Hannah Whelan

Referrals to the Urgent Eye Clinic (UEC) are rising, leading to an increased demand on services. Many of these referrals are deemed as non-urgent (1). One method of referral to the UEC is via Accident and Emergency (A&E). In some areas in the country, patients who present to A&E with an acute eye problem will be initially seen by A&E clinicians and be referred to the UEC to be reviewed by ophthalmologists (2).

As a foundation doctor working in ophthalmology, it has been clear that many referrals from A&E have been inappropriate. These have included blepharitis, conjunctivitis and deterioration in vision over the course of a few months being referred to the weekend UEC. I have witnessed all three of these referral examples. Inappropriate referrals from A&E and General Practices lead to increased demand on the UEC (2). 

Why are inappropriate referrals being made?

This is a vast topic which requires further research. One reason identified is a lack of education leading to reduced confidence and competence amongst non-ophthalmology specialist clinicians (3). During my medical training, I completed one week of ophthalmology placement in five years. A clinical placement in ophthalmology is not a requirement of the undergraduate medical curriculum and a study has shown the average length of ophthalmology placements amongst UK medical schools is 7.6 days (4). As a junior doctor who has rotated in A&E and general practice prior to rotating in ophthalmology, I can confirm my ability to competently perform fundoscopy was lacking and my knowledge on acute eye pathology was limited in comparison to clinical knowledge in other areas of medicine. This may not be surprising given such a small focus on ophthalmology in my medical degree, yet it feels very wrong.

When I first began my ophthalmology rotation, I was shocked by how disappointed the ophthalmologists seemed in A&E clinicians. One ophthalmologist explained that they received a referral where the clinician was unable to distinguish if the injury was on the sclera or the cornea as they were unsure of how to tell the difference between the two. A study by Sim et al compared the confidence of managing ocular emergencies in A&E senior house officers (SHOs) between 1993 and 2003. They concluded that confidence was low in both studies, showing no signs of improvement over the past ten years (5). Although this study was 20 years ago, a more up to date National Study showed that in comparison to 2003, there has been a large reduction in the training of management of acute ocular emergencies for A&E staff from 77% to 45%. Additionally, only 6% of Foundation Year two doctors (FY2s) in A&E felt confident managing ocular emergencies as opposed to 36.1% in 2003 (6). In theory, low confidence amongst A&E clinicians in management of ophthalmic emergencies or common ophthalmic presentations would correlate with more referrals to the UEC.

In other referrals from A&E that I have seen, visual acuity was not documented in the written assessment (and unlikely performed). A study comparing A&E documentation with UEC documentation demonstrated that in 59% of A&E records, there was omission of examination findings including no documentation of visual acuity (7). Visual acuity is a simple, yet highly important part of the ocular examination and should be performed on anyone presenting with an eye complaint (8). Are clinicians not documenting visual acuity because they do not feel confident assessing it?

Only after I had left the A&E department and began working in ophthalmology did I find out that the A&E department in my hospital had a slit lamp. Albeit, if I did know it was there, I wouldn’t have had any ideas how to use it. Studies have demonstrated that slit lamp training in the emergency department is also lower than it has been previously (6).

The National Surveys illustrate that confidence and competence amongst junior doctors in A&E is on the decline. We currently have no obvious data to correlate the lack of confidence dealing with ocular presentations with the increase in UEC referrals. This could be something worth looking in to. Despite this, it is evident that further education on ophthalmology is required for our junior doctor colleagues to support our patients with ocular presentations. 

References

1. Siempis T. Urgent Eye Care in the UK Increased Demand and Challenges for the Future. Med Hypothesis Discov Innov Ophthalmol. 2014 Winter;3(4):103-10. PMID: 25756059; PMCID: PMC4352203.
2. HB Smith, CS Daniel, S Verma. Eye casualty services. Eye (Lond) 2013 Mar;27(3):320–8. doi: 10.1038/eye.2012.297. PMID: 23370420. 
3. Scantling-Birch, Y., Naveed, H., Tollemache, N. et al. Is undergraduate ophthalmology teaching in the United Kingdom still fit for purpose?. Eye 36 2002 343–345
4. Baylis O, Murray PI, Dayan M. Undergraduate ophthalmology education – A survey of UK medical schools. Med Teach. 2011;33(6):468-71. PMID: 21355698.
5. Sim D, Hussain A, Tebbal A, Daly S, Pringle E, Ionides A. National survey of the management of eye emergencies in the accident and emergency departments by senior house officers: 10 years on–has anything changed? Emerg Med J. 2008 Feb;25(2):76-7. PMID: 18212138.
6. Sim PY, La CJ, Than J, Ho J. National survey of the management of eye emergencies in the accident and emergency department by foundation doctors: has anything changed over the past 15 years? Eye (Lond). 2020 Jun;34(6):1094-1099. PMID: 31649348;
7. Flitcroft DI, Westcott M, Wormald R, Touquet R. Who should see eye casualties?: a comparison of eye care in an accident and emergency department with a dedicated eye casualty. J Accid Emerg Med. 1995 Mar;12(1):23-7. PMID: 7640823
8. Caltrider D, Gupta A, Tripathy K. Evaluation Of Visual Acuity. [Updated 2023 Feb 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564307/