What to include in referrals for common ocular conditions

The key clinical details needed in referrals for common ocular conditions was the subject of a Main Stage lecture delivered by SpaMedica’s Christine Purslow on the Saturday of 100% Optical (1 March).

In the lecture, Purslow outlined SpaMedica’s perspective on the key details that should be included in referrals for cataracts, glaucoma, and wet age-related macular degeneration (AMD).

Purslow began by highlighting that, as of February 2025, there are 6.24 million people on the elective care waiting list in England, and that 10% of these are waiting for ophthalmology treatment.

Good referrals are key to tackling this, she said, adding: “By good, we mean accurate, sensitive, specific – all of those things, trying to make sure that our false positive rates are as little as they can be.”

Optometrists should “take every chance you get” to promote the message of self-care in terms of not smoking and good nutrition and hydration with patients, Purslow emphasised.

Purslow went on to ask the audience to consider the number of different pathways that they have for referrals into ophthalmology, emphasising that the number of options often make the process complex.

One common frustration in the hospital clinic is the way that forms are laid out, she said.

False positives in cataract referrals

“In the world of cataract, there are some patients who that don’t want surgery or don’t want it just yet, but they’ve been referred,” Purslow noted.

“Maybe they change their mind in the middle [of the process]. None of us can predict that, but it’s important to establish all that we can before we send that referral in, because of that 600,000-strong waiting list.”

She added that, “false positives are what it is all about,” and that attention to detail is the most important factor.

Often cataract referrals turn out to in fact be dry eye or corneal dystrophy cases, Purslow said.

She advised always using high magnification on the slit lamp in order to check which layer you are dealing with, and seeing if vision improves with eye drops before a cataract referral is made.

Cataract cases can vary in complexity, so risk stratification is key to efficiency for SpaMedica, Purslow shared.

One example of a case that would immediately find itself on the low volume, high risk surgery list is posterior polar cataract, she said.

Another is pseudoexfoliation, which can be subtle but more identifiable via dilation.

It is better to know about pseudoexfoliation as early as possible as it can pose a challenge for the surgeon, Purslow added.

She advised that community optometrists “share what you know about the patient, because you’d be surprised by which details are helpful.”

Share what you know about the patient, because you’d be surprised by which details are helpful

Refractive details such as axial length and corneal curvature can be used to predict intraocular lens power choice, Purslow said, adding that hospital optometrists will refer to previous prescriptions to sense check the accuracy of biometry.

History, including any laser treatment, squint, previous eye trauma or use of certain medications, should also be shared in the referral, she noted.

Other factors that can be useful in a cataract referral include details of any co-existing referrals, grading of the cataract, and any previous investigations for other forms of eye disease.

Purslow went on to speak about the ‘I’m fine’ conundrum – the phenomenon of patients telling practitioners that they are fine when they are not.

“Sometimes it takes a little bit of coaxing,” she said.

She added that patients have often heard both extremes when it comes to cataract surgery – instances when it has either gone extremely badly or very well – and that neither of these outcomes is completely realistic.

Patients can be prepared for a pre-operative assessment by being advised not to drive, being told that they can bring family or an unbiased interpreter, and being encouraged to read the information booklet, Purslow said.

She also advised practitioners to emphasise that a referral to be assessed is not a commitment to the surgery going ahead.

Common fears voiced by patients ahead of cataract surgery include wondering what will happen if they cough or if they cannot lay still, along with general anxiety.

Glaucoma and community optometry

In glaucoma referrals, “false positives are the name of the game,” Purslow said.

She noted that SpaMedica’s connection with community optometrists is strong, allowing for good communication back to practices after a referral into the hospital is made.

“You need feedback to change anything,” she noted.

Purslow revealed that there are 1.5 million NHS glaucoma appointments every year.

Meanwhile, NHS Digital data suggests that there are 160,000 new referrals for glaucoma made into the NHS every year, Purslow said. 

At SpaMedica, “letters back from our glaucoma services are definite and will be a priority, and we look forward to more interaction with the community optometrists to get that embedded,” she said.

Purslow shared a list of the tests needed before making a referral for glaucoma, according to NICE:

• Central visual field assessment
• Optic nerve assessment and stereoscopic fundus examination
• Optical coherence tomography (OCT) if available
• IOP measurement using applanation tonometry
• Peripheral anterior chamber configuration and depth assessments using gonioscopy, or, if not available or if the patient prefers, the Van Herick test.

Most community optometrists will be very aware of the risk factors for glaucoma, including age, family history, ethnicity, diabetes and hypertension, Purslow said.

However, optometrists should also include the patient’s refractive error in their referral, because patients often do not know it and do not bring their prescription to follow-up appointments.

Optometrists should also note whether a patient is or was myopic, Purslow said.

She noted that good glaucoma care comes from patient compliance and persistence.

Purslow also reminded attendees that there will be some overlap between patients with cataracts and those with glaucoma – in which case, minimally invasive glaucoma surgery might be suitable.

“Don’t miss the opportunity with these patients, because they could benefit in both ways,” she said.

Wet AMD considerations

Purslow noted that fast-track wet AMD referral pathways exist across the country, but while the paperwork might be the same, the routes are not.

Optometrists working in practices that straddle two different integrated care boards might be working across different pathways, she said.

When referring, optometrists should consider whether a patient is likely to be seen within 14 days, whether confirmation of receipt of the referral is guaranteed, and whether feedback is likely after the patient is seen, Purslow advised.

Optometrists can also empower their patients by giving them a copy of the referral, she said.

This article was edited on 11 March to clarify that 1.5 million NHS glaucoma appointments take place every year.