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Home , Chalazion

Ophthalmological Conditions - What To Do and When?

(in Adults and Children) for Optometrists and GPs

Priority Treatment and Management Emergency conditions, vision immediately WEEK DAYS: 8am – 7pm Monday to Friday threatened (same day Phone appropriate Department for same day appointment: appointment)  Southlands Hospital Tel: 01903 205111 ext. 83112  St Richards Hospital Tel: 01243 788122 ext. 33532

And email a referral letter to the relevant hospital to the relevant department:  Southlands Hospital: [email protected]  St Richards Hospital:[email protected]

OUT OF HOURS: Weekends, bank holidays & after 7pm week days Telephone 01903 205111 and ask for On-Call Ophthalmology Doctor

Please DO NOT send patients to Ophthalmology without prior discussion – We do not provide a walk in service

Urgent conditions but no immediate threat to the WEEK DAYS: 8am – 7pm Monday to Friday vision (1-2 week Start treatment and discuss with Ophthalmology Department appointment)  Southlands Hospital Tel: 01903 205111 ext. 83112  St Richards Hospital Tel: 01243 788122 ext. 33532

And email a referral letter to the relevant hospital to the relevant department:  Southlands Hospital: [email protected]  St Richards Hospital: [email protected]

OUT OF HOURS: Weekends, bank holidays & after 7pm week days Telephone 01903 205111 and ask for On-Call Ophthalmology Doctor

Please DO NOT send patients to Ophthalmology without prior discussion – we do not provide a walk-in service

Non-acute Ophthalmic conditions, no Start treatment if required and refer patients, where appropriate to Ophthalmology immediate threat to following standard CCG referral pathway vision

Revised January 2020 AIC Ophthalmology Group (Mr Haziq Chowdhury and Mr Khin Nyunt) Renew by January 2021 Page 1

Contents Emergency conditions, vision immediately threatened (same day appointment) ...... 3 Bacterial / Red suggestive of serious pathology ...... 3 Dendritic ulcer ...... 3 Flashes and ...... 4 Headache or pain around the eye (provided eye symptoms) ...... 4 ...... 4 Sudden loss of Vision ...... 4 Trauma...... 4 Urgent conditions but no immediate threat to the vision (1-2 week appointment) ...... 5 Suspected intraocular malignancy ...... 5 Suspected peri-ocular malignancy ...... 5 Suspected wet AMD ...... 5 and Itchy ...... 6 ...... 6 HerpeZoster Ophthalmicus ...... 6 Non-acute Ophthalmic conditions, no immediate threat to vision ...... 7 Low vision aids ...... 7 referral thresholds (Adults) ...... 7 Cataract referral thresholds (Children) ...... 7 Chalazion (Meibomian ) ...... 8 / ...... 8 ...... 8 Hordeolum () ...... 9 Isolated and dermatochalasis ...... 9 Non acute blurred vision (Not loss of vision)...... 9 Paediatric ...... 9 ...... 9 Watery and dry eyes ...... 10

Revised January 2020 AIC Ophthalmology Group (Mr Haziq Chowdhury and Mr Khin Nyunt) Renew by January 2021 Page 2

Priority Treatment and Management

WEEK DAYS: 8am – 7pm Monday to Friday Emergency Phone appropriate Ophthalmology Department for same day appointment: conditions, vision  Southlands Hospital Tel: 01903 205111 ext. 83112 immediately  St Richards Hospital Tel: 01243 788122 ext. 33532 threatened (same day appointment) And email a referral letter to the relevant hospital to the relevant department:  Southlands Hospital: [email protected]  St Richards Hospital:[email protected]

OUT OF HOURS: Weekends, bank holidays & after 7pm week days Telephone 01903 205111 and ask for On-Call Ophthalmology Doctor

Please DO NOT send patients to Ophthalmology without prior discussion – We do not provide a walk in service

Condition suggestive of Condition Treatment and further Management  , pain , non-limbal or corneal Emergency Condition Bacterial corneal ulcer infiltrate with Fluorescein staining Phone Ophthalmology / Red eye suggestive  Any child with red eye, in pain and:- Department or On-Call of serious pathology  obvious corneal ulceration, Opthalmology Doctor for same day  opacity or very poor red reflex appointment  Contact wear  Decreased vision  Severe pain or photophobia  -> ulcer, cloudy, hazy  abnormalities  high intraocular pressure  <2 weeks post-ops  patients with previous glaucoma surgery (blebitis)/corneal graft (rejection)  Patient with red eye or blurred vision Emergency Condition Dendritic ulcer  Corneal staining with Fluorescein and examination Phone Ophthalmology with cobalt blue light Department or On-Call Opthalmology Doctor for same day appointment (Initiate treatment with Ganciclovir Gel)

Revised January 2020 AIC Ophthalmology Group (Mr Haziq Chowdhury and Mr Khin Nyunt) Renew by January 2021 Page 3

