BHRUT Eye Casualty referral guidelines

These are referral guidelines to help support community eye services. It allows us to plan, direct and optimize the patient referral pathway to allow appropriate, timely referrals. This will reduce unnecessary attendance and ensure urgent, appropriate care is provided to patients, avoid diagnostic and management delay, and improve patient safety and satisfaction.

Referral Forms

Urgent eye emergency referral form [docx] 17KB

Adult chalazion referral form [docx] 43KB

Opening hours

8.30am to 5pm, Monday to Friday (excluding bank holidays).

We no accept walk in attendees – appointment only. If a patient needs a same day review or you would like ophthalmic advice and in hours, please telephone the Eye clinic on 01708 435 000, extension 6662 and complete the Urgent eye emergency referral form [docx] 17KB . Please email bhrut.urgenteyecare@nhs.net.

Following triage, non-urgent referrals may be booked to be seen on a different day. We ask that you email the emergency referral address or telephone our advice line to prevent unnecessary patient journeys.

Before referring it is helpful if you could provide our nurses and doctors with the following patient information:

  • Demographics and contact details
  • Present concern or issue
  • Patient’s past ophthalmic, family history and relevant medical history

Our department contains facilities to perform OCT, photography, visual field testing and full ocular motility testing.

Out of hours: non urgent treatment

If a patient is seen by you out of hours and the problem may wait until the next day (or Monday morning if it is the weekend) then please fill in the Urgent eye emergency referral form [docx] 17KB  and email it to bhrut.urgenteyecare@nhs.net and include the patients full contact details. This inbox is monitored during working hours and we will call the patient to arrange a follow up appointment at their convenience.

Out of hours: urgent treatment

If the problem is a sight threatening one (for example):

  • acute angle closure suspect
  • penetrating eye injury
  • severe chemical injury

Please telephone Moorfields Eye Hospital switchboard on 020 7253 3411 and ask to speak to Emergency Department staff. Alternatively, telephone Moorfields direct: 020 75214682.

Please do not send patients without prior discussion as they may not be accepted and may be turned away. Alternatively, telephone Whipps Cross Hospital on 020 85395522 and ask to speak to the oncall ophthalmologist for advice. Most eye problems may wait until the next day for review at Queen’s Eye Casualty Clinic

Referral Guidelines to ophthalmic subspecialties

Please include:

  • As much clinical information as possible
  • Proposed urgency:
    • ‘Emergency’ (referred directly- see above pathway)
    • ‘Urgent’ (2-4 weeks)
    • ‘Routine’ (up to 18 weeks)
    • ‘Soon’ referral is a flagged ‘routine’ referral but may still take up to 18 weeks

Neuro-ophthalmology Conditions and appropriate referral pathway

1. Third nerve palsy

  1. Third nerve palsy
  2. Fourth nerve palsy
  3. Sixth nerve palsy
  4. Seventh nerve palsy
  5. Adult Strabismus (squint)
  6. Myasthenia
  7. Thyroid eye disease
  8. Horner's syndrome
  9. Neurological visual field defects
  10. Nystagmus
  11. Pupils/anisocoria
  12. Swollen optic discs
  13. Migraine with visual aura

1. Third Nerve Palsy

Acute onset, painful with headache or neck-ache please refer immediately to a local Emergency Department.

Sudden onset with minimal headache and a history of microvascular disease may be referred to our eye casualty for urgent assessment.

Ocular motor cranial nerve palsies may indicate intracranial pathology so if encountered the patient should have a full neurological assessment to assess for any other localizing defects and have imaging of the brain (ideally a CT venogram) as part of their initial workup.

If the cranial nerve palsy is then determined to be an isolated finding and likely due to a vasculopathic cause such as diabetes or hypertension, these risk factors should be managed medically and the patient should be referred for an orthoptics assessment and a neuro-ophthalmology review as described above.

2. Fourth Nerve Palsy

Fourth nerve cranial nerve palsies are less commonly acute and are usually congenital, manifesting in adulthood with double vision,traumatic or microvascular. These can be referred to casualty if sudden-onset or to clinic routinely (up to 18 weeks) if longstanding or minimally symptomatic.

3. Sixth Neve Palsy

Please refer patients with acute sixth nerve palsies to our eye casualty service.

Ocular motor cranial nerve palsies may indicate intracranial pathology so if encountered the patient should have a full neurological assessment to assess for any other localizing defects and have imaging of the brain (ideally a CT venogram) as part of their initial workup.

If the cranial nerve palsy is then determined to be an isolated finding and likely due to a vasculopathic cause such as diabetes or hypertension, these risk factors should be managed medically and the patient should be referred for an orthoptics assessment and a neuro-ophthalmology review as described above.

