Ophthalmology has long been the specialty with the most referrals and patient appointments in an outpatient environment, having had over 8.7 million clinic appointments scheduled in 2022-23 across the NHS.¹ The volume of Ophthalmology referrals, both from primary care and from inpatient settings, continues to increase every year and poses a problem for the on call ophthalmologist in terms of triaging each referral. Very few Ophthalmology referrals have all the necessary information to allow for appropriate triaging, which increases the risk of adverse outcomes.² Although making a referral to Ophthalmology might seem like a daunting task, especially if you have not had any experience with the specialty, here is some advice on how to make a good referral and include all useful information for the Ophthalmology team to review and advise appropriately.

How do you make a referral to Ophthalmology?

This answer depends heavily on the systems utilised in your trust. As a general rule, there should be an ophthalmologist on call at all times (both an SHO/SpR and a Consultant) who you can call for advice if this is required urgently or you need to discuss the best way to manage a patient with an ophthalmic condition (e.g. in terms of booking them into the Emergency Eye Clinic).

In certain trusts, you can also put through referrals to Ophthalmology via software such as ICE, in which you type in particular information for the Ophthalmology team to triage. This is generally a method that should best be used if someone can be reviewed in the Emergency Eye Clinic but does not need to be seen out of hours, and ideally as much information as possible should be included to assist with triaging the patient correctly. This also applies to primary care, where there are different types of referrals to Ophthalmology you can make (both routine and urgent).

How urgently does the patient need to be reviewed?

For certain conditions, the sooner the patient is seen by Ophthalmology the better. As a general rule, eye trauma with significant damage caused will often need to be seen the same day, therefore cases such as this should be discussed over the phone with the Ophthalmology team. Furthermore, conditions which can lead to irreversible loss of vision very quickly, such as corneal ulcers, endophthalmitis, acute angle closure glaucoma, temporal arteritis, retinal artery occlusion or retinal detachment, should also be reviewed as quickly as possible.

For other conditions, a referral that can be triaged should usually suffice, and those will be dealt with in order of severity. If there are any questions, however, do not hesitate to call the on call Ophthalmology team as they will be able to provide invaluable advice and ensure a potentially serious condition is not missed.

What information should a referral contain?

Invariably, this will depend on the way in which referrals are made in your trust – in some trusts, for example, the software will have a word limit beyond which you won’t be able to add any further information. Therefore, you need to be very selective with the information you include, but also ensure you don’t miss out important details.

As a general rule, this information would be very useful to help the on-call ophthalmologist provide advice or triage referrals, and get the best outcome for the patient:

• What is the reason for referral/clinical question?

As with referrals to other specialties, this is arguably the most important piece of information that needs to be included. It provides essential context to the referral and helps streamline management, either by facilitating triage or allowing the on-call ophthalmologist to provide appropriate advice.

• History of presenting complaint

This section should include a description of the signs and symptoms the patient is experiencing, the duration of the symptoms (and whether there is increasing severity), the presence/absence of pain, any subjective visual changes as described by the patient and other features that would be important in making a judgment about underlying conditions. Non-ocular symptoms are also useful if they point towards a particular diagnosis, e.g. for a patient with exophthalmos or proptosis the presence of a goitre or palpitations points more heavily towards thyroid eye disease.

• Past medical history (including drug/allergy, family and social history if relevant)

In this section, try to ensure all relevant conditions are included, as there are many conditions with ocular manifestations. If there are also elements from the medication or social history or conditions running in the family that might be related to the current presentation, this would also be helpful information.

• Past ophthalmic history

If you have time, adding this information would also be very appreciated. Important sections you can cover include:

1. Previous ophthalmic surgery
2. Known ophthalmic pathologies/medications
3. Previous laser therapy
4. Known amblyopia
5. Patient wearing glasses/contact lenses (and prescription if available)

For a complete guide on how to take an ophthalmic history, you can visit the relevant Mind the Bleep article³ or use the guide cited here.⁴

• Examination findings

This includes pupillary response to light, eye movements, eyelid abnormalities/proptosis, anterior segment examination (where able) and other findings that may be relevant. Understandably, some investigations may be difficult to perform in certain environments, e.g. a formal visual acuity test if the space is not suitable/a Snellen or LogMAR chart is not available, or fundoscopy if no ophthalmoscope is available.

• Relevant investigations (e.g. CT/MRI head, bloods)

Make sure that if you refer with a specific clinical question you add any information that would be relevant from investigations; for example, CRP/ESR can be requested as a minimum if temporal arteritis is suspected, or a CT/MRI head if there is suspicion of intracranial pathology leading to visual problems (e.g. diplopia or papilloedema).

Take home points

While making a referral to any specialty can seem like a daunting task, especially if you are unsure of your own clinical knowledge in the specialty or are unfamiliar with managing ophthalmic conditions, always remember you can ask the Ophthalmology team for advice at any time! In general, a good referral consists of having as much information possible for the Ophthalmology team to triage it effectively, and ensuring appropriate advice is provided so the patient being referred can be managed safely for their condition.

References

1. Hospital Outpatient Activity 2022-23 [Internet]. NHS Digital. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/hospital-outpatient-activity/2022-23
2. Khou V, Ly A, Moore LS, Markoulli M, Kalloniatis M, Yapp M, et al. Review of referrals reveal the impact of referral content on the triage and management of ophthalmology wait lists. 2021 Sep 1;11(9):e047246–6.
3. Eye History & Exam – Mind The Bleep [Internet]. mindthebleep.com. 2020 [cited 2023 Dec 20]. Available from: https://mindthebleep.com/eye-history-exam/
4. ‌Takusewanya M. How to take a complete eye history. Community Eye Health [Internet]. 2019;32(107):44–5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7041835/

Written by Dr Tasos Emmanuel (FY3) & reviewed by Dr Pavel Sharma (ST3 Ophthalmology)