Referral Pathways

Please find downloadable, editable GOS 18:

Derbyshire GOS 18 editable PDF 20.1.23

Please go to the Member’s area to read the referral pathways for North and South Derbyshire WITH NECESSARY TELEPHONE NUMBERS, EMAIL ADDRESSES AND FEES.

Here are some links to useful resources:

Eye conditions | Moorfields Eye Hospital NHS Foundation Trust for information by Condition (Moorfields Eye Hospital)

Medicines Management – Home (derbyshiremedicinesmanagement.nhs.uk)

Patient self-help information- the following Ophthalmology self-care and prevention pages provide information about prevention of eye conditions, where to get help and common types of eye conditions: https://joinedupcarederbyshire.co.uk/about/our-governance-1/ophthalmology-self-care-how-take-care-my-eyes

Referrals to The Eye Centre at Chesterfield Royal Hospital

This Quick guide information applies to referrals for patients registered with a North Derbyshire GP.
If the patient chooses to be referred routinely to another hospital please send via the GP unless urgent.

Use Downloadable GOS 18 form or Derbyshire wide pad where possible, please complete as much as possible and remember to include VA’s, IOP and your Provisional diagnosis.

Please make this guide available to all clinicians- Trainees, Residents and Locums.

Remember we have a MECS Scheme and IOP Refinement Scheme in the area.

Emergency / Urgent Eye Care:

During Working Weekdays: Call TRIAGE NURSE, to discuss for advice & appointment, then email referral. Open Mon- Thurs: 9.00am- 4.00pm Fri: 9.00am- 1.00pm THIS IS NOT A WALK IN SERVICE- DO NOT send the patient without discussing it first Out of hours: For anything outside the hours above, call CRH Switch board and ask for On Call Ophthalmologist. PLEASE NOTE: The patient may be sent to Chesterfield or Kings Mill Hospital, Mansfield as this is a shared service.

MECS / CUES:

Please refer patients under the MECS scheme to participating practices for:

Red eye      Flashes and floaters      Double vision   Dry eye / Watery eye    Anterior eyelid lumps and Bumps        Sudden onset Field loss Sudden Onset loss of vision

See Appendix 1 for further details

AMD Fast-Track:

Any findings suggestive of Wet AMD please call to discuss with the bleep holder for advice & to arrange an AMD New Patient appointment

Routine Referrals:

By post to: Community Eye Clinic, Surgery at Wheatbridge, 30 Wheatbridge Road, Chesterfield, S40 2AB or email.

Glaucoma:

Repeat Testing / Refinement referral (high IOP or suspect glaucoma field defect):

If IOP 24mmHg or above, or visual fields suggest glaucoma, refer to an accredited Level 1 Optometrist for repeat IOP with GAT and / or repeat visual fields. See Appendix 2 for further details.

NOTE: There is also a Level 2 scheme for patients with OHT or Glaucoma Suspect who have been identified as stable and DISCHARGED from HES. See Appendix 3 for further details.

Cataracts:

Direct referral, with an accompanying PCLV form. Patients MUST be dilated and benefits/risks discussed. Please check criteria for 1^st and  2^nd eyes before referring. See Appendix 4 for further details

Choice of Chesterfield Royal Hospital, Newmedica at Barlbrough, Spa medica or another hospital of patients choice. The same PLCV criteria applies to all providers.

For CRH (Cataracts/Post-cataract PCO): Email or post to: The Eye Centre, Chesterfield Royal Hospital, Calow, Chesterfield, S44 5BL.

Orthoptic Referrals:

Paediatric – Refer via direct email to CRHFT or via GP unless it is urgent. If so, then see above for urgent referrals.

Adult – Please refer Wheatbridge first for further assessment, unless it is urgent. If so, then see above for urgent referrals.

Oculoplastics: including Chalazions

Refer via GP unless it is urgent. If so, then see above for urgent referrals

Consultant Connect (Tele-Ophthalmology):

App-based, Advice & Guidance for NON-URGENT queries. Response time: up to 5 days. Information and Images need to be relevant & clear enough to identify concern.

For information on how to use, see this guide:
Ophthalmology Guide – CRH

See Appendix 5 for further details

Sight Support

For Sight Impairment Registration and Low Vision queries – See Appendix 6.

