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Referral Guidance for patients of Birmingham GPs

Guidance for optometrists in Birmingham on the referral of patients with ocular conditions requiring medical intervention and relating to patients of GPs in Birmingham and Solihull (BSol) CCG and that part of Sandwell and West Birmingham CCG that used to be associated with Heart of Birmingham Primary Care Trust.

PLEASE REMEMBER that BMEC / Sandwell Hospital, Heart of England Foundation Trust and University Hospitals Birmingham all have rapid access clinics for patients with Wet AMD.  For information on how to refer to these clinics please go to “Ophthalmology Provider Contacts.

We recommend eye care professionals seeking information about eye conditions for their own education or that of their patients should go to the The College of Optometrists website (www.college-optometrists.org), The Association of Optometrists web site (www.aop.org.uk) or the Good Hope Eye Clinic website (www.goodhopeeyeclinic.org.uk) set up and kept up to date by associate specialist ophthalmologist David Kinshuck, these websites are an invaluable resource from which patient information leaflets can be downloaded or obtained free of charge to members.

Introduction

On 1st April 2005 the wording of the GOS regulations relating to referral were changed, the change remaining in place when the GOS contract was renewed in 2008.

The major change was that the old requirement to refer patients to a ‘medical practitioner’ changed to a requirement that optometrists should refer patients “found to have injury, disease or abnormality in the eye direct to a hospital eye department where appropriate”.  More recently, in the area covered by Birmingham and Solihull CCG (BSol CCG), an intermediate ophthalmology service provided by “Health Harmonie”, has been introduced  so, for certain eye conditions, particularly ocular hypertension (OHT) and chronic open angle glaucoma (COAG) referrals to intermediate ophthalmology may frequently be more appropriate than a referral to secondary care.

For your information the actual wording of paragraph 31 of the contract is as follows:

  1. Where the Contractor or an ophthalmic practitioner employed or engaged by it to perform the Contract is of the opinion that a patient whose sight has been tested pursuant to clause 30—

31.1.       shows on examination signs of injury, disease or abnormality in the eye or elsewhere which may require medical treatment; or

31.2.       is not likely to attain a satisfactory standard of vision notwithstanding the application of corrective lenses,

s/he shall, if appropriate, and with the consent of the patient—

     31.3.       refer the patient to an ophthalmic hospital, which includes an ophthalmic department of a hospital,

     31.4.       inform the patient’s doctor or GP practice that s/he has done so, and

     31.5.       give the patient a written statement that s/he has done so, with details of the referral.

 Reasons for referral, obviously, remain unchanged and the change applies to all referrals where the optometrist might previously have referred via the patient’s GP expecting him or her to refer the patient on to a hospital eye department. Referral of such conditions via the GP is no longer appropriate.

 Birmingham Local Medical Committee welcomed the change and advised GPs to return eye referrals intended for the hospital eye service to the referring optometrist should any be sent to them in error.

 It is, of course, still appropriate to refer signs of systemic conditions such as hypertensive retinopathy or non sight threatening diabetic retinopathy in an undiagnosed diabetic patient to the GP since treatment to lower blood pressure or commence diabetic control is more appropriately administered by a GP than by an ophthalmologist. Dry eyes is another condition best referred to the GP with appropriate advice so that lubricant drops can be put on prescription.

For the time being most referrals to the HES or intermediate ophthalmology have to be made by fax or post, except in the case of emergency (same day) referrals which should be made by telephone with a written letter of referral given to patient to take with them to eye casualty at BMEC. Increasingly referrals can be made by email where the optometrist has a nhs.net email account as all secondary care providers have a suitable nhs.net address to which referrals can be sent.

NB Referrals should be made to intermediate ophthalmology or a hospital eye department with reference being made to the particular clinic that it would be most appropriate for the patient to attend (e.g. Birmingham Heartlands Hospital ophthalmology medical retina clinic).  Where you know of a particular consultant, whose team you would like your patient to be seen by it is now quite acceptable to name the consultant.

 The preferred referral route is by fax with a copy of the referral letter being faxed to the patient’s GP for information. The copy sent to the GP should clearly state that it is for information only and that the patient has already been referred.  It will also be useful to invite the GP to forward any pertinent medical history to the eye department to which the patient has been referred.  Alternatively, if you can obtain full details of current medication and conditions being treated you should include that information in your referral.

