Adam Hatoum

As a junior doctor, knowing how to make appropriate referrals to specialists is essential for ensuring optimal patient care. What can often seem like a daunting task can be made much simpler once broken down into pertinent information that should be communicated.

When it comes to eye-related concerns, referring patients to ophthalmologists requires attention   to detail and inclusion of crucial information. Here are some key points to consider when making a referral to an ophthalmologist:

Reason for referral and patient information:

As with any referral, start by clearly stating the reason. Whether it’s an acute condition, chronic eye problem, or the need for further evaluation of an ocular finding, providing a concise and accurate description of the patient’s eye condition is crucial.

Include basic patient details such as name, age, gender, and contact information. Additionally, mention any relevant medical history, medications, allergies, and past eye-related issues.

Ocular symptoms:

Document the patient’s symptoms in detail. For instance, note if they experience blurry vision, eye pain, redness, double vision, light sensitivity, or any other relevant issues.

External eye examination:

Comment on the appearance of the eye as you see it. To an experienced ophthalmologist, this will itself help them narrow down the likely diagnoses. Describe any swelling around the eye, is it medial or lateral? Does it involve the upper lid or lower lid? Is there any proptosis, or protrusion of the eye? What is the appearance of the conjunctiva? Is it red and angry, or white and quiet? If the patient presents with discharge, is it clear and runny, or thick and sticky?

In cases of trauma, it would be diligent to stain the eye using fluorescein (available in any Emergency Department) to assess for any corneal abrasions.

Pupillary reflex:

Firstly, comment on the size of the pupils and presence of anisocoria (difference in pupillary size), if so is this anisocoria more pronounced in dark or light conditions?

A pupillary reflex is essential to any eye examination, providing critical information into the neurological, ophthalmic, and autonomic function of the patient.

It is important to assess both the direct and consensual response, and to reflect on whether there is any RAPD (relevant afferent pupillary defect).

Visual acuity:

This is one of the most crucial pieces of information for an ophthalmologist. Include the patient’s best-corrected visual acuity for both eyes, using the Snellen chart or other relevant measurement tools. For example, record it as 20/20, 20/40, etc.

The ‘Eye Test Snellen Ishihara’ app can be accessed via any smartphone and provides an easy way for quick assessment in any setting, be it Emergency Department, General Practice, or inpatient ward. It also has the added benefit of Ishihara plates for colour-vision testing.

Visual fields:

If possible, provide information on the patient’s visual fields. This can be particularly helpful in cases of suspected glaucoma or neurological conditions affecting vision.

A formal visual fields assessment is often not accessible, but a gross assessment of confrontational visual fields is a technique that all doctors should be familiar with, as it forms part of the cranial nerve examination.

Eye movements:

Make an assessment of the eye movements and by extension, any extra-ocular muscle defects. If the patient complains of double vision, it is important to note in which direction the double vision   is maximal (up-gaze, down-gaze, left-gaze, right-gaze), as this will indicate the likely culprit muscle.

Intraocular pressure (iop):

If you have access to point-of care IOP measurement, include this in your referral, especially if the patient is being referred for glaucoma evaluation.

If the patient has a history of glaucoma, a look through their medical notes to find their most recent review and pressures would also be of value.

Fundus examination:

If you’ve conducted a fundus examination, share the findings. Mention any abnormalities in the optic nerve, retina, or blood vessels. This will be difficult without first dilating the pupil, the drops for which can be found in every Emergency Department.

Relevant test results:

If there are any recent pertinent test results, such as optical coherence tomography (OCT) scans or visual field tests, include them to aid the ophthalmologist in their assessment.

Urgency:

Indicate the level of urgency for the referral. If it’s an emergency, make sure to emphasize it to expedite the appointment.

Other considerations:

If there are any additional factors that may impact the referral, such as the patient’s mobility, special needs, or language barriers, mention them to ensure appropriate accommodation is made.

By following these guidelines, junior doctors can ensure that their referrals to ophthalmologists are comprehensive and effective, leading to better patient outcomes. Collaborating with specialists and providing them with the necessary information is vital in delivering top-quality eye care to patients.