Condition Signs and Symptoms suggestive of Condition Treatment and further Management  Refer sudden onset of new floaters + daytime Emergency Condition Flashes and Floaters flashes with blurred vision + Visual field loss Phone Ophthalmology Department or On-Call Opthalmology Doctor for same day appointment  GCA - Temporal headache/tenderness/painful Emergency Condition Headache or pain scalp/feeling unwell/jaw pain in patients over 50 with Phone Ophthalmology around the eye any visual disturbance (please refer to medical team if Department or On-Call (provided eye no visual symptoms) Opthalmology Doctor for symptoms)  Stroke/increased Intra cranial pressure - Headache same day appointment associated with new onset of droopy , unequal , double vision, swollen discs, or any visual loss. (Please refer via A&E)  Proptosis Emergency Condition Orbital cellulitis  lid swelling Phone Ophthalmology  Department or On-Call  Limited ocular motility Opthalmology Doctor for same day appointment  Decreased vision  Fever or systemically unwell  Sudden onset marked loss of vision, visual field Emergency Condition Sudden loss of Vision defect, central or distortion. Phone Ophthalmology  Check temporal arteries in elderly. Department or On-Call Opthalmology Doctor for same day appointment  Any suggestion of penetrating injury Emergency Condition Trauma  Lid margin laceration Phone Ophthalmology  Chemicals (particularly alkalis) in eye, wash out Department or On-Call first Opthalmology Doctor for same day appointment  Blunt trauma – severe or small projected object with decreased vision or obvious hyphaema

Revised January 2020 AIC Ophthalmology Group (Mr Haziq Chowdhury and Mr Khin Nyunt) Renew by January 2021 Page 4

Priority Treatment and Management

WEEK DAYS: 8am – 7pm Monday to Friday Urgent conditions but no Start treatment and discuss with Ophthalmology Department immediate threat to the  Southlands Hospital Tel: 01903 205111 ext. 83112 vision (1-2 week  St Richards Hospital Tel: 01243 788122 ext. 33532 appointment) And email a referral letter to the relevant hospital to the relevant department:  Southlands Hospital: [email protected]  St Richards Hospital: [email protected]

OUT OF HOURS: Weekends, bank holidays & after 7pm week days Telephone 01903 205111 and ask for On-Call Ophthalmology Doctor

Please DO NOT send patients to Ophthalmology without prior discussion – we do not provide a walk-in service

Condition Management

2 week rule referral Suspected intraocular Phone Ophthalmology department directly for urgent conditions, patient to be seen malignancy within 2 weeks

2 week rule referral Suspected peri-ocular Use relevant proforma and email to [email protected] malignancy Urgent referral Suspected wet AMD 2 weeks to treatment and email to [email protected]

Revised January 2020 AIC Ophthalmology Group (Mr Haziq Chowdhury and Mr Khin Nyunt) Renew by January 2021 Page 5

Condition Signs and Symptoms suggestive of Condition Treatment and further Management

 Redness and inflammation of Urgent Condition Conjunctivitis and Itchy  Managed in community. eyes  Sticky coating on Consider self-care (purchase  Vision not normally affected over the counter) at a local community pharmacy.  If purulent discharge (can be purchased over the counter for patients aged 2 years or over) qds x 5/7 otherwise antihistamines for young patients, lubricants for elderly, (can be purchased over the counter at Pharmacy  Lid Hygiene for suspected  Phone Ophthalmology Department regarding photophobia or decreased visual acuity  Acute swelling, erythema, pain Urgent Condition Dacryocystitis in medial canthus area  Start oral to  Excess () cover staph  Phone Ophthalmology Department

 Non-descript facial pain Urgent Condition HerpeZoster  Vesicular rash in distribution of 5th  Does not need ophthalmic work- Ophthalmicus cranial nerve up if Ocular Surface NOT involved  Treat with Acyclovir 800 mg 5 unless Hutchinson sign +ve then times a day for 1 week refer to Ophthalmology  Treat with Acyclovir 800 mg 5 times a day for 1 week  Phone Ophthalmology Department if reduced VA or red and painful eye at 10 days post rash onset.

Revised January 2020 AIC Ophthalmology Group (Mr Haziq Chowdhury and Mr Khin Nyunt) Renew by January 2021 Page 6

Priority Treatment and Management Start treatment if required, and refer patients, where appropriate, to Ophthalmology following standard CCG referral pathway Non-acute Ophthalmic conditions, no immediate threat to vision

Condition Management

Non-acute condition Low vision aids For low vison aids refer to: [email protected]

Condition Signs and Symptoms suggestive of Condition Treatment and further Management  Reduce visual acuity Non-acute condition Cataract referral  Lens opacity Refer if cataract meets CWS CCG thresholds (Adults) The CWS CCG Cataract Surgery criteria are as follows: Cataract Surgery criteria:

