Urgent advice line: 01708 435 000 Ext. 6662

Please fill in the urgent eye care referral form [docx] 17KB and email it to bhrut.urgenteyecare@nhs.net

1. Age related macular degeneration
2. Diabetic retinopathy
3. Central/ Branch retinal Vein occlusion
4. Central/Branch retinal Artery occlusion
5. Central serous retinopathy
6. Bulls eye maculopathy (Hydroxychloroquine screening)
7. Toxoplasmosis
8. Uveitis-Acute Anterior Uveitis, Intermediate Uveitis, Posterior Uveitis
9. Episcleritis/ Scleritis
10. Retinitis Pigmentosa
11. Choroidal naevus
12. CHRPE
13. Ocular oncology

Age related macular degeneration

Wet Age related macular degeneration (w-AMD)

The patient may present with a sudden deterioration in central vision or complain of metamorphopsia (linear objects appear curved or wiggly). Signs include drusen, RPE changes and sub-retinal fluid or haemorhmagic exudates on OCT scan.

• Please refer to the Emergency Eye clinic for a review within one week, or call our advice line for discussion and to refer the patient on the same day. 
• Please include the patient’s phone number and any OCT images if possible.

Dry Age related macular degeneration (d-AMD)

Dry AMD does not need to be referred routinely if you are confident there are no sinister features.

• Advise the patient to use an Amsler grid weekly to monitor any progression and to get back in contact if they notice any changes. If you have any concerns please refer routinely (up to 18 weeks) to the MR services.
• Advise all patients with suspected AMD to self-monitor on an amsler grid, such as the one below. Advise on smoking cessation and council on the use of over the counter AMD vitamins.

Instructions on how to use Amsler grid:

1. Hold the grid at a comfortable reading distance (generally, about 12-14 inches away). Wear your reading glasses if you normally use them.
2. Cover one eye and focus on the black dot in the middle of the grid.
3. Cover the other eye and repeat the test. If the lines appear to be wavy, dim, irregular or fuzzy, schedule an eye exam immediately.

2. Diabetic retinopathy

See local Diabetic screening guidelines.

• Vitreous haemorrhage secondary to proliferative diabetic retinopathy should be referred for same day or next day review (if out of hours).
• Clinically significant macular oedema should be referred for a review within two weeks.

Advise patients to maintain optimal diabetic control and ensure they are booked under their GP or endocrinologist for a review of their diabetic medications and other vascular risk factors.

3. Central/ Branch retinal vein occlusion

Central retinal vein occlusion

A patient with a new central retinal vein occlusion should be seen within one week. If possible blood pressure, blood sugar, full blood count, ESR, U&E, lipids, thyroid function and ECG should be performed if seen in A&E at the presentation.

Branch retinal vein occlusion

A branch retinal vein occlusion should be referred for a review within four to six weeks in the medical retinal clinic. If possible blood pressure, blood sugar, full blood count, ESR, U&E, lipids, thyroid function and ECG should be performed if seen in A&E at the presentation

4. Central/Branch retinal artery occlusion

This may occasionally present as a transient monocular loss of vision (amaurosis fugax) but usually manifests as sudden painless unilateral profound vision loss.

The patient often has vascular risk factors such as diabetes, hypertension, hyperlipidaemia, or is a smoker. The retina appears pale, often with a ‘cherry red spot’ of vascular perfusion seen over the macular area.

• The patient should have a neurology examination. If there is any suspicion of a transient ischemic attack (TIA)-please follow local Emergency Department guidelines on local stroke referral and imaging.
• Once the stroke team has assessed and managed the patient, they may be referred to the Emergency Eye clinic.

5. Bulls eye maculopathy (Hydroxychloroquine screening)

Hydroxychloroquine is an immune-modulating drug used commonly in a number of rheumatological conditions. It may rarely cause ocular side effects including vortex keratopathy or ciliary body dysfunction; both of which may rarely affect vision. It may also cause a retinopathy which is irreversible.

• Patients started on hydroxychloroquine treatment DO NOT need baseline ophthalmology assessment as per the current guidelines of the Royal College of Ophthalmologists.
• Patients require screening every five years by the medical retinal services.
• Hydroxychloroquine screening in BHR is provided in the community by Evolutio.

6. Toxoplasmosis

Often a peripheral pigmented retinochoroidal scar is seen on routine examination which implies a previous infection which may have occurred in childhood. This does not need routine referral.

However, acute infection can cause a posterior uveitis presenting with loss of vision and floaters. A fluffy white focal retinitis is seen on fundal examination with overlying vitreous inflammation (‘headlight in the fog’).

This may be accompanied by a granulomatous anterior uveitis, ocular hypertension (10-15% of cases) or a retinal vasculitis.

• If this is suspected, please call for an ophthalmic review on the same day via the urgent advice line: 01708 435 000 ext. 6662.
• If out of hours then advice may be sought from Moorfields Eye Hospital Main switchboard number 020 7253 3411 and ask to speak to the Emergency Department staff or Moorfields Direct A&E: 020 7521 4682.

*Please do not send patients without prior discussion. Patients will be triaged and may be turned away.*

7. Uveitis-Acute Anterior, Intermediate and Posterior Uveitis

Patients with anterior uveitis present with pain, photophobia, often with an injected red eye. On slit lamp examination, cells or flare is seen in the anterior chamber.  

Patients with posterior uveitis may present with vision deterioration or floaters and the patient may not have any pain. Cells in the vitreous may be seen in intermediate uveitis and choroidal or retinal changes may be seen in posterior uveitis.

Please refer the patient to the Emergency Eye clinic for a review by calling the urgent advice line: 01708 435 000 ext. 6662. Do not send the patient in without discussion.

8. Episcleritis/ Scleritis

See section 6 above in B. Cornea/ Conjunctiva/ Scleral section

9. Choroidal naevus

This is a benign melanocytic lesion of the choroid. They are typically found sporadically on routine examination of the posterior pole and are often in the periphery and are asymptomatic. Occasionally they may lead to sub retinal fluid or neovasularisation which may affect vision. They tend to have clearly defined edges, be flat or only mildly elevated and remain stable in size.

Very rarely they may have malignant transformation with an incidence of around 1 in 8845.

• Increasing nevus thickness is thought to be the most important risk factor for malignant transformation.
• Other factors include thickness >2mm, sub retinal fluid, orange pigment deposits.

Please refer routinely (up to 18 weeks) for an ophthalmic review in the medical retina clinic. Please include any OCT/ colour fundus imaging in the referral if possible.

10. CHRPE (Congenital Hypertrophy of the retinal pigmented epithelium )

Congenital Hypertrophy of the retinal pigmented epithelium (CHRPE) is a benign, typically asymptomatic, congenital lesion seen in the retina that is characteristically a flat, dark lesion varying from a few to 10mm in diameter.

Very rarely, it is associated with familial adenomatous polyposis (FAP) an autosomal dominant condition characterized by numerous adenomatous polyps of the colon and rectum.

Please refer routinely (up to 18 weeks) for an ophthalmic review in the medical retina clinic. Please include any OCT/ colour fungus imaging in the referral if possible.

11. Ocular oncology

If an intraocular malignant lesion is suspected e.g uveal melanoma, choroidal metastasis, intraocular lymphoma, retinoblastoma etc. please refer to the ophthalmology department via the two-week wait system.