Moaz Hamid contact

Western Sussex Hospitals, Worthing, United Kingdom

Acknowledgements

Nil.

Conflicts of Interest: 

The author declares no conflicts of interest.

Funding:

Nil received.

1. Introduction

With increasing specialisation and multidisciplinary approaches to healthcare [1], referrals are becoming an every present part of working in any speciality. Despite the daily occurrence of the task of referring a patient, referrals are commonly cited as a challenging task by junior doctors [2]. This challenging nature is demonstrated in the often anecdotally mentioned complaint amongst doctors of receiving inappropriate referrals. A particular difficulty found with ophthalmology referrals is the lack of exposure many doctors have had in medical schools and subsequently in their careers to ophthalmology [3], [4]. This can result in certain questions or examinations steps not being carried out prior to referral. This paper is an attempt to address this problem, by giving doctors a framework for ophthalmology referrals as well as by delineating which conditions should be referred and how urgently.

2. A framework for referral

A commonly used technique for handovers in any field of work is the ‘ISBAR’ approach. This, when adapted for clinical work, is a good systematic way of referring a patient. The ‘I’ stands for introduction. Here the referring doctor should introduce himself by name, role and division and explain generally what they would like (whether that be advice, a patient review or a transfer of care).

Then the referring doctor should explain the situation, in terms of its most basic details, which would be the patient’s identifiers (name and age usually), the patient’s locations and the major problem for which you’re referring. An example of what the referring doctor could say would be “The patient is named Sarah Jones, she is a 59-year-old woman in A&E Majors, with suspected acute glaucoma”

Next the referring doctor should discuss the patient’s background, which refers to their admission details and medication history. For instance, “the patient presented with severe headache and visual loss 2 hours ago, she has a past medical history of cataracts and hypertension”. Following this a focussed summary of the assessment should be given. This includes examination and investigation findings, as well as the management so far. Lastly the referring doctor should make a recommendation which is the action they would like the doctor they are talking to, to take.

I	Introduction
S	Situation
B	Background
A	Action
R	Recommendation

Table 1. The components of the ‘ISBAR’ framework

3. Important history taking and examination steps

Many referrals to ophthalmology don’t contain crucial assessment aspects which makes making decisions about management of the patient by the on-call ophthalmologist difficult. Firstly, it is important to take a thorough history which should include details about the character of the visual changes – specifying whether there is blurring of vision, double vision or loss of vision. It’s also important to ask if the patient is seeing any flashing lights, floaters or zig zag lines. Often a systems enquiry is overlooked, however many systemic diseases have ocular manifestations and therefore it is important to enquire about associated features. The past ocular history is also crucial, even enquiring more about a patient’s glasses and determining whether they are short or long sighted can help the ophthalmologist with identifying the most likely differential and subsequent management.

In terms of examination, it is vital to assess visual fields and ideally this should occur with a Snellen chart. Similarly, a color vision assessment using Ishihara plates can be very useful. If a Snellen chart or Ishihara plates are not available then various mobile apps can be used to assess acuity and color vision; although these apps may not be as accurate as gold stand measures, several studies have shown they are useful alternatives [5], [6], [7]. Other important aspects of assessment are performing a visual fields exam and inspecting the external eye and pupils. Pupillary reflexes, eye movements and fundoscopy are also useful to perform.

4. Referral scenarios

In ophthalmology there are several urgent conditions which should be assessed by an ophthalmologist immediately, however there are others which do not require such urgent assessment. Below is a general guide elucidating urgent and non-urgent conditions. However, one should note these might vary slightly from department to department.

4.1. Immediate

The following scenarios should prompt immediate contact with the on-call ophthalmologist

1. Acute glaucoma
2. Intraocular foreign body
3. Globe perforation
4. Corneal laceration
5. Orbital cellulitis
6. Hypopyon
7. Iris prolapse
8. Central retinal vein occlusion (that has <8 hours onset)
9. Acute oculomotor nerve palsy
10. Sudden, unexplained visual loss (that has <24 hours onset)

4.2. Very urgent

The following scenarios should ensure prompt ophthalmologist review within one day. Usually it is sufficient to make an eye clinic appointment for the patient, unless the next day is a non-working day.

1. Retinal detachment
2. Retinal tear
3. Vitreous haemorrhage
4. Corneal abrasion
5. Corneal foreign body
6. Blunt trauma
7. Orbital fractures
8. Lid laceration
9. Iritis
10. Hypheama
11. Severe eye pain

4.3. Mildly urgent

The following scenarios necessitate a referral to an ophthalmologist for review within one week.

1. Bell’s palsy
2. Optic neuritis
3. Recent onset diplopia
4. Recent wet AMD
5. Herpes zoster ophthalmicus with eye involvement
6. Painful entropion
7. Proliferative diabetic retinopathy

4.4. Not urgent

The following scenarios do not require urgent ophthalmology review. They should be managed locally and if they cannot be managed a routine referral to ophthalmology should be made

1. Conjunctivitis
2. Chalazion
3. Dry eyes
4. Ectropion
5. Blepharitis
6. Subconjunctival haemorrhage
7. Squint (chronic)
8. Cataract

5. Conclusion

Eye presentations often pose s challenge for junior doctors with limited ophthalmology experience. It is inevitable that help will be needed at times and appropriate and structured referrals are an essential skill for every junior doctor to master. Referrals can be structured using the ‘ISBAR’ approach to ensure clarity of communication, and a knowledge of key history and examination steps to convey with ophthalmological conditions can greatly improve the quality of referrals. It also useful to have an idea of which conditions to refer and how urgently. Although we have specified many scenarios in this article, it is by no means an exhaustive list and whenever there is any doubt with regards to a patient’s ophthalmic management the doctor should not hesitate to seek support from their colleagues or the ophthalmologist on call.

References

1. J. P. Loefler, “Are generalists still needed in a specialised world? The renaissance of general surgery,” British Medical Journal, vol. 320, no. 7232. BMJ Publishing Group, pp. 436–438, 12-Feb-2000.
2. P. Franks, G. C. Williams, J. Zwanziger, C. Mooney, and M. Sorbero, “Why do physicians vary so widely in their referral rates?,” J. Gen. Intern. Med., vol. 15, no. 3, pp. 163–168, 2000.
3. T. Y. B. Chan, A. S. Rai, E. Lee, J. T. Glicksman, and C. M. L. Hutnik, “Needs assessment of ophthalmology education for primary care physicians in training: Comparison with the international council of ophthalmology recommendations,” Clin. Ophthalmol., vol. 5, no. 1, pp. 311–319, 2011.
4. D. A. Quillen, R. A. Harper, and B. G. Haik, “Medical student education in ophthalmology: Crisis and opportunity,” Ophthalmology, vol. 112, no. 11. Elsevier, pp. 1867–1868, 01-Nov-2005.
5. S. Pathipati, E. H. Wood, C. K. Lam, C. S. Sáles, and D. M. Moshfeghi, “Visual acuity measured with a smartphone app is more accurate than Snellen testing by emergency department providers,” Graefe’s Arch. Clin. Exp. Ophthalmol., vol. 254, no. 6, pp. 1175–1180, Jun. 2016.
6. W. K. Yeung et al., “eHealth tools for the self-testing of visual acuity: a scoping review,” npj Digit. Med., vol. 2, no. 1, p. 82, Dec. 2019.
7. S. J. Dain and A. Almerdef, “Colorimetric evaluation of iPhone apps for colour vision tests based on the Ishihara test,” Clin. Exp. Optom., vol. 99, no. 3, pp. 264–273, May 2016.