(Where to send what and when!)

Worcestershire Local Optical Committee James Osborne MSc FCOptom FAAO

Preface

Redditch and Bromsgrove practices referral direction conversion guide

Condition referral urgency Referral Centre Urgent (same day/immediate, includes

flashes and floaters)

Office hours (See pages 28 & 29) Kidderminster Treatment Centre Out of hours BMEC Wet AMD (see page 32) Worcester Hospital PEARS referrals (excludes flashes and floaters)

Over 16 years of age Refer to The Practice Under 16 years of age Refer via GP Soon and Routine referrals Non-Surgical over 16 years of age Refer to The Practice Non-Surgical under 16 years of age Refer via GP Surgical (e.g. cataracts) Refer via GP to Worcester

NB: Patient must be registered with a GP in Redditch and Bromsgrove CCG

Contact details for The Practice for both the Bromsgrove Hospital location and Mill Stream Surgery, Cherry Tree Walk, Redditch location: The Practice Ophthalmology Service, Anglo House, Bell Lane Office Village, Bell Lane, Little Chalfont, Nr Amersham, Bucks HP6 6FA Tel: 01494 690950 Fax: 01494 765531

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Introduction This guide is primarily aimed at optometrists working as contractors or performers in the South Worcestershire CCG and Wyre Forrest CCG areas who are referring patients who are registered with a GP practice in South Worcestershire CCG or Wyre Forrest CCG. Where a patient is not registered with a local GP, please direct the referral to the patient’s GP practice accordingly. Please note that “out of hours” urgent referrals are directed to BMEC or, where appropriate, the Gloucestershire NHS Acute Trust. Redditch and Bromsgrove CCG use a different referral route and a short conversion guide has been included for practitioners in Redditch and Bromsgrove.

Worcestershire LOC request that a copy of this guide is issued to all performers by contractors in the South Worcestershire CCG and Wyre Forrest CCG areas. It is based on the agreed commissioning policy “The Referral Guidelines and Clinical Thresholds for use in the Management of Common Ophthalmic Conditions (Primary and Secondary Care) April 2014 – Redditch and Bromsgrove CCG, South Worcestershire CCG, and Wyre Forrest CCG”. The route for referral is classified either as Immediate, Same Day, PEARS, Soon i.e. 1 week to 1 month or as Routine.

The Guide consists of a preface and introduction followed by five sections and four appendices. Section 1 Quick reference of urgency and direction of referral by signs and symptoms Section 2 Quick reference of conditions by urgency of referral Section 3 Direction of referral guide classified by condition Section 4 Contact details for local Acute NHS Trust Ophthalmology units Section 5 Notes on referring patients Appendix 1 Kidderminster Ophthalmology Unit Telephone Triage Form Appendix 2 Worcestershire Wet AMD Rapid Access Form Appendix 3 Gloucestershire Wet AMD Rapid Access Form Appendix 4 GP Direction of Ophthalmic Referrals Guidelines

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Quick reference by symptoms/signs

Classification of symptoms and signs - Sore and Itchy - Lumps and Bumps - Red Eyes - Gunky - Painful - Flashes and Floaters - Acute reduced or sudden vision loss - Gradual vision loss

Referral Route Relative Urgency Sore and itchy

• Dry eye PEARS • Anterior Blepharitis PEARS • Posterior Blepharitis PEARS • Giant Papillary Conjunctivitis PEARS – or refer back to CL fitter if appropriate • Allergy PEARS • Interstitial Keratitis PEARS – or refer to Kidderminster if positive diagnosis 1 week • Herpes Simplex Keratitis PEARS – or refer to Kidderminster if positive diagnosis Same day • Entropian Worcester/Kidderminster 2 weeks

Lumps and bumps

• Chalazion (if over 6 months old) Worcester/Kidderminster/Evesham Routine • Cysts & Stye PEARS • Lid Tumours PEARS – or refer to Kidderminster if positive diagnosis See Guide • Viral lesions Worcester/Kidderminster/Evesham (Child 1 month) Routine • Pterygium and Pingueculae PEARS – Where pterygium invading cornea • Blocked punctum PEARS – (Where Acute Dacryocystitis- Kidderminster) Same day • Cellulitis Kidderminster Treatment Centre Immediate • Xanthelasma Refer to GP - serum cholesterol assessment as necessary

Red Eyes

• Marginal Keratitis PEARS • Keratitis – others Kidderminster Treatment Centre Same day • Allergy PEARS • Viral Conjunctivitis PEARS • Chlamydial Conjunctivitis GP – Be sensitive (Telephone call to on call doctor) Same day • Acute Angle Closure Glaucoma Kidderminster Treatment Centre Same day • Acute Iritis (Anterior Uveitis) Kidderminster Treatment Centre Same day • Episcleritis PEARS • Scleritis Kidderminster Treatment Centre Same day • Sub-conjunctival haemorrhage No referral required unless posterior edge poorly defined • Bacterial Conjunctivitis PEARS • Pterygium PEARS – Where pterygium invading cornea • Trauma PEARS or Kidderminster Treatment Centre Same day

(low severity) (medium/high severity)

Gunky • Bacterial Conjunctivitis PEARS • Bacterial Keratitis Kidderminster Treatment Centre Immediate • Chlamydial Conjunctivitis GP – Be sensitive (Telephone call to on call doctor) Same day • Dacryocystitis Kidderminster Treatment Centre Same day • Anterior Blepharitis PEARS

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Quick reference by symptoms/signs Referral Route Relative Urgency

Painful • Anterior Uveitis Kidderminster Treatment Centre Same day • Acute angle closure Glaucoma Kidderminster Treatment Centre Same day • Herpes Zoster Ophthalmicus Kidderminster Treatment Centre Same day • Foreign bodies, abrasions or trauma PEARS (Surface foreign bodies, light abrasions)