Once faxed, the original referral document should be retained with the patient’s record and a note made in the record stating to whom the referral has been sent and copied.

Updated information on optometric referral can be found in this guidance and is based on that issued by the College of Optometrists but has been brought up to date to allow for current best practice expected in the Birmingham area.

You may feel that some of the suggestions made are above and beyond the remit of a GOS practitioner and, indeed, the document is merely “guidance” so it is entirely your own choice whether you heed the advice included or not. It has, however, been written and modified with the best interests of the profession at heart and having taken into account various comments made by the GOC in recent years following cases brought against optometrists where serious professional misconduct has been alleged.

Finally I would urge you not to confuse general direct referral with “patient choice in cataract”, OHT repeat readings or MECS/CUES where these services are commissioned by the relevant CCG. All conditions requiring assessment by an ophthalmologist should, from now onwards, be referred direct to intermediate ophthalmology or a hospital eye department.  You will all be aware of the eye departments to which your patients have previously been referred when going via their GP and you should continue to refer to the same hospital(s).  It is perfectly acceptable to ask the patient which hospital or ophthalmology community clinic they would like to attend.  Cataract choice information is also included.

You will also find a list of useful fax numbers for use when referring, hospital and GP addresses can be obtained from the internet using Google or other search engines, from telephone directories or from the Birmingham medical list should you be fortunate enough to have a copy.

Clinical Decision Making

1) Clinical Decision Making in Ocular Conditions Requiring Urgent Referral

1.1 It is suggested that the following conditions require emergency or urgent referral. This is for guidance only; there may be guidelines issued by your local ophthalmic unit. The list below is not intended to be exhaustive

(a) Emergency (same day) referral

Acute glaucoma                                      CRAO<12 hours old

 Corneal foreign bodies                       Pulsating proptosis

 Hypopion                                                     Papilloedema

 Pre-retinal haemorrhage                  Retinal Detachment

 Sudden severe ocular pain               Unexplained sudden loss of vision

Uveitis                                                             Chemical injuries

Hyphaema                                                  Orbital cellulitis

Penetrating injuries                              Retinal breaks and tears

Sight threatening keratitis              Suspected temporal arteritisVitreous

Haemorrhage                                            3rd Nerve Palsy

Vitreous detachment symptoms with pigment in the vitreous.

 

 

(b) Urgent referral

Basal cell carcinoma                            Central serous retinopathy

CMV and Candida retinitis               Commotio retinae

 CRVO with elevated IOP                    Dacryoadenitis

 Dacryocystitis                                          Diabetic maculopathy (to screening)

 Disc haemorrhage                                  Entropion

 Scleritis                                                          Sudden onset diplopia

 IOP > 35 mmHg                                          Keratitis

 Macular hole < 6 – 12 months old          Pre proliferative diabetic retinopathy

Proliferative diabetic retinopathy           Retrobulbar/optic neuritis

 Rubeosis                                                      Squamous cell carcinoma

 Wet macular degeneration*                                                                                        

*Special arrangements for referral of wet AMD are in place see section on wet AMD.

 2) General Information

 2.1               This document contains referral frameworks intended for use in Birmingham U.K.  The guidance given is not prescriptive but is an illustration of good practice. There are clear long term benefits to patients and the health care system from reducing unnecessary referrals and ensuring that the referral process is effective.

2.2               A primary role of the optometrist in a routine eye examination is that of opportunistic case finding.  Part of the practitioner’s clinical obligation to the patient lies in his duty to detect and diagnose ocular problems and refer for medical advice and/or treatment where appropriate.  Referral is not a substitute for an inability to make a decision.  The General Optical Council rules on referrals that came into force on 1st January 2000 allow optometrists to manage patients’ conditions and only refer when clinically necessary.  The GOS terms of service were similarly amended to require referral of patients “when appropriate”.  Patient management can, therefore, include monitoring in practice at suitable intervals or referral to another optometrist with specialist expertise.  It is an abrogation of professional responsibility to refer the patient simply as a means of avoiding further patient management.

