Download OPTHALMOLOGY REFERRAL RECOMMENDATIONS

REFREC014
OPTHALMOLOGY REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
Evaluation
Eye referrals may be patients with
symptoms undiagnosed. The following
are of particular concern:
A thorough history and physical
examination is required to determine
the specific diagnosis:
Best corrected visual acuity (glasses
and/or pinhole).
Relevant* family history.
Relevant* drug history.
Relevant* past history eg hypertension,
diabetes, CVA.
Relevant social history.
Fundoscopy findings where
appropriate.
*Relevant to visual system.
•
Diabetics
•
Paediatric squint/vision problems
•
Loss of vision (sudden)
The following diagnoses or symptoms
are considered under Ophthalmology:
•
Cataracts
•
Diabetes
•
Diplopia
•
Eye infections / inflammations
•
Eyelids / malposition
•
Glaucomas
•
Intra Ocular Foregin Bodies
•
Loss of vision (non cataract)
•
Opthalmological headache
•
Orbital
•
Paediatric squint / vision problems
•
Toxicity screening for systematic
drugs
•
Trauma
•
Watery eye
Last updated February 2006
Management Options
Topical Steroids:
SHOULD ONLY BE USED WITH
REFERENCE TO AN
OPHTHALMOLOGIST
Referral Guidelines
Referrals from GPs should be
assessed as per
Immediate/urgent Category 1-2 cases
should be discussed with an
Ophthalmologist/Registrar.
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REFREC014
Diagnosis / Symptomatology
Cataracts
Evaluation
•
BCVA (with dist. gls).
•
Last optometrical assessment.
•
Level of visual impairment
(recreational, educational
occupational, driving).
•
Social circumstances.
•
Whether first or second eye.
Diagnosis / Symptomatology
Diabetics
Diagnosis / Symptomatology
Diplopia
Evaluation
•
Screening (IDDM/NIDDM).
•
Duration/new case.
•
Drug regime.
•
Previous ocular examination.
•
Systemic diabetes disease.
•
Risk factors (smoking,
hypertension, pregnancy, poor
control).
Evaluation
Management Options
If appropriate optometrical
assessment.
If vision in each eye is 6/12 or better,
review in six months (unless
occupational factors over-ride, eg
passenger service licence).
Management Options
Prediagnosed NIDDMs – occult
retinopathy – refer photoscreening.
If vision in either eye is worse than
6/12 – Category 4.
Referral Guidelines
New NIDDM and:
Prediagnosed NIDDM/IDDM: Refer
for photoscreening.
New IDDM at 5 years.
Prompt referral for the following cases:
progressive/intermittent LOV,
pregnancy, multiple risk factors –
Category 2-3.
Management Options
Referral Guidelines
Refer immediately – Category 1.
– painless.
Last updated February 2006
Ideally a recent optometrical
assessment (within six months) done
prior to referral.
Consider appropriate domiciliary aids.
Acute diplopia – painful.
Chronic diplopia (old strabismus).
Referral Guidelines
Refer urgently – Category 2.
Temporary ocular patching as
indicated.
If troublesome, consider non-urgent
referral – Category 3-4.
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Diagnosis / Symptomatology
Eye infections / inflammations
Evaluation
•
Reduced vision.
•
Discharge (purulent or watery).
•
Photophobia (with or without pain).
•
Itch/irritation.
•
Unilateral/bilateral.
•
Fluoroscein training (yes/no).
•
Duration/frequency.
•
Current topical therapy.
•
Contact lens wearer (hard/soft).
•
Ocular pain.
Management Options
Viral/bacterial conjunctivitis with
discharge:
Appropriate broad spectrum topical
antibiotic (eg, chloramphenical). If
unresponsive after four days, reevaluate and refer if appropriate.
Last updated February 2006
Mandatory referral Category 1-2 for:
1.
2.
3.
4.
5.
Acute dacryocystitis: One full course
of broad spectrum systemic antibiotic
(eg Augmentin, flucloxacillin) and refer.
Drug Allergy: Cessation of drug,
conservative treatment, eg lubricants,
topical decongestants, antihistamines,
mast stabilisers and removal of
allergies.
Vernal catarrh is severe conjunctivitis,
often in younger age group,
characterised by severe itch, stringy
mucoid discharge and typical thickened
swollen “leathery” inferior fornix +/cobblestone papillae, upper lid.
Note: The discharge is quite
Referral Guidelines
Contact lens wearer: Avoid
secondary topical drug therapy.
Review management by patient of
contact lens.
