Rough guide to follow up of Eye Casualty patients

Aim:

To reduce unnecessary follow ups for patients attending A&E. Patients who need up to 1 follow up may be booked into Primary Care Follow Up Clinics which are held in out patients. Patients requiring more than one clinic visit may be referred for vetting by clearly documenting in the notes “Notes to consultant”. For corneal patients who require urgent follow up and require consultant opinion the notes should be clearly marked for Mr Aralikatti’s attention so he can decide further action.

CORNEA:

Blepharitis / Viral, Bacterial, Allergic Conjunctivitis:

The patients with above diagnosis do not need follow up arranged in eye casualty. Patients are asked to phone and book into primary care clinic only if symptoms are worsening or non resolving after 2 weeks.

Corneal Abrasion / Recurrent Corneal Erosions:

Prescribe Occ Chloramphenicol qds for 1 week then Occ Lacrilube bd long term if recurrent erosions. No follow up is required in eye casualty.

Bacterial Keratitis:

Perform corneal scrapes / send contact lenses for microbiology unless there is a good reason no to do so. Patients need intensive hourly eye drops such as G. Ofloxacin. Most of these patients need admission but smaller ulcers may need to be followed up in A&E. Patients requiring senior opinion may be referred for Mr Aralikatti’s opinion after starting treatment.

Herpes Simplex Keratitis:

Patients with epithelial keratitis (Dendritic ulcer) may be prescribed Occ Acyclovir 3 % 5 times a day and mostly do not require PCFU. Patients with disciform keratitis need clinic follow up and notes should be sent to consultant for clinic follow up. Please start the patient on topical steroids and Occ Acyclovir and advise slow tapering of steroids. If the IOP is raised patient will need one follow up in Primary Care Clinic before referral to consultant clinic.

Herpes Zoster Ophthalmicus:

Patients with no ocular complications may be discharged. Patients with complications such as posterior uveitis, secondary glaucoma and cranial nerve palsy need to be seen in consultant clinic. Patient with anterior uveitis may be followed up in PCFU.

GLAUCOMA:

Acute Glaucoma:

These patients need emergency management as per protocol and admission. Refer to suidelines for this. It is good practice to involve glaucoma team at an early stage. Do not arrange follow up in eye casualty after emergency treatment.

Raised IOP (any aetiology):

Patients present with intraocular pressures ≥ 40mmHg are at a high risk of losing their eyesight. These patients should be managed in A&E immediately to bring their IOPs down. If the patient needs to be admitted then you should contact / consult with 4th on call and / or on-call Consultant.

Monday to Friday 9 am – 9 pm there is an on call glaucoma fellow who will be happy to take your call and give advice. If required, the glaucoma fellow will organise for the patient to be seen by the Glaucoma team either the following day or later. Patients should not be discharged without proper management plan and handover.

Rubeosis / Neovascular Glaucoma:

Long standing established patients do not require any urgent laser or Avastin.

Acute cases require emergency laser photocoagulation during casualty visit if cornea permits. Patient should be discussed with a medical retina consultant so that intravitreal Avastin can be requested urgently from DTC as a non formulary drug. Start topical steroids / cycloplegics / antiglaucoma medication if eye inflamed. Follow up will be arranged in medical retina clinic.

MEDICAL RETINA:

CRVO / BRVO / CSR:

Refer to consultant clinic. No follow up in A&E or Primary care clinic.

CRAO:

Start on Aspirin if no contraindications and refer to TIA clinic. Control risk factors such as hypertension and advise to quit smoking. Refer to medical retina clinic by ticking notes to Consultant.

Proliferative Diabetic Retinopathy:

If possible first session of Argon laser panretinal photocoagulation should be performed during visit to eye casualty. Notes should be sent to medical retina clinic urgently for further laser and follow up.

Wet AMD:

Refer to FAST TRACK MACULAR CLINIC at BMEC urgently.

NEURO-OPHTHALMOLOGY:

Optic Neuritis:

Typical optic neuritis patients (age 20 to 40, acute unilateral visual loss with painful eye movements, reduced colour vision, RAPD, no proptosis) need reassurance and need follow up in general clinic in a few weeks time (Notes to consultant). Atypical optic neuritis patients need to be discussed with senior doctor and if available please get neuro-ophthalmology opinion. Do not arrange follow up in A&E.

3rd Cranial Nerve Palsy:

This may be a medical emergency. Patients with painful (headaches), pupil involvement, partial or evolving 3rd nerve paresis need urgent referral to RMO for admission and neuro imaging. Please discuss with neuro-ophthalmology team if unsure. Ischaemic 3rd nerve palsy needs referral to clinic.

4th Nerve Palsy:

Please arrange orthoptic assessment and follow up in clinic.

6th Nerve Palsy:

If ischaemic palsy (microvascular risk factors such as hypertension, diabetes in an older patient) needs orthoptic and routine clinic review. If in a younger patient or any other cranial nerve involved needs referral to medics. Please discuss with neuro-ophthalmology team if unsure.

OCULOPLASTY:

Lid Abscess or Lacrimal Abscess:

Incision and drainage in eye casualty procedures room if pointing. Oral antibiotics may be prescribed and follow up arranged in a week in PCFU.

Preseptal Cellulitis:

Prescribe a course of oral antibiotics and possible review in 5 to 7 days depending on severity. Orbital cellulitis needs admission for IV antibiotics and investigations.

UVEITIS:

Recurrent anterior uveitis:

It is important to ensure the fundus has been checked and there are no sight threatening complications such as posterior segment inflammation, raised eye pressure and macular oedema. Patients with recurrent anterior uveitis without complications should be prescribed intensive topical steroids such as G. Dexametahsone or G Predforte 1 % and Cycloplentolate 1%. Patients should be given instructions to taper the steroids gradually. One follow up may be arranged in PCFU in 2-3 weeks time.

VR:

Epiretinal Membrane / Macular Holes:

GP to refer to consultant clinic. No follow up in A&E or PCFU.

Argon Laser Retinopexy for Retinal Breaks:

These patients need follow up in nearest outpatient clinic. If patient has vitreous haemorrhage with poor visibility of fundus, multiple breaks, small amount of subretinal fluid or other complicating factors please refer for vitreo-retinal follow up.

Retinal Detachment:

All patients to be discussed with VR team (fellow / Co-ordinator / consultant) and their advice followed. Do not accept referrals from outside Birmingham without discussing with VR team, or give patients a specific timeframe for their surgery.

Vitreous haemorrhage:

If vitreous haemorrhage is dense with poor fundal view please arrange urgent ultrasound in visual function to ensure retina is flat. Diabetic vitreous haemorrhages may need laser and intravitreal Avastin and should be referred urgently to the appropriate medical retina consultant. Vitreous haemorrhage due to posterior vitreous detachment needs ultrasound and vitreoretinal clinic appointment soon. Patients with retinal tear or detachment with poor view should be referred for urgent VR opinion.