Referrals to The Eye Department at Derby Royal

This Quick guide information applies to referrals for patients registered with a South Derbyshire GP. If the patient chooses to be referred routinely to another hospital outside Derbyshire please send via the GP unless urgent.

Use Downloadable GOS 18 form or Derbyshire wide pad where possible, please complete as much as possible and remember to include VA’s, IOP and your Provisional diagnosis.

Please make this guide available to all clinicians- Trainees, Residents and Locums.

Remember we have a MECS Scheme and IOP Refinement Scheme in the area.

Emergency / Urgent Eye Care:

CALL EYE PRIMARY CARE CLINIC during normal working hours of Mon – Fri 9 – 5pm
Out of hours, call switchboard and ask for the on call ophthalmologist
• Email your referral via NHS.NET to RDH and request a sent and read receipt
when sending an email
• A copy should be sent to the GP marking it clearly as INFORMATION ONLY.

DO NOT REFER TO GENERAL A&E or advise the Px to present there themselves.

MECS / CUES:

Please refer patients under the MECS scheme to participating practices for:

Red eye      Flashes and floaters      Double vision   Dry eye / Watery eye    Anterior eyelid lumps and Bumps        Sudden onset Field loss Sudden Onset loss of vision

See Appendix 1 for further details

AMD Fast-Track:

If signs and symptoms are suggestive of wet AMD and vision is 6/12 to 6/96, Px must be referred urgently by email marked urgent.
• UNSURE? NEEDING ADVICE? CALL EYE PRIMARY CARE CLINIC as per urgent referral.
A copy should be sent to the GP marking it clearly as INFORMATION ONLY.

Routine Referrals:

By post or email to Royal Derby email address. These are triaged and prioritised by Ophthalmologist.

Glaucoma:

Repeat Testing / Refinement referral (high IOP or suspect glaucoma field defect):

If IOP 24mmHg or above, or visual fields suggest glaucoma, refer to an accredited Level 1 Optometrist for repeat IOP with GAT and / or repeat visual fields. See Appendix 2 for further details.

Cataracts:

Direct referral, with an accompanying PCLV form. Patients MUST be dilated and benefits/risks discussed. Please check criteria for 1^st and  2^nd eyes before referring. See Appendix 4 for further details

Choice of Royal Derby or Spa medica or another hospital of patients choice. The same PLCV criteria applies to all providers.

New Children’s Pathway

Referral pathway from Community Optometry to Orthoptics at Royal Derby Hospital for children aged 7 – 12 years with suspected amblyopia

New guidance

The incidence of untreated amblyopia in older school children appears to be increasing, with a greater number of children being referred into the HES for consideration for treatment.

Following guidance in a recent literature review ⁽¹⁾, at RDH we are proposing to offer occlusion / atropine penalisation to a limited age group, namely children aged 7 – 12 years, with newly diagnosed anisometropic amblyopia under the conditions outlined below. We cannot endorse treating strabismic amblyopia due to the lack of evidence surrounding the assessment tools for depth of suppression and hence the risk of inducing intractable diplopia.

Suitable cases for consideration for treatment

• No detectable strabismus.
• Refractive error corrected by community optometrist and appropriate glasses worn for the refractive adaptation period of 18 weeks.
• After refractive adaptation period visual acuity levels of between 0.5 (6/19) and 0.3 (6/12) will be accepted for consideration of treatment, subject to a normal fundus and media examination. The rationale being that the child may then have a chance of achieving driving standard acuity in the amblyopic eye. For lower levels of acuity the benefits of treatment will be of less practical value.
• Occlusion dose to follow department guidelines for younger children.
  Atropine may be considered as a first line treatment but will need to be reviewed at monthly intervals.
• Treatment to cease at 8 weeks if there is no improvement..
• REFER TO ORTHOPTICS AT ROYAL DERBY.

Latest Orthoptic Newsletter: Summer 2023

Oculoplastics: including Chalazions

Refer via GP unless it is urgent. If so, then see above for urgent referrals

Consultant Connect (Tele-Ophthalmology):

App-based, Advice & Guidance for NON-URGENT queries. Response time: up to 5 days. Information and Images need to be relevant & clear enough to identify concern.