Kidderminster Treatment Centre (deeper items) Same day • Recurrent Corneal Erosions PEARS • Scleritis Kidderminster Treatment Centre Same day • Corneal ulcer Kidderminster Treatment Centre Same day • Cellulitis Kidderminster Treatment Centre Same day • Endophthalmitis Kidderminster Treatment Centre Same day • Hyphema/hypopium Kidderminster Treatment Centre Same day

Flashes and Floaters • Innocent age-related cellular debris PEARS (Where diagnosis uncertain) • Posterior vitreous detachment PEARS • Retinal Detachment PEARS (Where diagnosis uncertain)

(Where Certain) Kidderminster Treatment Centre Same day (Birmingham if out of hours)

Acute reduced or sudden loss of vision

Acute total and acute partial loss • Acute angle closure glaucoma Kidderminster Treatment Centre Same day • Consider vascular anomalies • Retinal

– Arterial occlusion – embolism Worcester Medical Retina Immediate – Venous occlusion - full or part thrombosis Worcester Medical Retina Same day – Wet ARMD Worcester Medical Retina Pathway – Macular hole Worcester Medical Retina Routine – Proliferative Diabetic Retinopathy Worcester Medical Retina 2 weeks

• Nerve pathway vascular interrupts Worcester/Kidderminster Same day • Retinal detachment Kidderminster/Worcester Same day

(Birmingham if out of hours) • Temporal Arteritis Kidderminster Treatment Centre Immediate • Vitreous haemorrhage Worcester Medical Retina Immediate

Transient loss • Establish duration, one or both eyes? • Carotid or cardiac emboli? Kidderminster Treatment Centre Same day • Atrial fibrillation? GP • Temporal Arteritis? Kidderminster Treatment Centre Immediate • Nonarteritic anterior ischaemic optic neuropathy Kidderminster Treatment Centre Same day • Intermittent angle closure Glaucoma? Worcester/Kidderminster/Evesham 1 month

Where IOP 40+ Kidderminster Treatment Centre Same day • Papilloedema Kidderminster Treatment Centre Same day • Amaurosis Fugax Kidderminster Treatment Centre Same day • Neurological? GP • Benign intracranial hypertension? GP

– Young, usually obese, female • Migraine - does not require referral to PEARS! GP – where medication indicated

Gradual vision loss • Cataract Worcester/Kidderminster/Evesham Routine • Suspect primary open angle glaucoma Worcester/Kidderminster/Evesham Routine • Retinitis Pigmentosa Worcester/Kidderminster/Evesham Routine • Refractive error Sight test

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Urgency of referral guide – Quick Reference Immediate Same Day 1 week 2 week Bacterial Keratitis Acute angle Atopic Bell’s Palsy closure glaucoma Keratoconjunctivitis Cellulitis CRVO Acute Iritis BRVO (Late presentation) CRAO/BRAO Amaurosis Fugax Cystoid Macular Entropian CRVO Oedema (severe Anterior Ischaemic Vision loss) Infantile Ptosis Orbital trauma/ Optic Neuropathy Blow out fracture Infantial Lid melanomas

Chlamydial Nystagmus Temporal Arteritis Conjuntivitis Non-proliferative & Interstitial Proliferative Vitreous Corneal ulcer Keratitis Diabetic Retinopathy Haemorrhage Dacryocystitis Ocular Mucous Other Ocular Wet ARMD* Membrane Pemphigoid Oncology Endophthalmitis Toxic

Foreign bodies Retinopathies (deep)

Vernal Fungal Keratitis Keratoconjunctivitis

Sicca Herpes simplex

Keratitis (HSK) 4th and 6th Nerve palsies

Herpes Zoster Ophthalmicus

Hyphema/

Hypopium

Orbital Tumour

Peri-orbital Inflamation + pain

Retinal detachment Scleritis

Trauma (mod/severe)

3rd nerve palsy

*Follow appropriate Wet ARMD pathway

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Urgency of referral guide – Quick Reference 1 Month Routine PEARS GP Chronic Angle Closure Cataract Allergic conjunctivitis Atrial fibrilation Glaucoma (IOP<40 mmHg) Chalazion Anterior Blepharitis Benign intracranial hypertension Lid Viral Lesions Bacterial conjunctivitis Chlamydial Macular hole Blocked Punctum conjunctivitis (Unless suspect Pigment dispersion Dacryocystitis) Migraine (where Syndrome medication indicated)

Cysts and Styes Suspect Primary Neurological Open Angle Dry Eye disorders Glaucoma (non-acute) (Following local IOP Episcleritis

repeat protocol & Xanthelasma NICE guidelines) Flashes & Floaters (where cholesterol assessment required) Retinitis Pigmentosa Giant cell papillary

Conjunctivitis

HSK (where only suspect) Interstitial Keratitis (where only suspect)

Lid Tumours (where only suspect)

Marginal Keratitis Posterior Blepharitis Posterior vitreous detachment Pterygium (where Invading cornea)

Recurrent corneal erosions

Trauma & foreign bodies (low severity

only) Viral conjunctivitis

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Worcestershire LOC in association with South Worcestershire and Wyre Forrest CCGs

