The most important point for optometrists to bear in mind is that nowadays, no one ophthalmologist can be a master of all things ophthalmological. Each ophthalmologist has his special field of interest. Sure, you get Jack-of-all-trades especially in the rural areas, but this is usually out of necessity from an undersupply of ophthalmologists in that area.

It behoves all optometrist to get to know the ophthalmologists in their area and what their fields of interest are. A simple phone call or e-mail is all it takes and this will be appreciated by the ophthalmologist. Of course, it will also give you extra exposure to the ophthalmologist, who may then refer patients to you too. Remember that patients are always asking ophthalmologists who the best optometrists in the area are and where they should go for their glasses or contact lenses.

It is obviously important to refer the patient to the correct specialist in order to save the patient the time and expense of being referred again by that specialist to another specialist. But there is another more important reason: the doctor may take on the case despite not being an expert in that area. This may have disastrous consequences for the patient.

Here are some examples of sub-specialities in ophthalmology:

Cataract and refractive: cataract surgery has a large refractive component, so these two sub-specialities are often combined.

Retina: Most retinal specialists are also vitreoretinal surgeons, but some are just medical retinal specialists, who do Avastin injections, laser treatment, etc. but do not operate.

Corneal specialists: these doctors treat keratoconus with cross-linking and do corneal surgery. They also treat corneal ulcers, scars, dystrophies, etc

Uveitis: a rare sub-speciality often combined with medical retina.

Oculoplastics: lid lesions, lid disorders, orbital issues, nasolacrimal duct issues (eg epiphora).

Paediatrics: children under age 16. Often combines with strabismology.

Glaucoma: all ophthalmologists treat glaucoma with drops, but many will refer to a glaucoma specialist for glaucoma surgery.

Ocular oncology: a rare sub-speciality that treats ocular tumours especially choroidal melanomas.

Ocular trauma: a rare sub-speciality too. Major trauma involving the posterior segment is handled by vitreoretinal surgeons.

Neuro-ophthalmology: also very rare in South Africa. Most of these cases are handled by neurologists or neuro-surgeons.

Another important point is that the optometrist should explain the pathology to the patient as fully as possible before referring. Do not be scared to use the word “cataract” or “pterygium” or “glaucoma” or “macular degeneration” to explain to the patient what these entities are. It helps both the patient and the ophthalmologist if the arriving patient already knows about their condition and what to expect. Obviously if the optometrist is not sure what the diagnosis is, then this falls away. But don’t be scared to say that you think they may have a cataract or macular degeneration or whatever, but are not sure and would like a specialist opinion. Every optometry practice should have a model eye that you can use to explain things to the patients.

When writing a referral letter, be as detailed as possible. I realise that a busy optometrist may not have time to do all the tests and to write a detailed letter, so this is not compulsory. But if you have done the tests, then include the results in the letter. The most important results are refraction with best corrected acuities but again I realise that a refraction takes time and will not always be done by a busy optometrist who is not going to prescribe glasses yet anyway. If you have done the IOP, include this in the letter too. Obviously the letter should state the reason for your referral. At the end of the letter you may want to ask that the patient please be sent back for spectacles and that a report would be appreciated if you want one. A busy ophthalmologist may not have time to write replies and reports for every case, but if a report is specifically requested then it will be (or should be) forthcoming.

Ophthalmologists are probably the only medical specialists that optometrists should refer to directly. All other specialists should be via the GP. For example, if you see what you think is a third nerve palsy or a swollen disc and you feel that the patient should see a neurologist, send the patient to the GP with a letter suggesting that neurological referral may be in order. Another example would be if you suspect that sinusitis may be the cause of a deep pain felt behind the eye, but the eye is white and quiet, you may want to write a letter to the GP suggesting a possible ENT referral.

Emergencies must obviously be handled by the optometrist with the diligence that they require. A letter may not be sufficient and you may want to phone the ophthalmologist directly to arrange the urgent consultation. If you cannot speak to the ophthalmologist himself (he may be busy operating), don’t hesitate to explain the whole story to his receptionist. Most receptionists are well trained in the handling of ophthalmic emergencies. They usually have been taught what a true emergency is and what can wait till the next day. They also know how to get hold of the ophthalmologist or the doctor-on-call. Also remember that the casualty department of a hospital is open 24 hours per day for all medical emergencies and the casualty doctors are usually well trained in handling ophthalmic emergencies of most types.

If you have any specific questions on this topic, you are welcome to e-mail me at clivenovis@mweb.co.za.