Referral Guidelines:-

NNUH Referral Guidance for Community Optometrists

This comprehensive policy document covers procedures for Emergency, Urgent and Routine Referrals providing detailed information on the following:

Full document HERE

Contents Page
1. Introduction …………………………………………………………………………………………… 4
1.1. Rationale…………………………………………………………………………………………. 4
1.2. Objective …………………………………………………………………………………………. 4
1.3. Scope……………………………………………………………………………………………… 4
1.4. Glossary………………………………………………………………………………………….. 4
2. Responsibilities …………………………………………………………………………………….. 5
3. Processes to be followed ………………………………………………………………………… 5
3.1. Sending Referrals via Email:………………………………………………………………. 5
3.2. Including clinical images with referrals …………………………………………………. 5
3.3. Referral Urgency ………………………………………………………………………………. 6
Table 1 – NNUH Referral Urgency Definitions:……………………………………………. 6
3.3.1. EMERGENCY Referrals ………………………………………………………………. 6
3.3.2. URGENT Referrals……………………………………………………………………… 7
3.3.3. ROUTINE Referrals…………………………………………………………………….. 7
3.4. Condition-Specific Referral Guidance ………………………………………………….. 7
3.4.1. Patients presenting with flashes & floaters (inc’ non-VR causes)……….. 8
3.4.2. Wet Age-related Macular Degeneration (AMD) ……………………………….. 9
3.4.3. Glaucoma & Ocular Hypertension (OHT) ……………………………………….. 9
Table 2. ‘PLUS’ factors which should trigger referral for cases of PACS10,11…. 9
3.4.4. Cataract…………………………………………………………………………………… 11
3.4.5. Posterior Capsular Opacification (PCO) following cataract surgery…… 11
3.5. Non-routine procedures and clinical threshold policies …………………………. 11
Table 2 – Important Contacts: Summary …………………………………………………….. 12
Table 3 Useful websites……………………………………………………………………………. 13
4. References………………………………………………………………………………………….. 13
5. Appendices …………………………………………………………………………………………. 15
Appendix A – Referral Overview………………………………………………………………… 15
Appendix B – Definitions of ‘Sight Impaired’ & ‘Severely Sight Impaired’ ……… 16

Primary Angle Closure Suspects Referral Guidance

- - Norfolk & Norwich University Hospital Trust
  - Queen Elizabeth Hospital Trust
  - James Paget University Hospital Trust

issue the following guidance:

Primary Angle Closure Suspects (formerly ‘Narrow Anterior Chamber Angles’)

The Royal College of Ophthalmologists issued new guidance on the management of patients with narrow anterior chamber angles in June 20221.

In response, the College of Optometrists has revised its Clinical Management Guidelines accordingly2. Eyes are classified as ‘Primary Angle Closure Suspect’ (PACS) if they have a limbal AC depth less than 25% of limbal corneal thickness (or ITC confirmed on anterior segment OCT) but NO elevation of IOP. If elevated IOP is present (or PAS have been seen), the eye is classified as ‘Primary Angle Closure’ and should be referred.

Eyes with PACS should now only be referred to an ophthalmologist if at least one of the ‘PLUS’ factors in Table 1 below apply. Such eyes are described as having ‘PACS-PLUS’ status.

Referrals for eyes meeting the criteria for PACS but with neither ‘plus’ factors nor symptoms will be rejected back to the community optometrist for annual monitoring.

Table 1. ‘PLUS’ factors which should trigger referral for cases of PACS1,2
• people with only one ‘good’ eye	• diabetes or another condition necessitating regular pupil dilation
• vulnerable adults who may not report ocular or vision symptoms	• those using antidepressants or medication with an anticholinergic action (see http://www.acbcalc.com/ for details of drugs with anticholinergic properties)
• family history of significant angle closure disease	• people living in remote locations where rapid access to emergency ophthalmic care is not possible.