2.3               The process of referral is fundamentally one of decision-making.  Although guidance and referral protocols will help, frequently there is no simple cut off whereby an optometrist can say that he has discharged unequivocally his responsibility on referral.  The decision whether or not to refer will always be based on the patient’s personal circumstances, clinical needs and, where appropriate, local protocols.

2.4               Referral is intended to be for those sight- or health-threatening conditions that the optometrist might expect to see deteriorate within the period of time before the patient’s next optometric visit.  This may necessitate reducing the time interval between optometric visits in order that the probability of the presence of the suspected condition may be established.

2.5               The categories of referral decisions that can now be made by an optometrist are:

(i) emergency referral, i.e. same day referral to an eye casualty unit, ophthalmic outpatient clinic or an Accident & Emergency unit.

(ii) urgent referral, i.e. to an ophthalmic outpatient department to be seen within a week or two.

(iii) urgent referral by fax via the wet AMD co-ordinator for wet AMD.

(iv) routine referral to an ophthalmic outpatient department

(v) cataract choice referral for cataract surgery with patient choice of venue

(vi) referral to another optometrist with special expertise

(vii) referral to a GP for suspected systemic disease or simple eye conditions not requiring input from ophthalmology

(viii) to monitor a condition in practice until onward referral is indicated

2.6               Repeat measurements are desirable in the interests of establishing atypical norms, confirming a diagnosis, establishing rate of change if any, as well as refining the accuracy of referrals in the interests of reducing false positives.  Repeat measurements are an important ongoing part of everyday clinical practice but their importance is magnified when considering referrals.

2.7               Where, in this document, reference is made to optometrists in the masculine gender only, this is simply for ease of construction.  In such cases it is understood that ‘he’, ‘him’, ‘his’ should also be read as ‘she’, ‘her’ and ‘hers’.

2.8               Sections follow on emergency/urgent referrals and specific recommendations for the referral of a few of the most common conditions found in general optometric practice.  From time to time the LOC may issue further guidance for specific conditions.

2.9               These guidance notes should be kept in your clinical governance folder.

3) Guideline for the Investigation and Referral of Flashes, Floaters, PVD and Retinal Detachment.

3.1 Patients complaining of recent onset flashes and floaters frequently present in optometric practices or telephone for advice. This is an area of practice fraught with danger and potential for litigation and should be taken very seriously in all cases.

There is a Minor Eye Conditions Service (MECS) covering the whole of Birmingham and the surrounding areas, most optometry practices are sub-contracted to Primary Eyecare Services (PES) Ltd to provide it.Whilst the investigations required for the investigation of flashes and floaters are core competencies for all optometrists, those accredited to perform MECS have been assessed as being competent to carry them out and are aware of the most up to date referral criteria.

Refresher CET is available on the DOCET website including discussion cases

Patients with (recent – within the past eight weeks) sudden onset of flashes and floaters should be seen as an emergency within 24 hours of making contact, as should patients whose symptoms are getting worse even if they have had symptoms for up to 12 weeks.

Patients whose symptoms are staying the same can book with 48 hours and those who have had symptoms for three months or more can book a routine sight test.

Those who are not sub-contracted to PES for MECS may see the patient themselves if they are able to offer an appointment and feel competent to do so.  Alternatively they can refer to a nearby MECS accredited practice which will have to arrange for the patient to be seen within 24 hours.  In particular MECS practitioners are absolutely required to either see, or arrange for another accredited MECS practitioner to see such patients within 24 hours.

A full and thorough dilated examination must be carried out using every instrument at the practitioner’s disposal which may include any or all of the following:

  • Slit lamp examination of the anterior vitreous – to check for tobacco dust.
  • Slit-lamp bio fundus exam with 90D Superfield or Digital Wide Field Volk lens.
  • Slit-lamp bio with 3 mirror contact lens.
  • Indirect (headset) ophthalmoscopy with or without scleral indentation.
  • Ocular Coherence Tomography.
  • Full field visual field test
  • Direct ophthalmoscopy must always be backed up by slit lamp bio.

Look very carefully for Shafers sign (pigmented cells in the anterior third of the vitreous) observed with the slit lamp by asking the patient to look up and then straight ahead. 100% of patients with a positive Schaffer’s sign will have a retinal break.

Should a retinal tear, detachment or Shafers sign be observed refer the patient straight to BMEC, after phoning the triage nurse in the casualty department (0121 507 4440) and issue a leaflet on PVD and retinal detachment to the patient.

