Seven ways to improve cataract referrals

How optometrists can improve their referrals into eye hospitals was the subject of a SpaMedica session at 100% Optical 2024.

The session, hosted by Christine Purslow, SpaMedica’s clinical director of outpatients, outlined a number of ways that optometrists can make their referrals from primary to secondary care smoother.

1 Reassuring anxious patients

Purslow began by explaining that patients are often anxious when they learn that they are being referred to hospital.

Including details of a patient’s anxiety on the referral means the referring optometrist and the hospital team can work together to ease patients’ nerves, Purslow said.

“Some of you will come across anxious patients,” she said, adding: “When they come for their pre-assessment, the time with the nurse is really important.”

At SpaMedica, this time will involve ascertaining whether the patient can lay down comfortably or if they need extra emotional support, Purslow explained.

She noted that SpaMedica hospitals include mocked-up theatres, so patients can be led through the process and even lay down on a theatre bed before they go in for their surgery, if this helps to ease their nerves.

This can be particularly beneficial for patients with learning disabilities, Purslow said.

“There are some people that are genuinely fearful of that situation,” she added. “Where we know that a patient might be fearful, don’t be afraid to put that on the referral.”

2 Acknowledge social circumstances

Social circumstances, including whether a patient is living alone, are important, Purslow said.

She noted that a patient’s individual circumstances might mean they are more reluctant to undergo surgery.

The pros and cons of both having and not having surgery should be discussed and key points noted in the referral, Purslow advised.

Their status when it comes to driving should also be discussed and included in the referral.

3 History of refraction

Optometrists should consider the patient’s previous refraction and include this in the referral, Purslow said.

“If you know the previous refraction, that’s really helpful,” she said.

Including details of the previous refraction allows the hospital optometrist to see whether there has been, for example, any myopic shift, she explained.

4 Cataract versus visual acuity

Purslow advised optometrists to consider whether the degree of cataract matches the visual acuity.

The type of cataract – nuclear, posterior sub-capsular or cortical – can be relevant to the symptoms and the visual acuity, she explained.

She also noted that, whilst dilation is always desirable before a referral is made, it can be especially useful here.

An optical coherence tomography scan is also desirable, Purslow said, noting that patients with cataracts might have similar risk factors for other eye pathology.

“One of the most important things is weighing up whether the degree of cataract that you see when you’re referring the patient explains the visual, because if it doesn’t it might be something else,” she said. “Depending on your practice and your time, that's where correlation before the referral is desirable.”

5 Personal circumstances

Optometrists should include information on patients’ personal circumstances, such as their level of mobility or whether they have Parkinson’s disease, Purslow said.

Other factors to consider include whether they have a head tremor, a learning disability, dementia, or a back condition.

Including such information in the referral will give the hospital optometrist the chance to assess any safety concerns that should be noted ahead of surgery or treatment, she noted.

“Just because someone has a learning disability or they have dementia or Alzheimer’s doesn’t mean they shouldn’t or couldn’t have cataract surgery under local anaesthetic,” Purslow said.

“It really is a case-by-case basis. So, we always take time in our clinics to work with that patient to judge whether they have the capacity to consent and whether it will be safe. That’s really what it's about.”

She added: “That’s a personal choice for them.”

6 Ocular features

Other ocular features should be included in referrals, Purslow said, adding that a patient having certain features present can increase the risk of complications after surgery.

These features might include:

• Nystagmus
• Dry eyes
• Short axial length
• Shallow anterior chamber
• Corneal endothelial dystrophy
• Floppy iris syndrome
• Traumatic cataract
• Pseudoexfoliation sydrome (PXF)
• Brunescent cataract.

She noted that including this wider context means that the surgeon can include certain tools on their trolley during surgery, allowing them to be more prepared.

PXF, for example, can make the zonules unpredictable for the surgeon, Purslow said.

However, if “the surgeon is prepared for that fact they will use special devices within the procedure.”

Speaking about PXF, Purslow added: “When you refer patients, you might be thinking, ‘well, I hardly ever see that,’ or, ‘I’ve never seen it.’ That’s fine, because it really shows up better when patients are dilated, and that might be why. Actually, it is quite prevalent.”

7 Diabetic status

If a patient is diabetic they are likely to have an increased risk of infection, Purslow said.

She added that being diabetic comes with a greater risk of cystoid macular oedema (CMO), and that a diabetic patient’s post-operative medication will be different to that prescribed to a patient without diabetes – they are more likely to be prescribed extra anti-inflammatory medication, for example.

“The greater risk of CMO is something that is well known about people with diabetes, and because of that, after cataract surgery, patients with diabetes are usually given extra anti-inflammatory medication," Purslow explained.

She added that simply explaining to patients with diabetes that they might take longer to heal from the surgery than those without the condition can also be helpful, and that is all that really needs to be said: “We don’t want to alarm them.”

What really helps with referrals

Purslow explained that information included on a referral falls into one of two categories: ‘essential,’ or ‘desirable.’

Essential information includes:

• Symptoms
• Type of cataract
• Best-corrected visual acuity and current refraction
• Previous refraction, if myopic shift has occurred
• Intraocular pressure and optic disk description
• Amblyopia
• Any other pathology.

Desirable information includes:

• Pinhole vision
• If visual fields are known to be normal
• If macula are known to be normal
• Social circumstances that might be relevant
• Grade of cataract
• Driving status.