Important: As a local variation to the RCOphth guidance, NNUH, JPH & QEH will also accept referrals for PACS where the patient has symptoms consistent with primary angle closure (e.g. aching pain in or above the eye, intermittent blurring, rainbow haloes around lights, etc).

Norfolk & Waveney Cataract Threshold Policy

Norfolk and Waveney ICB

CATARACT SURGERY

Policy Document

The potential to benefit from cataract surgery depends on several factors including the patient’s visual acuity, whether they have any visually disabling symptoms such as glare and the severity of the symptoms, the impact of any visual disability on the patient’s ability to function, maintain independence and remain safe, and the impact on their ability to conduct any activities which are important to them and/ or which require particularly good vision.The benefits of second eye surgery have been demonstrated and patients with bilateral cataract should be offered second eye surgery provided they meet the criteria.Patients may benefit from cataract surgery in the first or second eye when:

1. They have evidence of significant cataract on assessment.

2. AND any of the following (but not limited to):

a. Visual disability: can no longer undertake their usual activities such as reading, watching television, or particular activities relating to their employment (if applicable).b. Where the presence of cataract is preventing a patient from meeting the DVLA visual requirements for their current form of driving licence.

c. Significant glare and dazzle in daylight or difficulties with night vision, due to the lens opacity. This may particularly affect patients who need to drive at night.

d. The patient has difficulty with activities of daily living or self-care, and/or are at increased risk of falls due to impaired vision.

e. They are a carer for their partner or other dependent adult and the cataract limits their ability to provide care.

f. The patient has significant optical imbalance between the two eyes (anisometropia) which will be reduced or resolved by removal of the cataract (this may be the result of cataract surgery on the first eye).

g. The patient has a refractive error / myopic shift which is primarily due to the presence of the cataract.

h. To treat existing angle closure glaucoma or prevent future angle closure glaucoma (in eyes with cataract deemed at significant risk of future angle closure).

i. To improve intraocular pressure control in eyes with glaucoma and inadequate intraocular pressure control.

j. To treat lens-induced ocular disease (e.g., phacolytic glaucoma, phacomorphic glaucoma, phaco-anaphylactic uveitis, etc.)

k. The patient has corneal or conjunctival disease where cataract removal would reduce the risk of losing corneal clarity or reduce the risk of complications.

l. The patient has a co-existing eye condition, and the removal of the cataract is required to enable better surveillance or management of the condition, for example, diabetic and other retinopathies, age-related macular degeneration, glaucoma, inflammatory eye disease or neuro-ophthalmological conditions.m. The patient has post-vitrectomy cataracts which hinder the retinal view or result in a rapidly progressing myopia.

Note: NICE NG77 recommends that access to cataract surgery should not be restricted based on visual acuity.NOTE: Surgeons may elect to insert toric lenses provided that this is the most appropriate implant at a cost equal to standard lenses. Cases for Individual Consideration On a case-to-case basis, patients might be eligible for surgical intervention, in consideration of their exceptionality. The requesting clinician must provide information to support the case for being considered an exception, by submitting an individual funding request.

Feedback This is a new Cataract Threshold Policy for Norfolk and Waveney that will be reviewed 12 months after implementation. If you wish to share any feedback, please contact Norfolk and Waveney Clinical Policy Development Group at nwicb.cpdg@nhs.net .

NHS Referral Criteria for Eyelid Conditions.

Please click on the links below for each condition to open the form GPs must complete for referring patients to Hospital who have these conditions. It is IMPORTANT TO INCLUDE IN YOUR REFERRAL TO THE GP ALL INFORMATION NECESSARY TO COMPLETE EACH FORM. By following this simple procedure duplication of effort by the GP and repeat examination for the patient can be avoided.

Please click the link for each condition for full details:

Blepharoplasty
Chalazion Meibomian Cyst
Epiphora
Eyelid Ectropion
Eyelid Ptosis
Skin Lesions (Benign)