 If no tear, detachment or Shafers sign is seen and whether there is evidence of PVD or not, carefully explain what a PVD is and also the signs and symptoms of a retinal detachment to the patient with strict instructions to proceed straight to BMEC should they occur. Also issue a leaflet on PVD and retinal detachment.

REMEMBER that MECS is designed to reduce referrals to ophthalmology to an absolute minimum.  If you do not see any signs of retinal detachment do not refer to Eye Casualty “just to be on the safe side”.

3.2 If flashes and floaters have been noticed for more than three months and do not appear to be getting worse it is probably safe to arrange to see the patient as soon as possible for a full routine exam including dilated Volk fundus assessment.

All practice staff should be made aware of this advice.

3.3 The contents of this guidance are not intended to be prescriptive and it is the duty of the individual optometrist to ensure that he is fully aware of the College of Optometrists emergency referral guidelines.

3.4 Patient Information

 Leaflets suitable for issuing to patients are available free of charge to members from:

The College of Optometrists: college-optometrists.org

Usually available in printed format but only available for download during Covid-19 crisis

And

The Association of Optometrists: aop.org.uk

Available for download by members.

Corporate practices will probably have their own leaflets for use by those who work for them.

RNIB produce a leaflet entitled “Understanding Retinal Detachment” in large print – available from RNIB customer services on 0845 702 3153.

The Good Hope Hospital Eye Department web site;

http://www.goodhopeeyeclinic.org.uk/leafletsavailable.htm

For those with no access to written information we suggest that you join one of the AOP or College.

3.5 It is always wise to fully document your actions on the patient’s record card and this should include a note that you have issued written advice to the patient and in which format it was issued.

4) Guidance for referral for Wet AMD in Birmingham and Solihull

 4.1 Background

 Wet AMD is one of the leading causes of severe visual loss in the UK. It is an acute and aggressive condition. Early diagnosis and prompt treatment may prevent further visual loss and can sometimes even restore some of the vision already lost. This guidance outlines the procedures to follow in order to access assessment and fast track to a consultant as appropriate.

All the major general hospitals in Birmingham and Solihull now have rapid access wet AMD clinics supervised by Lucentis Coordinators these are:

Sandwell and West Birmingham Foundation Trust:

Birmingham & Midland Eye Centre (BMEC) at City Hospital  Fax referrals to

0121 507 6726

University Hospitals Birmingham Foundation Trust:

Queen Elizabeth Hospital (UHB) email referrals to wetARMD@uhb.nhs.uk using the electronic form which can be found under the “Forms” link

Heart of England Foundation Trust: Fax referrals to:

0121 424 4464 stating which hospital the patient wishes to be seen at.

Birmingham Heartlands Hospital

Solihull Hospital

Good Hope Hospital

4.2 Assess the risk factors

Older person, though not exclusively.

Hypertension and treatment for hypertension.

Cardiovascular disease.

Elevated cholesterol levels.

Caucasian with occasional Asian and very occasional African / Caribbean.

Female (Greater incidence because more susceptible and longer life expectancy).

Family History.

It is important to take and record full history including medications.

4.3 Make an evaluation of the signs and symptoms

A patient reporting sudden central vision loss or distortion, clouding, a dark relative scotoma in central field when dark-adapted, flashing lights or hallucinatory forms should be checked for wet AMD

The VA may still be good especially if the lesion is para-foveal.

Your examination of the fundus under mydriasis should look for

Grey-green lesion

Sub-retinal fluid

Haemorrhage usually sub retinal but may be pre retinal

Drusen associated with haemorrhage

Some of these symptoms could indicate other retinal conditions such as a retinal tear. Always check all the fundus.

Undertake a full refraction and record the best VA

Assess and record distortion with an Amsler chart

4.4 Decide about the referral

Fast track if the vision is 6/96 or better

And the patient presents with symptoms of recent onset occurring within past few days/weeks/months

And the symptoms are affecting central vision

And you can see a retinal lesion at the fovea or within 1 disc diameter of the fovea, which would indicate the possibility of recent onset wet AMD (this may be very subtle)

If your patient does not meet the fast track criteria there may still need to be an assessment and you should use your judgement to refer in the usual way either to A&E or for an urgent outpatient appointment.

