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Retina and Vitreous

 

Unless profound loss of vision useful for patient to see optometrist for initial diagnosis.

Relative afferent pupil defect (RAPD) is excellent objective sign to detect significant visual loss

Refer to casualty if acute profound loss of vision >2 Snellen lines

 

Floaters/posterior vitreous detachment

Management

  • If lasting >3 months very unlikely to be related to retinal hole.
  • Warn of retinal detachment signs and reassure

 

When to refer : - 

  • If <1 week refer to eye casualty
  • If >1 week, but less than 3 months urgent clinic
  • Do not refer if >3 months with no visual loss and without vitreous pigment

 

Retinal detachment

Refer to eye casualty

 

Age related macular degeneration (ARM)

  • Where to refer: - 
  • If wet (WARM) has 2 week pathway. Send to MACULAR service (using macular form) if acute definite vision loss +/- macular haemorrhage
  • For all other suspect ARM refer patient to community optometrist and advise to be seen as soon as possible (though be advised optometrists are not required to have urgent appointments available). If optometrist concerned about macula changes patient should be referred using the new macular form.  (Please note an NHS eye test is not a universal entitlement in England, some patients will have to pay for their eye test privately.  More information on eligibility of NHS-funded sight tests is available here)

 

 

Amaurosis fugax

 

<24 hour loss of vision – TIA

  • Management
    • check atherosclerotic risk factors
    • Exclude giant cell arteritis
  • Where to refer
    • Refer to TIA clinic
    • Routine to Eye Clinic if need to confirm diagnosis

 

Branch/Central retinal artery occlusion

  • Management
    • Check atherosclerotic risk factors
    • Exclude giant cell arteritis
  • Where to refer
    • Eye casualty if <6 hours
    • Urgent clinic if > 6 hours
    • and Urgent TIA/stroke clinic

 

Branch/Central retinal vein occlusion

  • Management
    • Check atherosclerotic risk factors
    • Long standing CRVO will have anomalous disc vessels – check past notes i.e. letters from the hospital – no need to refer if unchanged
  • Where to refer
    • Urgent clinic to establish diagnosis and exclude ischaemic occlusion

 

 

Diabetic retinopathy

All diabetic patients should be on DRS database and are usually referred through them.

  • Where to refer
    • Background → Refer DRS
    • Significant maculopathy → Refer urgently to DRS or urgent clinic
    • Proliferative (new vessels) → Refer eye casualty

 

Macular hole

If vision 6/60 for more than 12 months unlikely to respond to surgery. Surgery not suitable for very frail

  • Where to refer
    • Urgent clinic  VR surgery done in Plymouth

 

Epiretinal membrane

VA 6/9 or better unlikely to have surgery, needs monitoring by optometrist

  • Where to refer
    • Routine clinic VR surgery done in Plymouth

 

Retinal pigment/choroidal naevus

Check old notes to see if seen before. Benign looking ones are photographed and referred to optometrist for annual monitoring

  • When to refer
    • Routine if new referral
    • Eye casualty if large, elevated and visual change suggesting recent change and so possible malignancy

 

Vitreous haemorrhage

Acute – usually no retinal view – maybe retinal hole/detachment, proliferative diabetic retinopathy

  • Where to refer
    • Eye Casualty for B scan diagnosis