Ocular conditions referral guidelines for optometrists

Condition name Signs/symptoms Referral pathway and urgency PEARS GP Secondary Care (Hospital) Urgency Ocular adnexa and eyelids Necrotising Fasciitis Peri-orbital infection with suspected ---- ---- Kidderminster Treatment Centre Immediate skin necrosis Lacerations/injury Eyelids or canalicular ---- ---- Kidderminster Treatment Centre Same day 3rd nerve palsy Sudden onset ptosis with motility ---- ---- Kidderminster treatment Centre Same day restriction +/- pupil anomaly (will need onward referral to pain, double vision Neurologist ) Ptosis (lid margin 1st presentation – Child under 8 yrs ---- ---- Worcester/Kidderminster/ 2 weeks over pupil when Evesham patient is relaxed) 1st presentation – Adult (no miosis) ---- ---- Worcester/Kidderminster/ Routine Child 8 yrs + Evesham With pupil miosis ---- ---- Kidderminster Treatment Centre Same day (Horner’s syndrome) Eyelid neoplasias

- Basal cell Nodular – hard, pearly appearance ---- ---- Worcester/Kidderminster/ Routine Evesham

Nodulo-ulcerative , raised borders ---- ---- Worcester/Kidderminster/ Routine Evesham Sclerosing – flat, hardened plaque ---- ---- Worcester/Kidderminster/ Routine Evesham - Squamous cell Thickened scaly lesion often bleed ---- ---- Kidderminster Treatment Centre Same day

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Ocular adnexa and eyelids PEARS GP Secondary Care (Hospital) Urgency - Sebaceous gland Aggressive tumour – often related to ---- ---- Kidderminster Treatment Centre Same day

recurrent chalazion or blepharo- conjunctivitis – usually arises from meibomian glands

- Lid melanomas Irregularly pigmented lesions ---- ---- Worcester/Kidderminster 2 weeks

sometimes Inflamed and bleeding

Eyelid neoplasias Where diagnosis is uncertain Yes ---- ---- ---- Trichiasis (entropian lashes growing back and abrading Yes ---- ---- ---- absent) cornea Entropian (with or Eyelid margin turning inwards ---- ---- Worcester/Kidderminster 2 weeks without trichiasis) (more often female patient) Ectropian (where Eyelid turning outwards leading to ---- ---- Worcester/Kidderminster Routine severe exposure) punctual displacement, conjunctival (No referral if not severe) thickening or corneal dryness (No referral if not severe) Bell’s palsy Facial (VII) nerve palsy – brow ptosis ---- ---- Worcester/Kidderminster/ 2 weeks cheek/mouth angle droop Evesham Molluscum contagiosum Single or multiple pearly indented ---- ---- Worcester/Kidderminster/ Routine peri-ocular lesion (poxvirus – may Evesham present as follicular conjunctivitis) (Child 1 month) Floppy eyelid syndrome Red eye, irritation, lid eversion on ---- ---- Worcester/Kidderminster/ Routine sleeping side at night Evesham Chalazion – if recurrent/ “pea” size lesion within the base of ---- ---- Worcester/Kidderminster/ Routine chronic for 6 months+ meibomium gland Evesham (No referral if under 6 months) Squamous papilloma Pedunculated lid lesion ---- ---- Worcester/Kidderminster/ Routine Evesham

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Ocular adnexa and eyelids PEARS GP Secondary Care (Hospital) Urgency Pillar cyst Sebaceous/epidermoid ---- ---- Worcester/Kidderminster/ Routine subcutaneous /dermal peri-ocular Evesham protruding mass Stye - Hordeolum Common lid margin cyst - glands Yes ---- Worcester/Kidderminster/ Externa of Zeis or Moll, often irritable, often (if persists) multiple, patients tend to rub lid margins (Where very large dome shaped Worcester/Kidderminster/ Routine Fluid filled cyst on lid margin) Evesham Xanthelasma Yellow slightly elevated elongated ---- Yes ---- deposits adjacent to medial canthus (if hyperlipidaemia undiagnosed) (middle aged patient) associated with hyperlipidaemia Blocked punctum Swelling at nasal canthus, watering, Yes ---- Worcester/Kidderminster Same day discolouration & scaling below canthus (If Acute Dacryocystitis) Cellulitis Painful swelling of eyelids (usually ---- ---- Kidderminster Treatment Centre Immediate upper lid), usually unilateral, pre-septal or orbital Orbital Trauma – History of recent trauma, associated ---- ---- Kidderminster Treatment Centre Immediate blow out fracture signs, double vision (check motility) Meibomium Gland Blocked meibomium glands, tear Yes ---- ---- Dysfunction foaming, lower corneal superficial punctate keratitis (SPK) Blepharitis

- Anterior Sticky residue/crusting at root of Yes ---- ---- eyelashes, redness and swelling of lid margins, irritation, burning sensation.

- Posterior lid margin redness and swelling, tear Yes ---- ----

foaming, lower corneal SPK, diffuse conjunctival injection, partial lash loss

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Ocular adnexa and eyelids PEARS GP Secondary Care (Hospital) Urgency Ocular Rosacea Thickened lids, chronic posterior Yes --- --- blepharitis, tear film deficiency, telangiectasia of facial blood vessels, upper facial hyperaemia Giant Cell Arteritis Headache, scalp tenderness, weight ---- ---- Kidderminster Treatment Centre Immediate (Temporal Arteritis) loss, jaw pain on chewing, transient vision loss, non-pulsile thickened temporal arteries, RAPD, pale disc, papilloedema with/without haemorrhages, sometimes CRAO External Eye Conditions Nystagmus Usually infantile presentation, ---- ---- Worcester/Kidderminster/ 1 week rhythmic or arrhythmic involuntary Evesham (Acute/symptomatic) eye movements, usually lateral but may be vertical or other gaze Worcester/Kidderminster/ Routine

directions, can be asymmetrical Evesham (Asymptomatic) reduced VA, may be acute onset Strabismus Usually managed under GOS/HES, ---- ---- Worcester/Kidderminster/ Routine refer newly diagnosed children and Evesham acute onset adults (Adult/child >5yrs acute onset with diplopia) 1 week 4th and 6th nerve Recent palsies – diplopia ---- ---- Worcester/Kidderminster/ 1 week Palsies Longer term palsies – head tilt, face Evesham (where recent)

turn, gaze directed diplopia Conjunctivitis

- Bacterial Sticky discharge, red eye, watery Yes ---- ---- mild lid oedema, initially unilateral

