Manual Manual Welsh Eye Care Initiative Welsh Eye Care Initiative

1.0 Terminology A Welsh Eye Care Initiative The following terms are important in this text: Retinal break This is a retinal tear or hole.

Retinal detachment Guideline This is any type of retinal detachment including rhegmatogenous, traction or exudative.

2.0 Optometric Assessment

2.1 History and Symptoms

A full and thorough history and symptoms is essential. In addition to the normal The Assessment and Management history and symptoms, careful attention must also be given to the following: of suspect History •Age Retinal Tear, Hole or Detachment. •Myopia •Family history of retinal break or detachment •Previous ocular history of break or detachment •Systemic disease •History of recent ocular trauma, surgery or inflammation

Symptoms •Loss or distortion of vision (a curtain / shadow / veil over vision) •Floaters •Flashes

For symptoms of floaters these additional questions should be asked: ØAre floaters of recent onset? These guidelines are intended for information only which may ØWhat do they look like? be used for reference. ØHow many are there? ØWhich eye do you see them in? ØAny flashes present?

Ensure that local protocols, initiatives or agreements are For symptoms of flashes these additional questions should be asked: followed; these guidelines are not meant as a replacement. ØDescribe the flashes? ØHow long do they last? ØWhen do you notice them? Manual Manual Welsh Eye Care Initiative Welsh Eye Care Initiative Welsh Eye Care Initiative

For symptoms of a cloud, curtain or veil over the vision these additional questions should be asked: 3.0 Management ØWhere in the visual field is the disturbance? Some HES ophthalmology departments will not have RD surgery facilities. In ØIs it static or mobile? these cases it is best to telephone the department first to find out what ØWhich eye? procedures to follow. ØDoes it appear to be getting worse? 3.1 Symptoms requiring same day referral (clinic hours)* 1) Sudden increase in number of floaters, patient may report as "numerous", 2.2 Clinical Examination "too many to count" or “sudden shower or cloud of floaters” ØSuggests blood cells, pigment cells, or pigment granules (from the All patients presenting for a PEARS or WEHE examination with symptoms retinal pigment epithelium) are present in the vitreous. Should be signs indicative of a potential retinal detachment should have the following of retinal break or detachment present. investigations (in addition to such other examinations that the optometrist feels are necessary): 2) Cloud, curtain or veil over the vision ØSuggests retinal detachment or vitreous haemorrhage – signs of retinal •Tests of pupillary light reaction, including swinging light test for Relative break or detachment should be present Afferent Pupil Defect (RAPD), prior to pupil dilatation

3.2 Signs requiring same day referral (clinic hours) •Visual acuity recorded and compared to previous measures 1) Retinal detachment with good vision

•Contact tonometry, noting IOP discrepancy between eyes 2) Vitreous or pre-retinal haemorrhage 3) Pigment 'tobacco dust' in anterior vitreous •Visual Field examination at discretion of optometrist 4) Retinal tear/hole with symptoms

•Slit lamp biomicroscopy of the anterior and posterior segments, noting: 3.3 Signs requiring referral ASAP next available clinic appointment o Pigment cells in anterior vitreous, 'tobacco dust' (Shafers sign) 1) Retinal detachment with poor vision (macula off) o Vitreous haemorrhage 2) Retinal hole/tear without symptoms o Cells in anterior chamber (mild anterior uveitic response) 3) Lattice degeneration with symptoms of recent flashes and/or floaters

•Dilated pupil fundus examination with slit lamp binocular indirect ophthalmoscopy using a Volk, or similar lens (Superfield or Super Vitreo 3.4 Require discharge with SOS advice (verbal advice and a leaflet -see fundus lens optimal) noting: sheet appended)

o Status of peripheral retina, including presence of retinal tears, 1) Uncomplicated PVD without signs and symptoms listed above* holes, detachments or lattice degeneration 2) Signs of lattice degeneration without symptoms listed above* o Presence of vitreous syneresis or Posterior Vitreous Detachment (PVD) Manual Welsh Eye Care Initiative

4.0 Referral Letters

Patients requiring referral for retinal breaks or detachment must have the following noted in the referral letter to the ophthalmologist. Letters should be typed whenever possible and may be faxed or sent with the patient in urgent cases.

•A clear indication of reason for referral as a title to referral. E.g Retinal tear in superior temporal periphery of Right eye

•A brief description of any relevant history / symptoms

•A drawing of the location of any retinal break / detachment / area of lattice with disc and macula for scale

•A description of the location any retinal break / detachment / area of lattice

•Urgency of the referral