If your patient has dry AMD then you may decide not to refer and the patient may be helped with a LVA

4.5 Fax referrals to the fast track wet AMD Service Co-ordinators if all criteria are met

BMEC   Fax 0121 507 6726 

         UHB       Fax 0121 627 8789

         HEFT     Fax 0121 424 5648 (single referral centre for all 3 sites i.e. Birmingham Heartlands Hospital, Good Hope Hospital and Solihull Hospital)

WHEN REFERRING TO HEFT PLEASE ASK THE PATIENT FOR THEIR PREFERRED SITE (BHH, SOLIHULL or GOOD HOPE) AND INCLUDE THEIR CHOICE IN YOUR NOTES ON THE REFERRAL FORM.

The wet AMD service co-ordinators will contact your patient by telephone and be able to arrange for them to be seen by an appropriate person within a few days.

Dry AMD

5  Dry AMD

There is currently no clinically effective treatment for dry AMD and patients’ sight will gradually deteriorate.

At the point where the patient becomes unable to read N8 or carry out their normal day to day tasks it is appropriate to issue a LVI letter so that self referral to Social Services can take place.

Consideration should also be given to referral to one of the low vision services operating in Birmingham.  Currently all Hospital Departments serving the Birmingham area have an Eye Care Liaison Officer (ECLO) so primary care optometrists can refer to refer to the “Low Vision Clinic” at BMEC, Queen Elizabeth, Solihull, Birmingham Heartlands or Good Hope Hospitals when it is felt that a low vision aid might be useful.

Referral to Birmingham Focus on Blindness for assessment and advice would be another option (www.focusbirmingham.org.uk)

6) Low Vision Services

Low Vision Referral Guidance

Approximately 300,000 people in England are registered blind or partially sighted (The Health and Social Care Information Centre 2011) and the National Eye Health Epidemiological Model (NEHEM) suggests that nationally 4.06% of the population of England have sight impairment or low vision. If these national figures are extrapolated locally this would indicate that approximately 40,000 people in Birmingham are living with low vision.

Many of these patients would benefit from low vision assessment. As an optometrist you are in an ideal position to offer help, advice and signposting to people with visual impairment and their families.

There are several places to access formal low vision services in the city:

Community Based: Focus Birmingham;

Focus Birmingham is a local charity offering a range of services for visually impaired users across the city. Services are free to the user and include:

  • Low vision assessment including free loan of aids (five venues across the city)
  • Resource shop for daily living aids.
  • Community services including, home assessment, befriending services, shopping assistance, art group etc.
  • Emotional support services for visually impaired.
  • CCTV and adaptive computer software demonstration and assessment.

Referral to Focus is by letter or phone:

Focus Birmingham             0121 478 5252

48-62 Woodville Road

Harborne

Birmingham

B17 9AT

Hospital Low Vision Services;

All of the main local hospital eye departments run low vision services on a sessional basis, offering advice and free loan of optical aids.  All HES Low Vision Clinics also now have an Eye Care Liaison Officer (ECLO) and these are able to offer excellent advice and guidance to the Sight Impaired.

If there is no treatable pathology it may be more appropriate to refer to the community based service, however please remember if a patient needs to be registered visually impaired this still needs to be done by an ophthalmologist.

Social services visual impairment team.B

Birmingham City Council employs a team of rehabilitation professionals to help re-enable visual impaired patients and encourage independence.

  • Services include:
  • Mobility and orientation training
  • Daily living support (kitchen skills etc)

Referral for services can be via the Low Vision Leaflet (LVL) which can be accessed at:

http://www.fodo.com/downloads/resources/Visual_Impairment_Leaflet.pdf

Phone: 0121 464 9455

Visual Impairment Team Southside Business Centre Room 1-3 249 Ladypool Road Birmingham B12 8LF

Glaucoma and Ocular Hypertension

7) Guideline for Suspected Glaucoma/Ocular Hypertension Referral in Birmingham

NB because of delays caused by the general referral system into BMEC the glaucoma consultants have introduced  a fast track glaucoma referral service.  They have also introduced a form specifically for glaucoma referrals please access this via the “Forms” page.  You may use the BMEC form or the normal GOS 18 form but the referral should be faxed to 0121 507 6726 

7.1 All glaucoma diagnosis and management in England is now governed by guidance issued by the National Institute for Health and Care Excellence (NICE) in 2017, NICE Guideline [NG81], published on 1st November 2017.

