Referrals and notifications by optometrists within the UK: 1988 survey

Assessment of delays in presentation of patients with retinal detachment to a tertiary referral centre

The referral pathway of patients with retinal detachment from primary care providers to a tertiary care ophthalmic unit was examined, in order to determine the length and source of any delays between the onset of symptoms and arrival at the hospital. A prospective survey of all symptomatic patients (n = 60) admitted for primary rhegmatogenous retinal detachment surgery was carried out over an 8 week period. Twenty-one patients were referred by their optometrists and 18 by their general practitioners. The remainder were referred by local accident and emergency and ophthalmic departments or presented directly to the tertiary referral centre. Patients who presented to their optometrists were symptomatic for an average of four times longer. More than half the patients thought that the time to initial presentation was the most significant delay. Referral from optometrists via general practitioners and local ophthalmic clinics was considerably longer. Increased awareness of symptoms, necessity of urgent referral and knowledge of available services locally may reduce delay for those who require emergency sight-saving surgery.

Primary care and ophthalmology in the United Kingdom

The National Health Service is now primary care led. There are different definitions for primary care and in this review they are analysed and related to ophthalmology to produce a working definition for ophthalmic primary care, summarised as the provision of first contact care for all ophthalmic conditions and follow up, preventive, and rehabilitative care of selected ophthalmic conditions, in a variety of settings, by a diverse workforce. The attributes of primary care are first contact, accessibility, continuity, longitudinality, comprehensiveness, coordination, equity, and accountability. The delivery of ophthalmic primary care should be governed by these and evaluated accordingly. The clinical content of primary care consists of the first presentation of disease, the management of minor illness and trauma, the recurrence of disease, the follow up and support of some chronic conditions, and the delivery of preventive health care. Planning for ophthalmic primary care needs to take service requirements of these categories of disease into account. Primary care research is abundant in ophthalmology but needs to be more structured and targeted. Ophthalmic primary care itself is urgently in need of recognition and formal adoption by the profession.

Efficiency of referral for suspected glaucoma

OBJECTIVE

To examine the efficiency of referral for suspected glaucoma to general practitioners and consultants by optometrists.

DESIGN

A prospective survey covering 5% of all sight tests performed by optometrists in England and Wales over six months, with analysis of referred patients.

SETTING

241 optometrists' practices in areas representative of England and Wales in socioeconomic terms.

SUBJECTS

Of 275,600 people attending for a sight test, 1505 were referred with suspected glaucoma (0.9% of those aged over 4%). Outcomes were recorded for 1228 patients, 1103 (90%) of whom attended for examination by a consultant ophthalmologist (8% on a private basis). The analysis was confined to the 704 cases in which the information on diagnosis was received directly from a consultant or general practitioner.

MAIN OUTCOME MEASURES

Diagnoses reported by consultant ophthalmologists. Waiting times before an appointment for examination by a consultant ophthalmologist.

RESULTS

Glaucoma was confirmed in 283 of the 704 referred patients, and another 222 patients were considered to require further monitoring. In all, 112 (41%) of 275 confirmed cases of glaucoma were in patients with intraocular pressures greater than or equal to 30 mm Hg. At all levels of intraocular pressure the accuracy of referral was greater when the optometrist also recorded the presence of suspicious optic discs or loss of visual field, or both; but only 331 (47%) out of the 704 referred patients had been tested with a field screener. The median waiting time for an NHS clinic appointment was nine weeks. Almost a 10th of confirmed cases of glaucoma were in people in a high risk category for glaucoma who had to wait at least 14 weeks for an appointment.

CONCLUSIONS

Closer cooperation, especially at the local level, among consultants, general practitioners, and optometrists is needed to improve testing and referral for suspected glaucoma. Optometrists should be encouraged to perform all the three main tests--ophthalmoscopy, tonometry, and perimetry--in patients before referral and to report precisely on reasons for referral to help prioritisation. The optometrist's referral letter to the general practitioner should always be passed on to the consultant. Similarly, the diagnosis should always be reported back to the optometrist.