For information on how to use, see this guide:

Ophthalmology Guide – UHDB

See Appendix 5 for further details

Sight Support

For Sight Impairment Registration and Low Vision queries – See Appendix 6.

Appendix 1: Minor Eye Conditions Service (MECS) and
COVID-19 Urgent Eyecare Services (CUES)

MECS covers patients presenting with:

• Sudden onset loss of vision including Transient loss
• Ocular pain
• Red eye
• Foreign body and emergency contact lens removal
• Dry eye / Watery eye
• Blepharitis
• Lumps and bumps in the vicinity of the eye
• Flashes/ floaters
• Trichiasis
• Sudden onset field defect

 If your Practice is not accredited or registered to see MECS patients please refer to one that is.

• In instances where the symptoms require urgent attention the MECS practitioner is expected to see the patient within 24 hours of contacting the service
• For symptoms which are non-urgent the MECS practioner is expected to see the patient within 5 days of contacting the service. You can arrange a follow up if it is clinically necessary, no fee paid for follow ups

 Update outcome on OPERA . Outcomes will usually be:

• Advice, follow up or signpost to pharmacy.
• Carry out minor procedure such as eyelash removal, foreign body removal
• Referral required done via OPERA will go to appropriate medical practitioner- GP or HES.
• Recommend an NHS or Private sight test.

NOTE: This in only for patients with a DERBY CITY or DERBYSHIRE GP.

NO age limit on patients. Is available for children and adults. Patients should be made aware that for future GOS sight tests they should return to their usual Optometrist. Link: https://www.college-optometrists.org/the-college/media-hub/news-listing/nhs-england-covid-19-urgent-eyecare-service-cues.html

Accredited practice may claim from PCT: The accredited practice can claim automatically on the Opera system. No extra is paid for follow ups these are included in the fee.

To become accredited WOPEC MECS module needs to completed. Contact LOC for further details

Appendix 2:  Intraocular Pressure (IOP) and Glaucomatous Visual Fields Repeat Readings /  Referral Refinement – LEVEL 1 Assessments

At initial eye examination if a patient is seen with either IOP’s above NICE guidelines, currently 24mmHg or above OR has a suspicious glaucomatous visual field defect in either eye but no other suspect findings refer to a LEVEL 1 accredited Optometrist to be seen within 2 weeks for repeat measures using applanation tonometry and/or reliable central visual field using standard automated perimetry (full or supra threshold).

At initial eye examination other suspect findings such as disc changes or narrow angles refer according to normal guidelines of routine or urgent. https://www.nice.org.uk/guidance/ng81/chapter/Recommendations

NON-ACCREDITED OPTOMETRISTS MUST REFER TO AN ACCREDITED OPTOMETRIST RATHER THAN REFER DIRECTLY TO THE HOSPITAL.

If a LEVEL 1 Optometrist is refining own patient as accredited Optometrist:

• Repeat readings are only required on the initial suspicious factors Only, i.e. IOP only, Visual Field only, or both.
• If discs are suspicious, refer as normal. Patients with suspicious discs are not included in the Level 1 repeat readings pathway – include Goldmann IOP (GAT) and Visual Field test results
• Check IOP using GOLDMANN (or Perkins if indicated) OR
• Examine and record the central visual fields where appropriate using standard automated perimetry (full threshold or supra-threshold). Confirm test reliability for each test and each eye.
• Repeat visual fields must be conducted on another day.
• NOTE: IOP repeat readings is a TWO repeat pathway – this means that the IOP must be above NICE threshold on 2 occasions for referral to be indicated based on IOP alone

If a LEVEL 1 Optometrist receiving a referral from another optometrist:

• Check IOP using GOLDMANN or if indicated Perkins AND
• Examine and record the central visual fields where appropriate using standard automated perimetry (full threshold or supra-threshold). AND
• Examine the optic disc using stereoscopic slit lamp biomicroscopy and anterior chamber angles for signs of glaucoma and conditions associated with glaucoma

Visual field should be repeated on a separate day to when initially checked as part of the routine eye examination. First IOP repeat can be conducted on the same day as the routine eye examination, but if this first repeat is above threshold, IOP must then be repeated on another day (within 2 weeks).