- Acute Allergic Sudden eyelid swelling, conjunctival Yes ---- ----

swelling (chemosis), itching (Only if recurrent)

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External Eye Conditions PEARS GP Secondary Care (Hospital) Urgency

- Seasonal Red eye, itching, watering (clear) Yes ---- ---- Allergic lid or peri-orbital oedema, slight chemosis, diffuse elevated papillae

- Viral Red eye, watery discharge, mild Yes ---- ----

(non-herpetic) to moderate lid swelling, palpebral (adenoviral) follicles (lower tarsal conj.), sub- epithelial infiltrates, initially unilateral (bilateral 5-10 days)

- Chlamydial Acute or subacute red eye, ---- Yes ----

irritation, mucopurelent discharge (Same day) initially unilateral, large follicles in upper and lower fornicies, superior epithelial keratitis

- Medicamentosa Initial improvement following use Yes ---- ----

Rx eye drops – then redness, lid swelling, reduced vision, punctate corneal staining cornea/conj.

- Contact lens Itching and non-specific irritation Yes ---- ----

associated mucus discharge, decreased lens (only if unable to papillary (CLPC) tolerance, micropapillae, reduced refer back to CL vision, conjunctival oedema, GPC prescriber)

- Giant papillary Chronic itching following exposure Yes ---- ---- (GPC) to allergen (usually contact lens). Large (jelly like) elevated papillae observed on eversion of upper lid, possible lid infiltrates

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External Eye Conditions PEARS GP Secondary Care (Hospital) Urgency

- Stevens-Johnson Bilateral conjunctivitis with or ---- ---- Kidderminster Treatment Centre Same day Syndrome without bullae, possible SPK, mild anterior uveitis, affects young (children, adolescents young adults), lesions on limbs back of palms and elsewhere

Keratoconjunctivitis

- Vernal Itching, stringy mucous ---- ---- Worcester/Kidderminster 1 week (Spring Catarrh) discharge, photophobia, limbal oedema, Trandos dots, corneal punctate epithelial keratopathy GPC, subepithelial scarring, Age under 10 yrs, usually male

- Atopic Bilateral itching, watering, Yes ---- Worcester/Kidderminster 1 week photophobia, limbal inflammation (if diagnosis white stringy mucous, punctate uncertain) corneal epitheliopathy, GPC, blurred vision, thickened eyelids

- Sicca (KCS) Ocular irritation, FB sensation Yes ---- ----

(Tear Deficiency) stringy mucous discharge, worse (Dry Eye) in smoke, wind or heat, usually bilateral, association with dry mouth (Sjogren’s syndrome)

- Adenoviral See above, under conjunctivitis Yes ---- ----

- Superior Limbic Middle-aged female, recurrent Yes ---- ----

sensations of burning and FBs, photophobia, tearing and mucoid discharge. Associated with thyroid dysfunction (50%)

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External Eye Conditions PEARS GP Secondary Care (Hospital) Urgency Ocular Mucous Px usually female ages 60-70 ---- ---- Worcester/Kidderminster 1 week Membrane Pemphigoid Chronic red eye (looks like Infectious conjunctivitis) Progression: conjunctivitis with subepithelial conjunctiival fibrosis possible cornea keratinization, symblephara, ankyloblepharon Subconjunctival Usually unilateral, limited at --- --- --- Haemorrhage limbus, associations include recent eye surgery, trauma (often No referral required unless posterior edge poorly defined very mild) or warfarin/aspirin Pterygium raised triangular growth at 3 & 9 Yes ---- ---- O’clock, usually nasal (where invading

cornea) Pingulecula Yellowish discoloured mass ---- ---- ---- at 3 & 9 O’clock on bulbar

conjunctiva No referral required

Chemical injuries Acids, alkalis, solvent, detergent ---- ---- Kidderminster Treatment Centre Immediate Corneal disease/injuries Corneal Abrasion and foreign bodies (Note History)

- Abrasion Acute discomfort, tearing, Yes ---- ---- photophobia, possible redness, corneal staining

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Corneal disease/injuries PEARS GP Secondary Care (Hospital) Urgency

- Surface foreign Acute discomfort, tearing, Yes ---- ---- Body photophobia, localised redness, foreign body (maybe sub-tarsal –

evert lid), corneal staining

- Embedded Acute discomfort, tearing, ---- ---- Kidderminster Treatment Centre Same day Foreign body photobphobia, localised redness, corneal staining, FB in stroma

- Penetrating Acute discomfort and tearing, ---- ---- Kidderminster Treatment Centre Immediate

Foreign body perhaps redness & photophobia, Seidel’s sign

Recurrent Corneal Pain, tearing, redness, typically Yes ---- ---- Erosion upon awakening, SPK to full thickness epithelial defects Dry Eye See Keratoconjunctivits Sicca Yes ---- ----

above. Also less severe symptoms, itchy, irritable, exacerbated by poor blink rate, environment, reflex tearing, dellen at 3 & 9 O’clock Keratoconus Irregular astigmatism, ---- ---- Worcester/Kidderminster/ Routine ‘Scissors’ topography, Evesham Munson’s sign, thin/displaced

central corneal cone, Fleisher ring

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Corneal disease/injuries PEARS GP Secondary Care (Hospital) Urgency Dystrophies Map-dot-fingerprint, Cogan’s ---- ---- Worcester/Kidderminster/ Routine (epithelial/Bowman’s), Evesham Meesmann’s (bilateral epithelial) Thiel-Behnke (curly fibre in Bowman’s; Stromal – Lattice, Granular, Central Crystalline.

