Hee La Lee
Introduction
Although most medical students are taught the ‘SBAR’ framework and similar tools for making referrals, referring to specialists like ophthalmologists can be still daunting. Part of it is because of how little non-specialists know about ophthalmology, the lack of equipment to examine the eyes, and fear of being laughed at for a lack of a differential diagnosis! However, we spoke to an ophthalmologist and got some tips that will help any A&E, GP or ward doctor make a better referral to ophthalmology.
1. Communicate a Good Past Ocular History
It is important to take good past ocular history. Ophthalmologists will likely want to know about any recent eye surgery or other eye conditions. Ask the patient whether their presenting complaint has happened before. Also, it is essential to know if the patient wears contact lens, especially if their symptoms are related to pain or redness in the eyes.
2. What are the ‘Observations’ of Ophthalmology
Similar to how you wouldn’t call an intensive care specialist without a complete set of observations, ophthalmologist’s view ‘visual acuity’ as one of the core ‘obs’ of any eye case. You can easily download Snellen acuity app on smart phones to check patient’s vision, and even just having attempted this would stand you really well with any ophthalmologist. If you’re unsure about distances, test it with yourself first. Even an estimated acuity can be incredibly helpful on the phone to know how worried you should be about the patient.
3. Have You Tried Examining the Eye?
When communicating your eye examination findings, it will be easier to follow a simple, systemic approach. For example, describe the eyelids, the conjunctiva and the cornea if you’re worried about a ‘front of the eye’ issue. It would also be very useful to include photographs that can be shared securely. If the presenting complaint includes scratches or injury to the front of the eye, it will be essential to carry out fluorescein examination. Most ophthalmoscopes have a blue light filter, and every A&E department will have fluorescein eye drops.
Finally, for referrals about disc problems – such as for suspected swollen discs or papilloedema, it is useful to try and have a view with the ophthalmoscope. Ophthalmologists tend to appreciate if a member of the team have at least tried to examine the optic discs, and will typically be very happy to get involved if there’s a reason for a difficult examination (for example a child, or a patient with learning difficulties).
4. Are They Systemically Well?
Because of the equipment-heavy nature of the ophthalmic assessment, ophthalmologists generally prefer to see patients in the eye clinic. If needed, investigations such as an OCT scan or visual field test can be arranged, and patients generally have much better care in- hours in the eye clinic. It’s also generally harder to examine a patient at the bedside, than at a slit-lamp. As such, ophthalmologists will want to know if this patient is well enough to come to the eye clinic, or if they will be discharged soon and can be seen in an outpatient setting.
Summary
Referring to ophthalmology is not as difficult as you may assume, often it includes using basic history taking or examination skills that you already know. Bear these four tips in mind when referring to an ophthalmologist, and you’ll find your referrals to be much smoother and better informed.