NOTE: Only Goldmann, or, if indicated, Perkins, readings accepted, not NCT, or ICare. If GAT is not available at your practice please refer to another practice with GAT.

Guide on Outcome following Level 1 accredited Optometrist appointment:

• If IOP by Goldmann is 24-30mmHg on two occasions, the patient should be referred routinely DIRECTLY to CRH – via post or email.
• If IOP is 31mmHg or greater, the patient should be referred URGENTLY
• If there are signs of Acute Angle Closure – please contact relevant HES directly for further advice.
• If a Visual field defect is found consistently, the patient should be referred.
• If the repeated visual field is a normal, but the patient is in an at risk group, see them again in 12/12
• If IOP’s/Visual Fields are within normal range advise patient to see their own regular Optometrist when next eye examination due. At risk groups advise annual eye examination.

The Referral to the hospital from the Optometrist should include:

• GOS REFERRAL LETTER and Visual Field plots and IOP measurements with GAT.

The ACREDITTED practice will be paid (via OPERA in North and direct from CCG in South):

• Goldman tonometry: First repeat and Second repeat
• Visual field assessment, standard automated perimetry.

To become Accredited WOPEC Glaucoma module lectures need to be completed. Contact LOC for further details.

Appendix 3 – HES Discharge Pathway for Ocular Hypertantion and Glaucoma Suspect Monitoring – LEVEL 2 Assessments

How does it work?

• Level 2 Optometrists must be accredited and registered with the GOC for at least 12 months.
• When a patient with confirmed diagnosis of OHT or Glaucoma Suspect that is stable, whether on treatment or not, are discharged from HES, they are referred to a Level 2 Optometrist.
• HES gives the patient a discharge letter, sends a referral letter (currently a hard copy, but this may be electronic in the future) to the Level 2 Optom Practice of Patient’s choosing, which details of reason and findings and discussions at time of discharge AND criteria for re-referral back to HES.
• On receipt of the referral, the Practice will invite the patient in for their own baseline measurements and then yearly checks for at least 3 years, in line with NICE guidelines.

Accredited Level 2 Optometrist should carry out:

• Goldmann Applination tonometry
• Suprathreshold perimetry [Note: Threshold VF test, e.g SITA Fast or equivalent, is preferred where possible]
• Van Hericks
• Dilated slit lamp biomicroscopic examination of the optic nerve head
• Digital photography of optic nerve head with CD ratio measured digitally.

Outcomes:

• No change in clinical status- next appointment as per agreed intervals in NICE guidelines
• Change in clinical status as per NICE guidelines – refer back to HES
• Occasionally if there is a query around the results obtained they may be followed up at a later date.
• Patient with OHT, on treatment and continuing to be stable after 3 years, continues under Optom Practice care. For these patients, at 5 years, a report can be generated as a routine for HES records, for Information Only.

Please see service spec available form your LOC for full details of these schemes.

LEVEL 2 FURTHER NOTES

• Acute Glaucoma is emergency referral and should be referred accordingly
• IOP over 30 are at risk of vessel occlusion and should be referred to HES and NOT for refinement.
• NCT will NOT be accepted.
• These schemes do not include patients under 18
• Only for Patients with a North Derbyshire/Hardwick GP
• GP to be notified of any referral to hospital.
• Patients should be offered choice of local hospital.
• If a hospital outside the local area is selected the refer to GP for onward referral.
• Level 1 cannot refer to Level 2 Practices for Glaucoma assessments.
• This is NOT a Shared Care scheme. The responsibility of care lies with the Optometric Practice once discharged from HES.

To become accredited Optometrist needs to have completes WOPEC Glaucoma module, including attending a practical Goldmann training session, and then approved by PECS to be added to accredited list.

The ACREDITTED practice will automatically be paid (via OPERA):

• given all tests stated above and appropriate management of recall or referral
• may be claimed if uncertainty of tests remains. Few cases should fall in this category.

Appendix 4: Cataract Referral Criteria

Patient can be referred directly to: Chesterfield Royal Hospital, Newmedica at Barlborough, Spa medica or Derby Royal.

If the patient wants to be referred to another HES refer via GP.

Same eligibility criteria apply regardless of where patient is being referred to.

