-eyed patients, possibility of total blindness, and suprachoroidal haemorrhage. The patient should wish to undergo surgery - do not refer patients who: do not want surgery; or do not feel they need it Glaucoma Referrals Please note that this information is not essential but classified as best practice for glaucoma referrals in Devon. Best practice for glaucoma and OHT referrals that have been refined by the IOP refinement scheme: Visual Fields: You must attach and send with the referral IOP: Document type of equipment used and the time of the day the reading was taken Disc assessment: Cup to disc, Pallor, Depth, Lamina cribrosa appearance, vessel structure and placement Document any family ocular history Other information if available: Van Herricks: Scale 0-4 Pachimetry Any other eye pathology Wet AMD Referrals For Wet AMD referrals to be as effective as possible then they need to be seen by the Local AMD centre within 2 weeks. There needs to be a rapid access to a retinal specialist and treatment irrespective of geographical location. This means that all Devon referrals should be marked as urgent and where appropriate the WET AMD forms should be filled out: Plymouth (REI): Referral form and additional wAMD form Exeter (RD&E): Referral Form only (send to DRSS) North Devon (NDDH): Referral form and additional wAMD form South Devon (SDHCFT): Referral form only (send to DRSS) For patients attending the REI then please fax the referral and WET AMD form to 01752 398783. For patients attending NDDH send the additional form to DRSS along with the DRSS referral form. We advise that your referral should include: all relevant patient data and GP details (as with all referrals to the Hospital Eye Service), the latest prescription with distance and Near VA's and IOP results. In the comments section please include: Affected eye, any large changes in prescription, any co morbidities, any changes to the retina: including haemorrhages, exudate, Amsler results, and any other information that you feel is appropriate.