Red eye with reduced vision.
Suspected iritis.
Suspected corneal ulcer.
Suspected herpes simplex
infections.
Herpes zoster ophthalmicus with
eye involvement.
Acute dacryocystitis: Refer
Category 1-2.
Drug Allergy: If unresponsive and
severe – refer Category 2.
Vernal Catarrh (children): Refer
Category 2.
Contact lens wearer: If subacute,
optometrical management preferred. If
acute, or associated conjunctivitis,
refer promptly – Category 1-2.
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Diagnosis / Symptomatology
Eyelids / Malposition
Evaluation
•
Discharge (purulent or watery).
•
Photophobia (with or without pain).
•
Itch/irritation.
•
Unilateral/bilateral.
•
Duration/frequency.
•
Current topical therapy.
•
Contact lens wearer (hard/soft).
•
Acutely inflamed eyelid.
•
Swelling lid and chymosis.
Management Options
Referral Guidelines
Blepharitis without co-morbidity:
Lid scrub regime with/without AB.
Severe and persistent blepharitis
with secondary ocular and lid
changes: Refer Category 3-4.
Trichiasis: Epilation – manual or
otherwise.
Trichiasis: If unresponsive/recurrent
– Refer Category 4.
Ectropion: Refer if severe symptoms
– Category 3-4.
Entropion: Check for corneal damage
with fluoroscein. Prompt referral.
Entropion: Prompt referral –
Category 3.
Peri orbital cellulitis: Prompt referral
– immediate for children (< 15 years) –
Category 1-2.
Acute chalazion/stye: systemic AB
(eg Augmentin) +/- cyst drainage.
Diagnosis / Symptomatology
Glaucomas
Evaluation
Note: Family history.
Acute, ie red, pain, LOV, photophobia,
steamy cornea, hard eye.
Management Options
Encourage all patients to have
glaucoma screened by optometrist at
age 45.
Chronic recurrent chalazia:
Removal/refer – Category 4.
Referral Guidelines
Acute: Refer immediately – Category
1.
Suspected: Suspicion of glaucoma
(eg optometrist evidence) – Category
2, otherwise Category 4.
Suspected chronic: Usually
asymptomatic.
Last updated February 2006
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Diagnosis / Symptomatology
Intra Ocular Foreign Bodies
Diagnosis / Symptomatology
Loss of vision (non cataract)
Evaluation
Site of entry.
X-ray.
History.
VA.
Attendant ocular signs.
Evaluation
Management Options
Cover eye (systemic AB only after
consultation.
Management Options
Severe LOV:
Speed of onset.
Pain.
Systemic disease.
Arterial occlusions (suspected giant
cell arteritis).
Afferent pupil defect.
Floaters/flashes.
Unilateral or bilateral.
Fundus examination (often normal).
Transient LOV.
TIAs: Fundus exam, bruit.
Retinal detachments:
Optic Neuritis.
Optic swelling or pathology –
Unilateral.
Bilateral.
Referral Guidelines
Refer immediately – Category 1.
Referral Guidelines
Stat referral – Category 1.
Immediate referral for high suspicion –
Category 1.
Refer appropriate specialist – Category
2.
Refer urgently to appropriate specialty
– Category 1-2.
Refer immediately to appropriate
specialty – Category 1.
Refer for multiple progressive episodes
– Category 1-2.
DO NOT DILATE PUPILS TO ALLOW
PUPILLARY EXAMINATION
Last updated February 2006
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Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Opthalmological Headache
Tension.
No neurological signs/symptoms.
* Needs work up to exclude other
causes
Vascular:
– Migrainous cluster
With visual symptoms.
Raised intercranial pressure.
+/- Neurological signs/symptoms.
No need for routine Ophthalmic
assessment.
No need for routine referral unless
suspect associated ocular pathology.
Depending upon severity, referral nonurgent to semi-urgent – Category 2-3.
Urgent referral to Neurology and/or
Paediatric Service – Category 1.
Referral to Ophthalmology Service is
optional and only to confirm suspicion
of papilloedema; however,
management options are to be coordinated by Neurology and/or
Paediatric Services.
Giant cell arteritis and other vascular
disease.
IMMEDIATE ESR.
Ocular pathology.
Headaches associated with ocular
signs and symptoms (red eye,
epiphora, proptosis etc).
Immediate referral if associated loss of
vision or progressive loss of function
(diplopia) – Category 1.
Confirm absence of neurological,
vascular, tension headaches etc.
Semi-urgent referral if no loss of vision
or no progressive loss of function (as
above) – Category 2.