FIRST EYE

Cataract surgery will be funded where the patient is symptomatic and willing to undergo surgery, AND the visual acuity after refractive correction is 6/9 or worse in the worst eye (the eye to be treated)

OR the patient has one of the following (with correction):

• Reduced mobility, experiencing difficulties in driving, for example, due to glare, or experiencing difficulty with steps or uneven ground, The ability to work, give care or live independently is affected.
• The patient has diabetes, or retinal condition, and requires clear views of their retina to monitor their disease or treatment
• The patient has glaucoma and requires cataract surgery to control the intraocular pressure.
• The patient has posterior subcapsular or cortical cataracts and experiences problems with glare and a reduction in acuity in bright conditions (can be referred with 6/6 in this case)
• The patient’s visual field defects are borderline for driving, and cataract extraction would be expected to significantly improve the visual field.

 The Optometrist must:

• Undertake a detailed dilated ocular assessment of patient that may benefit from cataract surgery and falls within the referral criteria
• Counsel patient of benefits vs risk of cataract surgery
• The Optometrist should give patient the choice to be referred, and offered a choice of Hospital, advise on process and likely waiting times

The patient should be given:

• Cataract Patient Information Leaflet

The Referral to the hospital from the Optometrist should include:

• GOS REFERRAL LETTER – GH, meds, ocular history and details of the cataract should be included
• PLCV Referral Form: For Forms and Patient Information Leafet please see link: http://www.derbyshiremedicinesmanagement.nhs.uk/clinical-policies-home/clinical-policies/ophthalmology

Referral should be sent:

• By post to Hospital of choice (NHS or private), or by NHS email to CRH
• A copy should be sent to the GP marking it clearly as INFORMATION ONLY

The practice may claim from the PCT:

can be claimed if the optometrist counsels and dilates a patient – whether or not patient is referred. (Note: if not referred, the Optometrist should still write to the GP to say the Px has been assessed under the Direct Cataract Referral scheme, but not referred)

NON ACCREDITED OPTOMETRISTS MUST REFER TO AN ACCREDITED OPTOMETRIST RATHER THAN REFER DIRECTLY TO THE HOSPITAL.

SECOND EYE

Will be considered / funded ONLY if:

• Best corrected vision is worse than 6/24, e. effectively 6/36
• Or if more than 3D anisometropia between the eyes
• Or if FIRST EYE does not achieve a VA of 6/9 or better.
• Or the patient is diabetic or has retinal condition and the cataract affects clear views of the retina to monitor the disease or treatment.
• Or the patient has glaucoma and requires cataract surgery to control IOP or has shallow angle and the cataract is causing risk of acute glaucoma.

Appendix 5: Consultant Connect Queries

• Guide for Optometrists for Non-Urgent Advice & Guidance Queries.
• FOR URGENT ADVICE, PLEASE CONTACT HOSPITAL EYE SERVICES DIRECTLY.

When sending the INFORMATION, DO:

• Obtain PERMISSION from patient, parent(s) or guardian to send images and information to HES
• Make the REASON for referral clear – what question would you like answered.
• Include both relevant positive, AND relevant negative, information.
• AVOID using abbreviations if possible.
• Send AS MUCH information on as you think is necessary for best Advice & Guidance
• For trainees – please confer with your supervisors if unsure whether to send as a query or not.

When sending IMAGES, DO:

• Acquire and send adequately CLEAR images relevant to the query. If you cannot see your area of interest on your image, then neither can we. See TIPS on sending images below.
• If UNABLE to add images, do feed this back to the Consultant Connect helpline.
• Include images of the FELLOW EYE, even if there are no concerns. This is useful for comparison.
• If PREVIOUS IMAGES are available, please include for comparison, highlighting the respective dates.

After COMPLETING YOUR QUERY, DO:

• If you are happy with the Advice & Guidance received – CLOSE the query AND Leave an OUTCOME.
• The query is complete only AFTER an Outcome is left.
• Send a proper REFERRAL if needed. This CC query can be referenced in the referral.
• LEARN from the Advice & Guidance received so that it may be applied to similar cases in the future.
• Feel free to SHARE KNOWLEDGE gained from the queries with your colleagues.
• Provide relevant FEEDBACK on how we may be able to improve the service.