First Eye Surgery Patients can only be referred where visual acuity as assessed by high-contrast testing (Snellen): o best corrected binocular visual acuity of less than 6/9 (6/10 or worse) for drivers OR o Best corrected binocular visual acuity of 6/12 or worse for non- drivers OR o Reduced to 6/18 or worse in one eye irrespective of the acuity of the other eye OR o The patient wishes to/is required to drive and does not meet Driving and Licensing Authority (DVLA) eyesight requirements OR o The cataract is preventing the management of other co-existing eye conditions

Second Eye Surgery Patients can only be referred for second eye surgery when their visual acuity meets the above criteria (as in first eye surgery) OR Difference in visual acuity between first and second eye is so significant that it is preventing driving Any suspicion of in children should be Requires appointment within Cataract referral referred urgently. 8 weeks thresholds (Children)

Revised January 2020 AIC Ophthalmology Group (Mr Haziq Chowdhury and Mr Khin Nyunt) Renew by January 2021 Page 7

Condition Signs and Symptoms suggestive of Condition Treatment and further Management  Can start with swollen painful eye lid that Non-acute condition Chalazion (Meibomian quickly settles into small smooth hard  Advise QDS heatpacks over cysts) lump on eyelid the area  Not normally painful unless rapid  Refer if meets CCG criteria growing, can cause blurred vision if presses on cornea.

This procedure is not routinely funded.

The CCG will fund excision of chalazion when ALL of the following criteria are met:  The chalazion has been present for more than 6 months;  And it is situated on the upper eyelid;  And it is causing blurring of vision; The CCG will fund removal where malignancy is suspected.  Foreign body sensation Non-acute condition Entropion/ ectropion  Irritation, red watery eye  Use ocular lubrication if  Blurring of vision uncomfortable  Corneal/epithelial disturbance  Consider referral if self-help  Localized hyperaemia, lid laxity measures not effective

Phone Ophthalmology department if evidence of corneal defect or associated  Reduction in visual fields Non-acute condition Glaucoma  Raised IOP>24 found by optometrist via Refer guidance Chronic Open Goldmann applanation tonometry Angle Glaucoma from NICE  Suspicious optic discs November 2017:  Narrow occludable angles  There is head damage on stereoscopic slit lamp biomicroscopy or

 There is a visual field defect consistent with glaucoma or

 IOP is 24 mmHg or more using Goldmann-type applanation tonometry.

Revised January 2020 AIC Ophthalmology Group (Mr Haziq Chowdhury and Mr Khin Nyunt) Renew by January 2021 Page 8

Condition Signs and Symptoms suggestive of Condition Treatment and further Management

 Painful lump on inner or outer eye lid Non-acute condition Hordeolum (Stye)  Watery eye GP to treat if not pre septal cellulitis. Reassurance given and warm compresses.  Important to differentiate between too lax Non-acute condition Isolated ptosis and eye lids and drooping eyelids Phone medical registrar on-call dermatochalasis  Exclude other causes for via switchboard if you suspect or symptoms e.g. Myasthenia, if patient has features of a Horners neurological ptosis. Worthing Hospital Switchboard The CCG will not routinely fund this procedure except Tel: 01903 205111 when certain criteria are met – Procedures to correct ptosis will only be funded in cases St Richards Hospital where:- Switchboard Tel: 01243 788122 Formal visual testing has demonstrated a visual field defect. The referral must be accompanied by documentary evidence of a visual field defect otherwise the referral will not be accepted.

 Blurred vision Non-acute condition Non acute blurred  Generalised persistent blur from vision (Not loss of should be vision) assessed by Optometrist in first instance  Poor vision Non-acute condition Paediatric  Squint – (Both eyes don’t look in same

direction)  Should be referred to Orthoptist first unless: sudden onset of squint or visual loss

 Wing shaped growth across cornea Non-acute condition Pterygium  Can present with slightly red eye and vision can be slightly blurred

Refer only when

 Proof of distortion of mires/irregular OR  Photography confirms progressive corneal growth (Should be seen by Optometrist in the first instance)

Revised January 2020 AIC Ophthalmology Group (Mr Haziq Chowdhury and Mr Khin Nyunt) Renew by January 2021 Page 9

Treatment and further Condition Signs and Symptoms suggestive of Condition Management  Watery gritty eyes Non-acute condition Watery and dry eyes  Poor tear film  Redness of eye Signpost to community pharmacy  Vision not normally affected Adhere to CWS formulary for Refer epiphora (comfortable watery eyes) choices; patients can purchase eye lubricants over the counter at  Treat lacrimation (irritable watery eyes) pharmacies. from blepharitis with lubricants and lid

hygiene http://www.coastalwestsussexformul  Dry eyes need lubrication. ary.nhs.uk/default.asp  For children <18 months year advise

parents to massage/stroke and .keep clean) Refer children at 18 months old

Revised January 2020 AIC Ophthalmology Group (Mr Haziq Chowdhury and Mr Khin Nyunt) Renew by January 2021 Page 10