4. Seventh Nerve Palsy

Patients with Bell’s palsy or lower motor neuron facial nerve palsies are more susceptible to exposure and dry eyes. Rarely this can lead to severe infection of the ocular surface. These can be usually managed in the community with topical lubricants 4-8 times per day e.g. Sodium Hyaluronate 0.2%, lubricating drops, and a lubricating ointment at night-time, with horizontal lid taping to prevent exposure.

Please refer if the eye becomes uncontrollably dry or red.

Corneal ulceration (opacity of the cornea) requires urgent same day referral to the ophthalmology unit via the emergency number or e-mail address.

Please refer if the eye becomes uncontrollably dry or red. Corneal ulceration (opacity of the cornea) requires urgent same day referral to the ophthalmology unit via the emergency number or e-mail address.

5. Adult Strabismus (Squint)

Sudden onset squint or strabismus with a likely neurological cause (progressive, associated ‘red-flags’) should be referred to the emergency e-mail address.

If the patient has a long-standing squint with diplopia, or feel they are adversely affected by the squint, and would like to undergo surgical intervention or botulinum toxin injection to treat this, they may be referred to our ophthalmology unit routinely (Up to 18 weeks), after correction of refractive error.

Convergence insufficiency may be managed in the community with full correction of refractive error, convergence exercises and the use of prisms if required. If these measures fail, a routine referral may be made to the hospital eye service for orthoptic assessment.

6. Myasthenia

Myasthenia gravis may present with eye symptoms alone in 70 per cent of cases, peaking at the ages of 20 and 60. It should be suspected when symptoms (double vision, drooping eyelids) are intermittent or variable, and become significantly worse towards the end of the day or with exercise.

This can be referred routinely (up to 18 weeks) to clinic.

The patient’s GP may consider Anti-Acetylcholine Receptor and Anti-Muscarine Receptor antibody testing prior to referral.

In the presence of difficulty swallowing, chewing or breathing, this must be immediately referred to the medical or neurology team as an emergency.

7. Thyroid Eye Disease

This may present as proptosis, lid retraction or strabismus.

Refer urgently to our emergency clinic if there is sudden change in vision which is not attributable to simple dry eye. Causes of loss of vision in thyroid eye disease include optic nerve compression (check visual acuity, pupils, Ishihara colour vision, pale nerve on fundoscopy) or exposure keratopathy (unable to close lids fully, corneal staining seen after installation of  fluorescein under blue light).

Routine referral (up to 18 weeks) to clinic should be considered if no sudden loss of sight.

If undiagnosed, the GP may wish to undertake thyroid function and auto-antibody testing prior to referral and the patient may need referral to the endocrine team.

8. Horner Syndrome 

Any patient with suspected acute onset painful Horner syndrome (ptosis and a small pupil) should be referred immediately to the ophthalmology unit in hours, or to the medical team on call out of hours. If there is anisocoria (asymetrical pupils) which is potentially of recent onset, with no pain, ptosis or visual symptoms, a referral may be made to our referral e-mail address for triaging. Please fill in the Urgent eye emergency referral form [docx] 17KB  and email it to bhrut.urgenteyecare@nhs.net. Long-standing anisocoria or ptosis may be referred routinely (up to 18 weeks). When the onset of anisocoria is unclear, it is useful in these cases to ask the patient to look through old photographs to see when the condition first arose.  

9. Neurological field defect  

A patient with an acute onset and symptomatic homonymous hemianopia requires immediate referral to the stroke or medical on call team out of hours. If this is an incidental finding and the patient is asymptomatic, referral to the ophthalmology unit may be made routinely (up to 18 weeks).

Referral to the eye casualty is recommended for new onset bi-temporal visual field defects once imaging (CT venogram or MRI) has been conducted.

10. Nystagmus 

Nystagmus is a condition of uncontrolled eye movement, and may be difficult to assess. Visual acuity, speed and time of onset, whether it is continuous or occurs in episodes, and the presence of other neurological symptoms/deficits are important factors. New onset acquired nystagmus in an adult may be secondary to stroke, demyelination, a compressive lesion, trauma or drug-induced. We will aim to review within two weeks per Royal College of Ophthalmology guidelines. A referral may be sent to our e-mail address for triaging. Please fill in the Urgent eye emergency referral form [docx] 17KB  and email it to bhrut.urgenteyecare@nhs.net (please see paediatric guidelines for nystagmus in a child).

11. Pupils / Anisocoria (unequal pupils)

Patients with new onset anisocoria with significant neck/headache or neurology (i.e. painful third nerve palsy or Hornerssyndrome) should be sent immediately to their nearest AandE department as they require urgent imaging (CT venogram or MRI).