For Both Information and Images, DO NOT:

• Send any Patient Identifiable Data (PID) where possible, UNLESS specifically asked to do so.
• Send a query based on images only, OR, Send images alone without accompanying information.

DO NOT use this pathway for:

• URGENT Referrals. If suspected, Contact Ophthalmology Triage desk, CRH Eye Centre.
• CANCER referrals. If suspected, please refer directly, so as not to delay the 2-week wait referral time.
• Cataract referrals. Use established pathways already in place.
• Definite Retinal Detachments.

TIPS on Imaging for Some Conditions:

• For Retinal concerns: include reference, or location lines, for OCT scans and/or colour fundus images. Where wide-angle, or OCT-generated multi-colour images are used, remember the colour blend is different to actual colour photos.
• For MACULAR FLUID (seen as dark, cystic or hypo-reflective areas, OR increased retinal thickening, on OCT scan) where Wet AMD is suspected, please Discuss with the Eye Centre AMD Bleep holder.
• For Choroidal Naevi: if possible, include an OCT of the central portion of the central base of the lesion. This is to gauge the elevation of the lesion.
• For Optic Disc Swelling: do radial scans and send the most central horizontal section as this give best detail of temporal and nasal segments of the disc. Enhanced Depth Imaging (EDI-OCT) also recommended, if available. If unsure, contact Eye Centre Triage Line for advice.

ADDITIONAL NOTES:

• At present, this is a NON-PAID service for Optometrists, with 1 exception:
  • If asked by HES to obtain more, or different images, then there is a provision for RECALL of patient for repeat imaging. This recall can be considered for reimbursement.
• Consultant Connect is NOT a monitoring service for the Optometrist and therefore not mean to run as a parallel service to the HES.
• If, however, Advice & Guidance received suggests review of patient at your discretion, then:
  • Always advise patient to OBSERVE and REPORT any worsening or deterioration, and …
  • If symptoms or signs warrant EARLIER than the normal 1-2 yearly review, then this can be considered on a case-by-case basis and seen accordingly by Optometrist, under GOS.
• No additional ACCREDITATION is needed for Consultant Connect.
• To REGISTER, contact Derbyshire LOC, and / or Consultant Connect for further information https://www.consultantconnect.org.uk/. There is no charge for registering, either as an individual or as a Practice.

Appendix 6: Referrals to Sight Support Derbyshire

Sight support Derbyshire (SSD) provide a wide range of services to people with sight loss living in Derbyshire. Some services are open to everyone; some are provided on behalf of other agencies and eligibility criteria may apply. If you see someone who you think would benefit from thier services, you can either refer them directly, or pass SSD contact details and ask the person (or their family/carer) to contact them directly.

 

Does the patient need to be registered with a certificate of visual impairment (CVI)?

People do not need to be registered or have a CVI in order to receive help and support from Sight Support Derbyshire (SSD). If they require a low vision assessment or rehabilitation services they should be registered, or registerable (ideally with a CVI).

Sight Support Derbyshire will provide information and advice to anyone in Derbyshire concerned about sight loss. They can help with information about eye conditions, services such as Talking Books, support groups, and with equipment such as talking clocks, magnifiers and lighting Eligibility may depend on being registered and/or on home address or GP address – ring SSD to find out.)

How do I refer a patient to be registered for a CVI?

If the patient may qualify to be registered, and  would like to be registered for a CVI please refer them to the Chesterfield Royal Hospital eye centre directly  to be registered by an Ophthalmologist. Any active pathology referrals need to be referred for BEFORE this step.  

If the person has a CVI, information will be sent automatically by the hospital to the relevant Local Authority. The Local Authority will then (with the person’s permission) pass the details on to SSD and  they will contact the person to see how they can help.

How do I arrange a low vision assessment for a patient?

Unless the person is already in contact with an opticians practice that is currently part of the Derbyshire Low Vision Service, it is best for referrals to come through SSD. This also means that we can help with any other sight loss issues in the one referral.

How do I refer to SSD?

A referral can be made by telephone, in writing, via our website or if you are an ‘eye care professional’ and likely to need to refer regularly, SSD can email you our referral form. The details below are for North and South Derbyshire patients.

Website: www.sightsupportderbyshire.org.uk

Contact Us:

• Phone: 01332 292262, 9.00am – 4.30pm