You can access the full guideline at www.nice.org.uk/guidance/ng81 this includes advice on monitoring intervals and treatment options for patients diagnosed with ocular hypertension  or COAG.

Of greatest importance to primary care optometrists are the first two sections on CASE FINDING and DIAGNOSIS – click on the link above and read them carefully

7.4 Indications for Referral

7.4.1     Emergency referral (same day)

  • Acute glaucoma (angle closure or secondary e.g. rubeotic).
  • Elevated IOP in the presence of acute uveitis

7.4.2      Urgent referral (within 2 weeks)

  • Confirmed IOPs measuring over 31 mm Hg but no acute signs.
  • Symptoms suggestive of angle closure in the presence of clinically narrow angles as assessed by slit-lamp (Van Herick, or, preferably, gonioscopy) i.e. intermittent pain/brow ache, blurring or coloured halos (particularly at night). Where available assessment of the drainage angle using an OCT linear scan will be helpfull.
  • Raised IOP in the presence of signs of chronic uveitis.

7.4.3  Routine Referrals

7.4.3.1 Elevated intra-ocular pressure

In West Birmingham there is a formally commissioned IOP repeat measures service provided by PES.  Patients found to have an IOP in excess of 23 mm Hg at sight test but with no other signs of glaucoma, should have their IOP measured again using applanation tonometry on the same day.  If the IOP is still found to be in excess of 23 mm Hg the patient should have a repeat applanation tonometry reading taken on another day.  If the IOP remains above 23 mm Hg a routine referral to ophthalmology should be made so that a diagnosis of ocular hypertension or glaucoma can be made.  If the second applanation result is 23 mm Hg or below the patient can be discharged and advised to return for a routine eye test at an appropriate interval.

In the areas covered by BSol CCG a historic IOP repeat measures service similar to the above remains in place.  The LOC is advised that BSol have agreed to add a formally commissioned IOP repeat measures service to their existing MECS service in the near future.

7.4.3.2 Field defect in the absence of anomalous discs and elevated IOP.

Threshold visual field defects should be carefully assessed and every attempt made to determine their aetiology. Remember that field defects can have many causes, by no means all of which are associated with glaucoma.

Unless you can be absolutely sure that there is a reasonable explanation for the field defect which does not require referral, e.g. hemianopia as a result of a stroke already known to the GP or tilted discs, all field defects should be referred for assessment by an ophthalmologist.

Where, in your opinion, the condition causing the defect might be sight or life threatening then an emergency (same day) referral to eye casualty at BMEC should be made.

In the absence of other diagnostic signs, visual field defects should be confirmed by at least one repeat measurement before referring.

7.4.3.3 Anomalous disc appearance in the absence of elevated IOP and field defect.

There are many congenital conditions resulting in an anomalous optic disc appearance e.g. disc coloboma, optic disc drusen and tilted discs. Pale discs may be a result of previous optic neuritis etc.

It is appropriate to monitor some anomalous discs (e.g. tilted discs) annually but most cases will need no special attention.

It would be inappropriate to refer a patient as a glaucoma suspect on disc appearance alone. One exception, however, is a splinter haemorrhage at the disc margin which should be referred as a routine case, preferably with an image to prove the existence of the haemorrhage since these have a habit of reabsorbing before they are seen in ophthalmology.

Optic disc assessment is best performed using dilated slit-lamp Volk assessment, retinal photography, OCT or any combination of the three.

7.5 If your initial diagnostic results are unequivocal, an immediate referral to the chosen ophthalmology department or local primary eye care enhanced referral scheme should be undertaken, indicating whether the patient should be seen “urgently” “soon” or “in turn”.                                                                

7.6 Initial referrals of patients with a GP associated with Sandwell and West Birmingham CCG for both OHT and COAG should be made to BMEC or Sandwell General Hospital.  Patients with a GP associated with BSol CCG should be referred to Health Harmonie for initial assessment.