Macular corneal; Posterior – Fuch’s endothelial, Congenital hereditary, polymorphous (holes in Descemet’s) Band Keratopathy May present with irritation, Yes --- Worcester/Kidderminster/ Routine calcium deposits in basement (where irritation Evesham layer of Bowman’s and anterior present) (If associated dystrophy present) stroma Corneal degeneration and deposits

- Climatic droplet Spheroid degeneration of cornea ---- ---- Worcester/Kidderminster/ Routine Keratopathy mostly males and outdoor work Evesham

- Terrien’s Slow progressive marginal superior ---- ---- Worcester/Kidderminster/ Routine

Marginal degn. nasal degeneration, bilateral, Evesham age 20 – 40 years male = female

- Lipid Keratopathy “Fish eye” syndrome, lipid ---- ---- Worcester/Kidderminster/ Routine

deposition from corneal vessels Evesham whitish deposit may encroach pupil area

- Saltzmann’s Bluish/white nodules associated ---- ---- Worcester/Kidderminster/ Routine

Nodular degn. with irregular astigmatism, redness, Evesham irritation, blurred vision; initially epithelial/Bowman’s, progress to stroma and corneal inflammation

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Corneal disease/injuries PEARS GP Secondary Care (Hospital) Urgency

- Arcus Senilis Corneal annulus, bilateral, ---- ---- ---- Symptom free. No referral required

- Kayser-Fleisher Copper deposits near limbus ---- ---- ----

Ring superficial to Descemet’s Symptom free No referral required

- Vortex Swirls of whitish/ghost striae ---- ---- ---- Keratopathy anterior stroma, associated with systemic medications, No referral required most common Amiodarone. Symptom free

- Corneal Farinata Age-related (elderly) grey ---- ---- ----

opacities in Descemet’s membrane, small punctate or No referral required larger circular. Symptom free

- Girdle of Vogt Stromal chalky/white deposits ---- ---- ----

adjacent to limbus Symptom free No referral required

Keratitis

- Interstitial (IK) Irritation, tearing, photophobia, ---- ---- Worcester/Kidderminster 1 week some redness; association with previous herpes infection - simplex and zoster, bacterial infections, adenovirus, chlamydia, Epstein Barr, sarcoidosis, syphilis.

- Marginal Localised red eye, whitish deposits Yes ---- ----

superficial adjacent to limbus, associated with staphylococcal disease

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Corneal disease/injuries PEARS GP Secondary Care (Hospital) Urgency

- Bacterial Unilateral red eye, discomfort/pain, ---- ---- Kidderminster Treatment Centre Immediate photophobia, discharge, tearing and blurred vision. Infiltrate/ulcer possible hypopyon

- Fungal Unilateral red eye, tearing, blurred ---- ---- Kidderminster Treatment Centre Same day

vision, progressing pain and photophobia, possible raised IOP. Corneal opacity/ulcer

- Acanthamoeba 85% CL wearer, swimming pools ---- ---- Kidderminster Treatment Centre Same day

chronic discomfort, reduced CL wearing time, peri-limbal injection, peri-neural infiltrates to dense ring infiltrates, SPK.

- Herpes Simplex Discomfort/pain, eyelid rash, mild ---- ---- Kidderminster Treatment Centre Same day

(HSVK) peri-limbal injection, epithelial dendritic ulcer, disciform oedema where stromal.

- Herpes Zoster Headache, ocular irritation, pain, ---- ---- Kidderminster Treatment Centre Same day

Ophthalmicus skin lesions (ophthalmic branch (HZO) trigeminal nerve), Hutchinson’s (HZO) sign (lesion at tip of nose), follicular or papillary conjunctivitis, micro- dendritic opacities, cells in AC

Corneal Graft Rejection 1-2 years after graft, mild irritation ---- ---- Kidderminster Treatment Centre Same day

and photophobia, small round subepithelial infiltrates (Bowman’s),

peri-limbal injection, AC cells and KP Ocular Hypertension IOP >21mm.Hg, normal field and discs Follow NICE Guidelines Worcester/Kidderminster/Evesham Routine

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PEARS GP Secondary Care (Hospital) Urgency Glaucoma

- Acute Angle Painful unilateral red eye, poorly ---- ---- Kidderminster Treatment Centre Same day Closure reacting vertically oval pupil, blurred

vision, halos around lights, hazy cornea, headache, possible nausea and vomiting, pupil block

- Chronic angle Intermittent headache and ocular ---- ---- Worcester/Kidderminster/ 1 month

Closure discomfort (may awake Px from Evesham sleep), episodes of blurred vision If IOP 40+ same day and halos around lights, variable referral elevated IOP, narrow angles, high hypermetropia, disc cupping

- Primary Open Follow local protocol for elevated ---- ---- Worcester/Kidderminster/ Routine

IOPs, follow NICE guidelines for Evesham Ocular Hypertension, field defects, suspect discs Earlier referral for suspect

advanced glaucoma

- Normal tension IOP <22mmHg, suspicious discs, ---- ---- Worcester/Kidderminster/ Routine suspect glaucomatous fields Evesham

Earlier referral for suspect advanced glaucoma

- Pseudoexfoliation Transient visual blurring, often ---- ---- Worcester/Kidderminster/ Routine

Syndrome (PXF) & late presentation or incidental Evesham Pigment finding Possible elevated IOP; Dispersion PXF – grey deposits between iris Syndrome (PDS) and lens, central transillumination

deposits in AC angle; PDS – pigment displaced from iris deposited on endothelium, peripheral transillumination, pigment in AC angle.

