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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. Page 1 of 10 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. Page 2 of 10 REFREC014 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. Page 3 of 10 REFREC014 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 Page 4 of 10 REFREC014 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 Page 5 of 10 REFREC014 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 Page 6 of 10 REFREC014 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. Page 7 of 10 REFREC014 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. Page 8 of 10 REFREC014 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. Page 9 of 10 REFREC014 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 Page 10 of 10