7.7 Key Factors in Glaucoma

  • Primary open angle glaucoma can occur at any intraocular pressure.
  • The higher the measured IOP the more likely it is that the patient will have glaucoma or require treatment to prevent it.
  • Approximately 5% of the over 50s will have an IOP measured greater than 23 mmHg on a single visit.
  • Patients with or without glaucoma tend to have higher IOPs in the morning due to diurnal changes.
  • Subtle optic disc changes may precede visual field defects.

7.8 Common Causes of Diagnostic Confusion and Misinterpretation of Test Results

  • Some patients become very tense when undergoing tonometry for the first time and tend to record higher IOPs.
  • Isolated visual field defects are common in normals as are superior defects due to “droopy” eye lids and rim defects caused by the trial lens.
  • Beware of confusing large physiological cups with changes caused by glaucomatous excavation.

This document is intended as guidance only. Individual practitioners must make their own clinical judgements and should always err on the side of caution.

7.9 If in doubt refer, but only after very careful consideration of all the evidence.

8. Clinical Decision Making in Diabetic Eye Disease

 8.1 Birmingham has an excellent diabetic retinopathy screening service  currently contracted to University Hospitals Birmingham (UHB) and based on the main grading centre at Birmingham Heartlands Hospital (BHH) with imaging carried out by selected, accredited optometry practices across the area.  The service currently covers the whole of both the BSol  and the Black Country STP areas

8.2 Unfortunately the service is currently restricted to only those practices that have a contract with Heart of England Foundation Trust.

8.3 All practitioners are conversant with the various grades of diabetic retinopathy and aware of the degrees of urgency attached to the referral of eye disease at each stage.  It remains the duty of all optometrists to detect and report eye disease where appropriate and patients with diabetes will frequently be seen in practices that are not involved in the National Diabetic Retinopathy Screening Service, between their screening appointments.

8.4 Where sight threatening retinopathy is detected by an optometrist who is not accredited for screening it is essential to determine whether the condition is already known to the patient’s GP or to an accredited screener and whether a referral to the hospital eye service has already been made.

8.5 If it appears that the patient is not aware that a referral regarding their condition has already been made or that they are not aware that they are under the care of a medical retina clinic,they should be advised to contact their normal screening practice as soon as possible so that an interrogation of the  digital screening system can be undertaken to determine whether or not the condition is already known or something new.   Where necessary the screening practice will be able to make appropriate arrangements.

8.6 In the case of emergencies such as a pre retinal haemorrhage or traction detachment an emergency referral to Birmingham and Midland Eye Centre should be initiated by first making telephone contact with the triage sister.

8.7 Where non referable retinopathy or no retinopathy is detected it will be sufficient to determine whether the patient has attended for screening within the past 12 months and remind them that they should attend their screening practice no later than 12 months subsequent to their last screening episode.

8.8 Accredited optometrists should be guided by the national screening strategy whenever they see a patient with diabetes.

 8.9 All contractors involved in retinopathy screening and their staff, should remember at all times that they may be seeing a patient that is only attending their practice for screening.  All patients should be given the opportunity to continue to have their sight tested and spectacles dispensed by their existing family optometrist

9.  Guideline for cataract referral in Birmingham

9.1 In West Birmingham, for the patients of GPs in the Sandwell and West Birmingham CCG area there is a direct cataract referral pathway provided by Primary Eyecare Services.  To use the pathway your practice must be registered as a sub-contractor to PES (if not already registered details of how to register can be obtained from info@primaryeyecare.co.uk ).  Similar referral pathways managed by PES also currently exist for patients of GPs in Solihull, Dudley, Sandwell, Walsall and Wolverhampton.  A fee of £30.00 is currently payable to PES sub-contracted practices for making these “enhanced” referrals.

In the area of Birmingham covered by BSol CCG no formal referral pathway currently exists but you may refer using the C1 form and claim a fee of £19.00 using the “Optoclaim” tab on the PES “Optoserve” website.

You may also refer direct to any cataract surgery provider using a GOS18 0r your own referral form but no fee will be payable.