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Glaucoma PEARS GP Secondary Care (Hospital) Urgency Bleb infection Redness, pain, photophobia ---- ---- Kidderminster Treatment Centre Same day reduced vision, discharge, inflammation around bleb Uvea/Pupil/Lens disorders Anterior Uveitis Redness, pain, photophobia, poor ---- ---- Kidderminster Treatment Centre Same day vision, usually unilateral, flare & cells in AC, keratic precipitates, posterior synechiae, hypopyon Posterior Uveitis Floaters and blurred vision, no Yes ---- Kidderminster Treatment Centre Same day discomfort or redness, systemic (If diagnosis disease associations, possible uncertain) hypopyon, macular oedema,

disc swelling, snowbanking (periphery), vitreous haze and peri-vascular infiltrates, cotton wool spots, retinal pigment

Episcleritis Usually unilateral red eye, mild/ Yes ---- ---- moderate discomfort, no

discharge Scleritis Painful red eye, deep localised ---- ---- Kidderminster Treatment Centre Same day patch, Diffuse – small or large area, Nodular – part of inflamed sclera raised, Necrotising – thinned blue

area (usually female)

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Uvea/Pupil/Lens disorders PEARS GP Secondary Care (Hospital) Urgency Endophthalmitis Reduced vision, headache and/or ---- ---- Kidderminster Treatment Centre Same day pain, usually associated with post eye operation or keratitis or trauma also bacterial in elderly, diabetics, immunosuppressed, i.v. drug users.

vitreous and/or AC inflammation, hypopyon, RAPD, may have poor view of fundus Adie’s pupil Usually unilateral, initially affected Yes ---- ---- (Holmes-Adie pupil is the larger, in long term (to confirm) tonic pupil) becomes the smaller, constriction/ redilation to light very slow, near reflex often quicker, in early cases poor accommodation often present Argyll Robertson Usually bilateral, but asymmetrical, ---- Yes ---- Pupil small irregular pupils, association of neuro-syphilis Horner’s syndrome Unilateral miosis and ptosis (same ---- ---- Kidderminster Treatment Centre Same day side), heterochromia in infants, (Adults and acute presentations) may be acute presentation in adult, anisocoria more apparent in dim Worcester/Kidderminster/ Routine illumination, possible carotid artery Evesham involvement in adults when acute (Later presentation children) presentation

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PEARS GP Secondary Care (Hospital) Urgency FUNDUS Toxoplasmosis May present with blurred vision, ---- ---- Worcester/Kidderminster/ Routine sometimes vitreous floaters. Active Evesham (active disease) disease shows focal yellow-white area with well-defined border. Inactive disease classic old Old choroiditis does not require referral choroiditis pigmented lesion Diabetic Retinopathy

- Background Scattered dot & blot haemorrhages, ---- Yes ---- (R1) (where within 1 disc diameter fovea (Where patient not

VA must be better than 6/12) in screening system)

- Non-prolif/ BDR + Cotton wool spots, venous ---- ---- Worcester (Medical Retina) 2 weeks Proliferative beading, New vessels at disc, new (even if patient in screening) (R2) vessels elsewhere, sub-retinal haemorrhage, vitreous haem., Kidderminster Treatment Centre Same day rubeosis (vit. Haem.)

- Maculopathy BDR + haems within 1 disc diameter ---- ---- Worcester (Medical Retina) 1 month

(M1) fovea and VA 6/12 or worse (even if patient in screening) Branch Retinal Vein Painless VA reduction or symptom ---- ---- Worcester (Medical retina) 1 week Occlusion free, distinct branch retinal haems,

possible cotton wool spots, macular oedema, disc & retinal new vessels Central Retinal Vein Unilateral painless acute loss of ---- ---- Worcester (Medical Retina)/ same day Occlusion vision, pan-retinal haemorrhages, Kidderminster Treatment Centre (2 weeks if cotton wool spots, dilated/tortuous late vessels, macular oedema, Presentation)

papilloedema, disc and retinal new vessels, rubeosis, RAPD

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Fundus PEARS GP Secondary Care (Hospital) Urgency Branch Retinal Artery Unilateral painless acute loss of ---- ---- Kidderminster Treatment Centre same day Occlusion visual field, localised narrow arteries, or Immediate whitening & oedema, emboli may be (if macula involved) present, possible history of recurrent episodes Central Retinal Artery Unilateral painless severe loss of ---- ---- Kidderminster Treatment Centre Immediate Occlusion vision, retinal opacification, oedema & whitening, cherry red spot at macula, RAPD Hypertensive Painless, often bilateral, flame ---- * Worcester/ Kidderminster/ Routine Retinopathy shaped retinal haemorrhages, Evesham (*or to GP)

A/V nipping and right angle crossings, reduced VA where (if severe, or cause of reduced Same Day macula involved Vision)

Nonarteritic Anterior Acute painless partial loss of vision, ---- ---- Kidderminster Treatment Centre Same day Ischaemic optic neuropathy often no symptoms, sectorial optic disc swelling, flame haemorrhages, occasional macular star Central Serous Unilateral, fairly quick disturbance Retinopathy of central vision, painless, usually ---- ---- Worcester/Kidderminster/ 1 month unilateral, detachment of sensory Evesham retina between major arcades+/- pigment epithelial detachment Retinitis Pigmentosa Ret pig: post puberty/young to ---- ---- Worcester/Kidderminster/ Routine early middle aged adults, visual Evesham field loss, night blindness, intra- retinal bone-spicule pigmentation in mid-periphery, usually bilateral painless

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Fundus PEARS GP Secondary Care (Hospital) Urgency Naevus Painless, slate grey/discoloured Yes ---- ---- flat area of fundus (if > 5 disc diameters) Choroidal Melanoma Painless elevated tan or brown ---- ---- Worcester/Kidderminster/ 2 weeks

fundus lesion, often orange Evesham pigment edge, mushroom type appearance, affects late middle age white patients

