Abstract
Background
Direct referrals from optometrists account for up to 10% eye casualty attendances. Despite this, there remains a paucity of literature on optometrist referrals to eye casualty. A better understanding of these referrals could be helpful in the development of shared care emergency pathways. Diagnostic agreement between optometrists and ophthalmologists for emergency referrals can be used to identify areas for development of shared care working strategies in emergency ophthalmology.
Methods
A retrospective evaluation of 1059 consecutive optometric emergency referrals to Moorfields Eye Hospital was conducted. Referrals were only included when a letter or documentation for the reason for referral was provided. Diagnostic information from the referring optometrist and casualty doctor was summarised for each patient by an investigator (VMT) and recorded on a single spreadsheet. These clinical summaries were compared by a second independent investigator (IJ) and marked as agreeing, disagreeing or uncertain. Each clinical summary was then mapped to a diagnostic category using key word searches which were manually re-checked against the original summaries. Information on the timing of the referral and the outcome at the emergency department visit was also collated. Inter-observer agreement for diagnostic categories was measured using kappa coefficients.
Results
Diagnostic agreement ranged between kappa 0.59 and 0.87. It was best for diagnoses within the red eye category (kappa 0.87). Compliance with College of Optometrists referral guidance ranged between 11 and 100%. More than half of referrals for elevated intra-ocular pressure were discharged at the eye casualty visit. Overall, 54% of patients were managed with advice alone, 39% required treatment following referral and 7% required onward referral from eye casualty.
Conclusion
The majority of patients referred by optometrists were managed with advice alone. A collaborative approach at the point referral could be helpful to improve referral efficiency.
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Appendix. College of Optometrists guidance for optometrists regarding emergency and urgent referral
Appendix. College of Optometrists guidance for optometrists regarding emergency and urgent referral
Emergency referral (within 24 h), symptoms or signs suggesting:
Acute glaucoma
acute dacryocystitis in children, or in adults if severe cellulitis (preseptal or orbital)
corneal foreign body penetrated into stroma, or with presence of a rust ring (unless optometrist is specifically trained in rust ring removal)
CRAO
Endophthalmitis
facial palsy, if new or with loss of corneal sensation
herpes zoster ophthalmicus with acute skin lesions (emergency referral to GP for systemic anti-viral treatment with urgent referral to ophthalmology if deeper cornea involved)
hyphaema
hypopyon
IOP ≥ 40 mmHg (independent of cause)
microbial keratitis
orbital cellulitis
papilloedema
penetrating injuries
pre-retinal haemorrhage, although a pre-retinal haemorrhage in a diabetic patient with known proliferative retinopathy who is already being actively treated in the HES would not need an emergency referral
retinal detachment unless this is long-standing and asymptomatic
scleritis
sudden severe ocular pain
suspected temporal arteritis
symptomatic retinal breaks and tears
third nerve palsy with pain
trauma (blunt or chemical), if severe
unexplained sudden loss of vision
uveitis
vitreous detachment symptoms with pigment in the vitreous, or
viral conjunctivitis if severe (e.g., presence of pseudomembrane)
Urgent referral (within 1 week), symptoms or signs suggesting:
acute dacryoadenitis
acute dacryocystitis if mild
atopic keratoconjunctivitis with corneal epithelial macro-erosion or plaque
unilateral blepharitis if carcinoma suspected
chlamydial conjunctivitis (refer to GP)
CMV and candida retinitis
commotio retinae
corneal hydrops if vascularisation present
CRVO with elevated IOP (40 mmHg refer as emergency)
herpes zoster ophthalmicus with deeper corneal involvement—urgent referral to ophthalmology, but refer to GP as an emergency for systemic anti-viral treatment
IOP > 35 mmHg (and <40 mmHg) with visual field loss
keratoconjunctivitis sicca if Stevens–Johnson syndrome or ocular cicatricial pemphigoid are suspected
retinal detachment if not an emergency, see above
retrobulbar/optic neuritis
ocular rosacea with severe keratitis
rubeosis
squamous cell carcinoma
steroid induced glaucoma
sudden onset diplopia
vernal keratoconjunctivitis with active limbal or corneal involvement, or
‘wet’ macular degeneration/choroidal neovascular membrane, according to local fast-track protocol.
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Mas-Tur, V., Jawaid, I., Poostchi, A. et al. Optometrist referrals to an emergency ophthalmology department: a retrospective review to identify current practise and development of shared care working strategies, in England. Eye 35, 1340–1346 (2021). https://doi.org/10.1038/s41433-020-1049-z
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DOI: https://doi.org/10.1038/s41433-020-1049-z
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