9.2 Appropriate Providers

You can refer your patients to any cataract surgery provider but most appropriate for the Birmingham population are:

University Hospitals Birmingham FT

 Including:

Queen Elizabeth Hospital – Edgbaston

Birmingham Heartlands Hospital – Bordesley Green

Solihull Hospital – Solihull

Good Hope Hospital – Sutton Coldfield

Cataract assessment can be carried out at any of the four hospitals in the UHBFT group but no surgery is carried out at Birmingham Heartlands Hospital.  Please include the patients choice of assessment centre in your referral

Sandwell and West Birmingham FT

 Including:

Birmingham And Midland Eye Centre – Ladywood

Sandwell General Hospital – West Bromwich

Optegra – Aston

SpaMedica – Edgbaston

 The Westbourne Centre – Edgbaston

 Most providers now have a cataract post-operative assessment service whereby patients undergoing uncomplicated surgery are returned to the referring optometrist for final assessment and discharge about four weeks after surgery.

To participate in Post-op cataract services most surgical providers require optometrists to have additional accreditation before they can participate.

9.3 During the patient’s eye examination you will have determined the following:

  • Type and Severity of cataract (note visual acuity is not the only consideration)
  • Symptoms and history
  • Right and/or left eye
  • Effect on daily living (glare, flare, poor contrast sensitivity affecting small print)
  • Whether the driving standard is still met if patient is a driver
  • Whether the patient wishes to have surgery (no point in referring if patient does not consent unless there is co morbidity)
  • Whether there is any co-morbidity (It is always wise to dilate and carry out slit lamp bio where the cataract is obscuring a good view of the fundus by direct ophthalmoscopy)

9.4 Remember that poor visual acuity may be caused by factors other than the cataract a routine referral for cataract will take several weeks if not months. Should there be an underlying condition such as wet AMD such a delay would be disastrous.

9.5 From the above you will have discussed with your patient whether to refer or not.

If under the regulations a referral is not made you must rule out any co-morbidity by examination of the eyes with dilatation if necessary. You must make a full record of this decision and the reasons for it in your patient record and inform the patient of your reasons.

If you decide to refer, the patient will wish to have surgery, will have significant effect on their daily life or will have co-morbidity requiring referral.

9.6 Your referral form should preferably be typed but must be legible. It must contain the following:

  • Date
  • Full patient details; name, address, postcode, dob
  • Patient telephone number (preferable)
  • Your details; address and with your name in block capitals
  • Refraction details with acuities for both distance and near for each eye separately
  • Type and severity of cataract R and/or L
  • Details of symptoms and effect on daily life
  • Pertinent ocular history including whether amblyopia previously documented with date and details
  • Patients current medication (ask patient to take repeat prescription list to hospital appointment)
  • Any existing co-morbidity e.g. glaucoma, AMD, diabetes with or without retinopathy.

10. Quality of referrals

 10.1 Delays, inadequate information provided within referral correspondence and unnecessary referrals are not beneficial to the clinical care of patients.  While some members from all professions are sending high quality correspondence with all the relevant information and results enclosed, others fall below what should be considered acceptable standards.

10.2 A good referral should contain the following

  • Date
  • Full name of referring optometrist and practice address in block letters
  • Full details of patient including name, address, telephone number, date of birth, NHS number (where known), reason for referral, supporting signs and symptoms, reports of relevant tests / investigations, include copies of any supplementary data e.g. field plots.
  • Family history
  • Provisional diagnosis
  • Current medication
  • Indication of urgency

Referral correspondence, whether GOS 18 or letter, should be legible and preferably typed.

An electronic copy of all referral forms used in Birmingham can be obtained by clicking the forms link on the home page.  These can be completed on your computer then either printed and faxed or attached to an email and sent via nhs.net mail

All referral reports, whether GOS18 or letter, should indicate the degree of urgency/ priority, if they are for information only, this should be clearly stated.

10.3 In some areas local protocols have been established to facilitate referral refinement by accredited optometrists.  Optometrists involved in such schemes on either side of the process must be aware of the ethical position vis-à-vis the patient and colleagues. In all instances the terms of reference for such protocols should act to enhance and improve referrals at a local level.

10.4 It is essential to be able to audit referrals so that the value to patients can be measured over the range of referrals, not simply on a case by case basis.  This means setting up appropriate recording systems within the practice to make sure that the information is kept centrally as well as on individual patient records.  Feedback from ophthalmologists is pivotal to the audit process and it is hoped that this will become the norm with optometrists taking on the role of primary referrer.