Other Ocular Conditions include Choroidal ---- ---- Worcester/Kidderminster/ 2 weeks Oncology metastasis, Retinoblastoma, Evesham Iris melanomas, malignant Conjunctival tumours

Retinal capillary haemangioma ---- ---- Worcester/Kidderminster/ Routine Choroidal haemangioma Evesham Cystoid Macula Painless reduction in vision ---- ----- Worcester/Kidderminster/ Routine Oedema often associated with post Evesham cataract surgery or YAG laser 1 week fluid accumulation in outer (if severe VA loss) plexiform and inner nuclear layers, macular oedema Stargadt’s Disease Poor central vision in children ---- ---- Worcester/Kidderminster/ Routine (JMD) can present in young adults, Evesham beaten bronze macula, macular atrophy (Juvenile Macular

Degeneration) Best’s Disease Childhood/young adult, lower ---- ---- Worcester/Kidderminster/ Routine VA, macula shows “egg yolk” Evesham lesion, atrophy, unilateral or bilateral

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Fundus PEARS GP Secondary Care (Hospital) Urgency Toxic Retinopathies Chlorquinine and ---- ---- Worcester/Kidderminster 1 week Hydroxychlorquinine: blurred vision, abnormal colour vision, scotomas, Bull’s eye

maculopathy, RPE atrophy. Deferoxamine: decreased VA ---- ---- Worcester/Kidderminster 1 week night blindness, scotoma, photopsia, irregular RPE pigmentation, disc oedema. Phenpthiazines: blurred vision, ---- ---- Worcester/Kidderminster 1 week night blindness, poor colour vision, fine/coarse pigmentary retinopathy affecting macula to mid-periphery

Age Related Macular Degeneration (ARMD)

- Dry Gradual loss of central vision, ---- ---- Worcester/Kidderminster/ Routine no discomfort, difficulty reading, Evesham (only if concerns) macular atrophy, pigment (When severe or geographic

advancement/clumping, hard atrophy refer for LVA assessment) drusen; (where soft, confluent drusen present – strong risk NB: This condition does not require referral unless there is concern regarding vision factor for developing wet ARMD) (Consider referral to LVA clinic if VA dropped back close to Partial Sight registration)

- Wet More rapid loss of central vision, ---- ---- Worcester/Cheltenham Same day (Exudative) distortion, symptoms usually (Follow protocol, complete appropriate referral form uniocular, greenish grey lesion, where required, fax to Worcester (for Evesham fax may

sensory retinal detachment, soft be sent to Cheltenham), ensure patient telephone number drusen, pigment changes, sub- included with fax)

retinal haemorrhages, exudates no discomfort

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Fundus PEARS GP Secondary Care (Hospital) Urgency Macular Hole Usually uniocular loss of central ---- ---- Worcester/Kidderminster/ Routine vision, no discomfort, small foveal Evesham circular lesion, 1/3 – 2/3 disc diameter, often idiopathic in late middle-aged women, may occur in trauma or high myopia or after

cystoid macular oedema (particularly following YAG) Posterior Vitreous Acute onset flashes and floaters, Yes ---- ---- Detachment vision unaffected apart from (Same day) awareness of floaters that may be slight or severe, no discomfort, flashes initially intense, residual flashes more apparent in low light, Weiss’s ring, retina satisfactory Retinal detachment Usually unilateral, flashes (often Yes ---- Kidderminster/Cheltenham Immediate persistent and independent of (If diagnosis (Birmingham if out of hours) (If macula on) ambient light), floaters, shadow uncertain) or curtain across vision, vision may Same day be unaffected or severely reduced, (If macula off) retinal break or tear, sub-retinal fluid, increased hypermetropia/ decreased myopia, tobacco dust behind lens in anterior vitreous Miscellaneous Aamaurosis Fugax Transient visual loss without features ---- ---- Kidderminster Treatment Centre Same day of migraine, usually monocular, usually no fundus signs, but check for retinal emboli, possible carotid insufficiency

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Hospital Addresses – Please address to the Ophthalmology Department

Hospital Address Telephone and Fax

Alexandra Hospital Woodrow Drive Tel: 01527 503030 Redditch Redditch Fax: 01527 507915 Worcestershire Secretary B98 7UB Fax: 01527 503851 Birmingham and City Hospital Tel: 0121 507 6712 Midland Eye Centre Dudley Road Fax: 0121 507 5636 Birmingham B18 7QH Cheltenham General Sandford Road Tel: 0300 422 2222 Hospital Cheltenham Fax: 0300 422 6749 Gloucestershire GL53 7AN Evesham Community Waterside Tel: 01386 502449 Hospital Evesham Fax: 01386 502513 Worcestershire WR11 1JT Gloucestershire Great Western Road Tel: 0300 422 2222 Royal Hospital Gloucester Fax: 0300 422 6749 GL1 3NN Hereford County Union Walk Tel: 01432 355444 Hospital Hereford Fax: 01432 364426 HR1 2ER Kidderminster Bewdley Road Tel: 01562 823424 Hospital and Kidderminster Fax: 01562 513036 Treatment Centre Worcestershire Secretary DY11 6RJ Fax: 01562 513062 Worcester Royal Charles Hastings Way Tel: 01905 763333 Hospital Worcester Fax: 01905 733947 WR5 1DD Secretary Fax: 01905 733553

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Hospital contact details for referrals

Worcestershire urgent eye care service:

Monday to Friday 8.00am – 4.00pm (patients being seen until 5.00pm) Contact Kidderminster Treatment Centre For acute referrals and advice:

