PEARS Referral Guidelines – The Lens, Vitreous, Optic Disc and Retina

The ocular conditions listed in this guide are intended to reflect those that might be encountered in community practice. The document is not intended to be exhaustive. The suggestions for referral have been devised for guidance only. The document does not remove the practitioner’s professional responsibility to each patient, who should be dealt with on an individual case basis. If in doubt, seek advice or refer.

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Referrals (within 24 hours)
Telephone Acute Referral Centre (RSH)
01743 261476 / Referrals (within 48 hours)
Telephone Acute Referral Centre (RSH)
01743 261476 / Referrals
(over 48 hours)
Refer via patient’s GP
Condition / Notes / Referral Recommendation
Congenital Cataract / Usually diagnosed at birth or as an infant but if not permanent visual loss can occur. Degree of loss will depend on size and location. Refer urgently if a child under age 7 or under. / Urgent referral to Hospital Eye Service (HES) if child is age 7 or under.
Routine referral to HES for children over 7 years.
Optic Neuritis / Sudden loss of vision (partial or complete), or sudden blurred or “foggy” vision, and pain on movement of the affected eye. May lose some of their colour vision in the affected eye, with colours appearing subtly washed out. Frequently there is no abnormal appearance of the nerve head though it may be swollen in some patients. / Referral to ARC within 24 hours.
PVD Uncomplicated / Patient presents with recent new floaters in the absence of photopsia, anterior vitreous pigment cells or retinal breaks. / Refer to HES only if any concerns (one eye etc).
PVD Uncomplicated / Patient presents with sudden recent photopsia and floaters. No pigment cells in vitreous or retinal breaks evident. Also if patient has high risk factors such as high myopia, history of RD in other eye, trauma or patient has one eye. / Urgent referral toARC to be seen within 48 hours.
PVD Complicated / Patient presents with recent, sudden onset floaters or photopsia. Pigment cells in anterior vitreous or retinal break. / Referral toARC within 24 hours.
Swollen Optic Disc / Optic disc margin is blurred with hyperaemia with or without splinter haemorrhage(s). Initially the vision, colour vision and pupillary responses are normal, but the blind spot is increased on field testing. Chronic cases have greater field and vision loss. / Referral to ARC within 24 hours.
Vitreous Haemorrhage / Can give rise to profound vision loss if macula is obscured even by a small bleed. Causes include retinal detachment, proliferative DR, CRVO and trauma. / Referral to ARC within 24 hours.

PEARS Referral Guidelines – The Retina

Condition / Notes / Referral Recommendation
Central Serous Retinopathy / Unilateral round or oval macula detachment giving blurred vision and positive scotoma. VA improves with weak +ve lens. Typically affects young or middle aged males often Type A. Causes include stress, BP, steroid use. / Non-urgent referral to HES.
Cystoid Macula Oedema / Fluid accumulation in macular area that can be asymptomatic or have decreased VA, metamorphopsia and scotomas. Loss of foveal reflex and contour on high magnification. / Referral to ARC within 24 hours.
Macular Hole / Typically 6th/7th decade and more common in females. Can appear as either a severe impairment of central vision or as a relatively asymptomatic deterioration. / Non-urgent referral to HES.
Epirentinal Membrane / Membrane develops at the vitreo-retinal interface and appears as irregular macula light reflex or sheen. Best detected using RF light. Often mild metamorphosia with slightly reduced VA but can be asymptomatic. / Non urgent referral to HES.
Retinal Detachment / Risk factors include myopia, cataract surgery or laser, trauma, family history of detachment or detachment in other eye. / Referral to ARC within 24 hours.
Retinal Haemorrhages / If retinal vascular disease present such as non-proliferative diabetic retinopathy, CRVO or BRVO if flame shaped outside optic disc. / Referral to HES to be seen within 4 weeks.
If uncontrolled glaucoma or normal tension glaucoma present or especially if flame shaped and localised near the disc. / Referral to ARC within 48 hours.
If infection suspected, haemorrhages are white centred, papilloedema present or any intra-cranial disease is suspected. / Referral to ARC within 24 hours.
Retinal Artery Occlusion (Central) / Painless sudden and severe loss of vision in one eye. Might be associated with a history of Amaurosis fugax. Can be as a result of atherosclerosis but it may be related to Giant Cell Arteritis in elderly. In younger patients it is due to collagen vascular disease, vasculitis, coagulopathy or embolic disease. / Referral to ARC within 24 hours.
Retinal Artery Occlusion (Branch) / Sudden onset of loss of visual acuity or field of vision. May be preceded by shorter episodes from seconds to minutes. Opacification of inner retina in distribution of blocked branch retinal artery. Sometimes embolus might be visible. / Referral to ARC within 24 hours.
Retinal Vein Occlusion (Central) / Presents with marked visual loss. The fundus showing retinal haemorrhages, dilated tortuous retinal veins, cotton-wool spots, macular oedema and optic disc oedema. / Referral to ARC within 48 hours.
Retinal Vein Occlusion (Branch) / Presents with blurred vision, visual field loss, metamorphosia or floater. It commonly occurs in 6th to 8th decade with risk factors of age, hypertension, glaucoma, cardiovascular disease and diabetes. Lots of retinal haemorrhage, cotton wool spots, vessel tortuosity and retinal oedema. / Referral to ARC within 48 hours.
Toxoplasmosis / Toxoplasma gondii is a parasite hosted in cats and livestock. Mainly asymptomatic finding with floaters or decreased VA but vitritis and retinitis in severe phase may give fog appearance. Old atrophic scars with pigmented borders. / Non urgent referral to HES.
Acute phase or if lesions involve disc, macula, papillomacular bundle or threatening a major blood vessel.
Fog appearance or if immuno-compromised. / Referral to ARC within 24 hours.
Referral to ARC within 24 hours.

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