Non-urgent routine referral if symptoms
are significant – Category 3.
Accommodative/aesthenopic
Immediate discussion with
Ophthalmologist for acute sight
threatening giant cell arteritis is
mandatory.
Immediate referral is mandatory if
associated loss of vision – Category 1.
Urgent referral if pathology is
suspected with confirmatory
signs/symptoms and raised ESR –
Category 2.
For minor to moderate aesthenopic
Last updated February 2006
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symptoms, suggest referral initially to
optometrist for initial assessment.
Diagnosis / Symptomatology
Orbital
Evaluation
Management Options
Proptosis: Acute, chronic, endocrine –
TFTs.
Referral Guidelines
Refer Category 1-3. Acute proptosis,
discuss with ophthalmologist.
Painful.
Masses.
Ocular movement.
Diagnosis / Symptomatology
Paediatric squint / vision problems
Evaluation
Age.
Management Options
Age less than 8 years.
Prompt referral to ophthalmologist –
Category 2-3.
Age 8 years plus.
Referral as appropriate. May consider
primary ophthalmic referral – Category
4.
Squints.
Suspected visual deficits.
White pupil.
Last updated February 2006
Referral Guidelines
Refer immediately – Category 1.
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Diagnosis / Symptomatology
Evaluation
Management Options
Toxicity Screening for Systematic
Drugs
Ethambutol (within one month). Over
15mgs/kg/day.
Adjust treatment as appropriate and in
discussion with relevant specialist for
all these drugs.
Note: Many systemically administered
drugs produce adverse effects.
Fortunately, relatively few are capable
of causing significant, irreversible
visual impairment.
Amiodarone: This drug almost
invariably produces corneal deposits.
They rarely produce symptoms and
resolve upon withdrawal of the drug.
Screening is questionable.
Referral Guidelines
Mandatory referral within one month
for ethambutal – Category 1-3, after
discussion with relevant specialist for
patients with visual symptoms.
(Note: It is recommended by the
Ophthalmic Society of NZ that
chloroquine be withdrawn from the
pharmaeopaeia.)
Chloroquine and derivatives.
Some psychotropic drugs (eg Melleril).
Vigabatrim.
Tamoxifen.
Last updated February 2006
Patients receiving more than 800 mg/s
day may develop a significant
retinopathy within 1-2 months of
commencing treatment. Early
screening is required.
May require screening.
No screening is recommended.
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Diagnosis / Symptomatology
Trauma
Evaluation
Adnexal (lids): functional anatomical
integrity.
Orbit: diplopia +/- x-ray.
Penetrating:
Management Options
Antibiotic ointment, pad.
AB as appropriate.
Referral Guidelines
Refer if appropriate, eg. all full
thickness lacerations of the upper lid,
suspected canicula disruption, levator
disruption – Category 1.
No nose blowing.
Refer to appropriate specialist –
Category 1.
Chemical: History (acid, alkali, other)
and phototoxic burns/UV burns.
Must be excluded in all ocular trauma.
Contact poisons centre.
Immediate referral for specialist
management – Category 1.
Blunt: Hyphema, traumatic mydriasis,
LOV.
Topical anaesthesia. Copious
irrigation; maintain for 15 minutes.
Immediate referral for specialist
management – Category 1.
Foreign bodies on ocular surface.
Removal of solid particles. Topical AB.
Refer if in doubt.
Corneal.
Dark glasses.
Non-magnetic, magnetic, metal/nonmetal, velocity.
External Foreign Bodies
Subtarsel – occult.
Site specific: within pupil zone. If
outside pupil zone, removal under LA.
Refer immediately – Category 1. Refer
if pain persists.
Remove under LA.
Adjunctive fluoroscein staining may
help localisation.
Last updated February 2006
Refer if difficult/incomplete – Category
1-2.
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Diagnosis / Symptomatology
Watery eye
Evaluation
Paediatric: Congenital.
Paediatric: Acquired photophobia/
redness.
Hazy and enlarged cornea.
Adult: Excessive lacrimation.
Management Options
Referral Guidelines
Congenital: Frank suppuration,
topical Abs, lacrimal sac massage.
Refer Category 4.
Non-supportive: Sac massage only.
Diagnose primary cause.
Refer Category 4.
See if Fluoroscein dye inserted in the
eye can be blown from the nose after 5
minutes.
Refer all acquired – Category 1-2.
Refer Category 4.
Inadequate drainage – lid/punctal
position, history of trauma, nasal
pathology.
Last updated February 2006
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