Tel: 01562 828826 (Direct line to triage nursing team) For urgent referrals not needing to be seen immediately: Fax: 01562 826368 Outside office hours direct acute referrals to BMEC (Birmingham Midland Eye Centre) Tel: 0121 507 6780

Gloucestershire urgent eye care service:

Monday to Thursday 9.00am – 5.30pm, Friday 9.00am – 1.00pm Ophthalmology GP/Optometrists phone line:

Tel: 0300 422 3578 (this line directs calls to eye casualty during office hours and redirects calls via main switchboard to duty ophthalmologist outside office hours)

For Cheltenham eye casualty department: Tel: 0300 422 8510 (Direct line, Monday-Friday office hours only) Fax: 0300 422 6749 Outside Office hours direct acute referrals via duty ophthalmologist Cheltenham

Tel: 0300 422 3200 Gloucester Tel: 0300 422 8358 (department line) Tel: 0300 422 2222 (switchboard from where duty ophthalmologists will be bleeped)

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Referral Fax Numbers

Wet ARMD

Rapid access fast track (complete appropriate form and forward via fax)

Worcester Royal Hospital Fax: 01905 733947

Gloucestershire Acute Hospitals Fax: 0300 422 6749

Non-urgent direct routine referrals to Booking Office For NEW PATIENTS ONLY i.e. cataracts etc.

Kidderminster Fax: 01562 513036

Worcester Fax: 01905 733947

Redditch Fax: 01527 507915 Alexandra/POWCH

Follow up queries and correspondence with secretaries etc. Kidderminster Fax: 01562 513062 Worcester Fax: 01905 733553

Redditch Fax: 01527 503851 Alexandra/POWCH

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Notes on referring patients

Please consider the following when referring a patient:

The patient must be registered with a GP practice in South Worcestershire CCG or Wyre Forrest CCG. Where the patient’s GP is outside South Worcestershire or Wyre Forrest then local protocols do not apply and the referral must be directed to the GP. Redditch and Bromsgrove practitioners – see preface. When referring for suspect glaucoma on grounds of IOP alone, as detailed in NICE guidelines, ensure Goldmann applanation tonometry has been completed in accordance with the local protocol. Where an optometrist has not used a Goldmann tonometer and is not contracted to a provide a repeat IOP measurement service, then the optometrist must refer the patient to a contracted optometrist for Goldmann tonometry prior to referring the patient to the hospital.

If referring for an urgent consultation please ask the patient how they will travel to the hospital. Ensure that the patient knows the hospital address as well as the time of their appointment.

Some urgent referrals will be seen the following day (as directed by the triage nursing team) please ensure patients understand that it may not be necessary for them to be seen immediately. Correct patient expectation reduces anxiety.

Please write the reason for the referral in the comments box on the GOS 2 form or record the reason on any private statement/prescription form. Please record these details in a fashion that will not induce alarm or further anxiety for the patient.

Details to be included in all referrals (For GOS 18, Letters and Rapid Access Wet AMD forms)

When sending a fax please include a reference to the number of pages being sent i.e. “Number of pages including this page = …..”.

Patient details:

Surname First name Preferred name (If applicable) Title

Date of birth NHS Number (please ask GP surgery if patient does not know NHS number)

Address (including post code).

Contact telephone number (mobile and landline) – very important!

Other administrative information:

GP name, address and telephone number. When referring direct to a hospital always send a copy to the GP.

Optometrist’s name, address, telephone and fax number (please print referring optometrist’s name in addition to signature)

Clinical information:

Short title description of “Why the patient is being referred”.

Patient’s symptoms (including duration and severity). Any appropriate history (both patient and family). Current medication (where known). Appropriate clinical findings and test results (include any field charts). The diagnosis/suspected diagnosis. The appropriate urgency of the referral.

Always include visual acuities and, if available, the refractive error (refraction details are quite important!)

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Appendix 1

Kidderminster Ophthalmology Unit Telephone Triage Form

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Appendix 2

Worcestershire Ophthalmology Department Rapid Access Wet AMD Referral Form

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Appendix 3

Gloucestershire Ophthalmology Services Wet AMD Rapid Access Referral Form

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Appendix 4

GP Direction of Ophthalmic Referrals Guidelines

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Appendix 4

GP Direction of Ophthalmic Referrals Guidelines

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Acknowledgements With thanks to Mr Luigi Flackett and Mr Nick Sargent, Associate Specialists in Ophthalmology Worcestershire Acute Hospitals NHS Trust; and Mr Tarun Sharma Consultant Ophthalmologist and Clinical Director Worcestershire Acute Hospitals NHS Trust, for their advice. Further reading: Moorfields Manual of Ophthalmology (Ed. Timothy L Jackson) 2nd Edition; Mosby Elsevier 2014 Oxford Handbook of Ophthalmology (Eds. Alastair K O Denniston, Philip I Murray) 3rd Edition; Oxford Medical Publications 2014 The Wills Eye Manual (Eds. Adam T Gerstenblith, Michael P. Rabinowitz) 6th Edition; Wolters Kluwer Health| Lippincott, Wiilams & Wilkins 2012 Ophthalmology An Illustrated Colour Text (Batterbury, Bowling and Murphy) 3rd Edition; Churchill Livingstone Elsevier 2009 Worcestershire Local Optical Committee members 2014/15

Chair: Peter Bainbridge Vice Chair: Harpreet Kular Hon. Secretary: Stuart Burdett Hon. Treasurer: Jim Osborne Committee members: Tim Allen

Matt Burford Amy Clarke Kathy Holland Steve John Jonathan Lee Victoria Merrett Geoff Roberts Peter Smith Phillip Virdi-Smith

Contact e-mail: jim@jamesosborne.com Copyright © James Reginald Osborne 2015 James Osborne has asserted his right under the Copyright, Designs and Patents Act 1988 to be identified as the author of this work