Please refer all other acute cases to our casualty referral system. Please fill in the Urgent eye emergency referral form [docx] 17KB  and email it to bhrut.urgenteyecare@nhs.net . Longstanding asymptomatic anisocoria may be referred routinely and the patient advised to attend casualty if symptoms develop.

Before referring please consider whether the patient may have had contact with any medications affecting the autonomic nervous system.

12. Swollen discs

Asymptomatic patients where unclear disc margins are found on routine examination may be referred routinely into clinic and advised to attend A&E if neurological symptoms develop in the interim.

Patients with increasing headache or neurological red flags should be referred to our casualty service. Please fill in the Urgent eye emergency referral form [docx] 17KB  and email it to bhrut.urgenteyecare@nhs.net

When referring patients, or simply asking for advice, please include in your email: an OCT of the disc; visual acuity; colour (Ishihara) acuity. This is helpful to our consultants in determining urgency.

Optic disc swelling extra guidelines

Optic neuritis

This is always associated with optic nerve function loss, such as decreased vision, decreased colour vision, depressed visual field, or a caeco-central visual field defect, and a relative afferent pupillary defect. Often seen in young patients.

Please provide a detailed account of findings and refer by email. If the patient has other neurological features, especially ones separated in space and time consider MRI imaging to assess for demyelinating disease and liaise with neurology. Please fill in the Urgent eye emergency referral form [docx] 17KB  and email it to bhrut.urgenteyecare@nhs.net

Arteritic Anterior ischaemic optic neuropathy 

(AION) e.g. Giant Cell Arteritis

Giant cell arteritis: any three of the following findings should provoke a referral;

An elderly patient with systemic signs of general malaise, musculoskeletal pains, headaches, scalp tenderness, jaw claudication, malaise, appetite loss and other systemic signs.

Please refer to main A+E. The patient needs an ESR/CRP and medical assessment.

  • Vision loss in the context of giant cell arteritis presents as acute and severe vision loss. Please contact the eye department emergency (01708 435 000 extension 6662) to arrange a review on the same day.
  • Giant cell arteritis can sometimes present with horizontal diplopia caused by sixth cranial nerve palsy, in addition to other systemic signs and symptoms. Please refer to the eye department emergency service by telephone to arrange a review on the day.

Non-Arteritic ischaemic optic neuropathy

(NAION) (more common, onset over days usually associated with diabetes, sudden drop in blood pressure or sleep apnoea).

Optic neuropathies would lead to RAPD, visual acuity loss, colour vision loss, and visual field loss.

Causes included infiltrative diseases (tumours/sarcoidosis), trauma, nutritional deficiencies (B12 or folate), toxic causes (methanol, ethambutol, amiodarone) or hereditary causes (Leber's heredity optic neuropathy). Often in an elderly patient. These tend to have a long-standing onset.

Please fill in the Urgent eye emergency referral form [docx] 17KB and email it to bhrut.urgenteyecare@nhs.net and we will triage the patient appropriately. Please include any past medical history, medication or imaging results which may be useful.

Central retinal vein occlusion

This can sometimes be associated with optic disc swelling in addition to the expected retinal hemorrhages and venous engorgement.

Check the patient's blood pressure and refer to the medical on-call team if over 200 systolic or the GP if over 140 systolic. Please fill in the Urgent eye emergency referral form [docx] 17KB  and email it to bhrut.urgenteyecare@nhs.net with a fundus photograph if possible.

Disc swelling in the context of papilloedema

This is due to raised intracranial pressure. This is associated with headaches, visual obscuration, swollen optic discs, and venous congestion and tortuosity. Visual acuity and fields are commonly unaffected, but this is variable. It is commonly associated with a history of weight gain.

Please provide a detailed account of findings and fill in the Urgent eye emergency referral form [docx] 17KB  and email it to bhrut.urgenteyecare@nhs.net with any fundus photography or OCT images of the optic disc if possible.

Pseudo disc swelling

This is common, and the patient typically does not have any other visual symptoms.

For suspected disc swelling with no other symptoms and where you are not able to be sure of the diagnosis, please provide a fundus photo and an OCT image of the disc if possible and send for advice and guidance by filling in the Urgent eye emergency referral form [docx] 17KB  and email it to bhrut.urgenteyecare@nhs.net

Migraine with visual aura

Migraine aura (jagged lines of light across one or both eyes) in a young, known migraineur is rarely of concern and can be referred routinely if there is no other neurological symptoms.

New onset migraines with aura in older patients or aura that increases in frequency always in the same area of the vision should be referred to neuro-ophthalmology/ neurology on a semi-urgent basis.

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