The College of Optometrists

Urgency of referrals

This list is intended to be guidance about which conditions require emergency or urgent referral. Familiarise yourself with and follow relevant local protocols for referral. If a patient presents with a condition requiring an emergency referral you may wish to seek advice from the on-call ophthalmologist. This list is not exhaustive. You should use your professional judgement and look at the College’s clinical management guidelines for further information.
  1. emergency referral (within 24 hours), symptoms or signs suggesting:
    • acute glaucoma
    • acute dacryocystitis in children, or in adults if severe
    • cellulitis (preseptal or orbital)
    • corneal foreign body penetrated into stroma, or with presence of a rust ring (unless optometrist is specifically trained in rust ring removal)
    • CRAO<12 hours old
    • endophthalmitis
    • facial palsy, if new or with loss of corneal sensation
    • herpes zoster ophthalmicus with acute skin lesions (emergency referral to GP for systemic anti-viral treatment with urgent referral to ophthalmology if deeper cornea involved)
    • hyphaema
    • hypopyon
    • IOP Greater than and equal to symbol 40mmHg (independent of cause)
    • microbial keratitis
    • orbital cellulitis
    • papilloedema
    • penetrating injuries
    • pre-retinal haemorrhage, although a pre-retinal haemorrhage in a diabetic patient with known proliferative retinopathy who is already being actively treated in the HES would not need an emergency referral
    • retinal detachment unless this is long-standing and asymptomatic
    • scleritis
    • sudden severe ocular pain
    • suspected temporal arteritis
    • symptomatic retinal breaks and tears
    • third nerve palsy with pain
    • trauma (blunt or chemical), if severe
    • unexplained sudden loss of vision
    • uveitis
    • vitreous detachment symptoms with pigment in the vitreous, or
    • viral conjunctivitis if severe (e.g. presence of pseudomembrane)
  2. urgent referral (within one week. We recognise that in some areas there may not be an appropriate pathway for patients to be seen within a week. You should familiarise yourself with local referral pathways to ensure the patient is seen within an appropriate timescale), symptoms or signs suggesting:
    • acute dacryoadenitis
    • acute dacryocystitis if mild
    • atopic keratoconjunctivitis with corneal epithelial macro-erosion or plaque
    • unilateral blepharitis if carcinoma suspected
    • chlamydial conjunctivitis (refer to GP)
    • CMV and candida retinitis
    • commotio retinae
    • corneal hydrops if vascularisation present
    • CRVO with elevated IOP (<40mmHg. If Greater than and equal to symbol 40mmHg refer as emergency)
    • herpes zoster ophthalmicus with deeper corneal involvement – urgent referral to ophthalmology, but refer to GP as an emergency for systemic anti-viral treatment
    • IOP>35 mm Hg (and <40mmHg) with visual field loss
    • keratoconjunctivitis sicca if Stevens-Johnson syndrome or ocular cicatricial pemphigoid are suspected
    • retinal detachment if not an emergency, see above
    • retrobulbar/optic neuritis
    • ocular rosacea with severe keratitis
    • rubeosis
    • squamous cell carcinoma
    • steroid induced glaucoma
    • sudden onset diplopia
    • vernal keratoconjunctivitis with active limbal or corneal involvement, or
    • ‘wet’ macular degeneration/choroidal neovascular membrane, according to local fast-track protocol.

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