Have you ever had a patient in your chair and wondered to yourself: Should I refer this patient or manage him/her myself? I have. And I’d be willing to bet just about every other OD out there has, too.
Some presentations are obvious, but many times, doctors are on the fence concerning a referral. Far too often, those patients could have been successfully managed by their primary eye care provider but were referred instead. Because of this commonality, we at NGO wanted to bring new grads a reference to help with that difficult decision. Here, I’ll review six conditions for which I see this dilemma frequently arise among colleagues.
1. Macular hole
The key to knowing when to refer a macular hole to a retinal specialist vs when to manage lies in knowing which stage of hole you are dealing with. Remember that a stage 1 hole (1a or 1b) has not yet developed a break in the inner layers of the fovea. The fovea may appear yellow on DFE, but no characteristic red spot will be evident. Stage 2 holes will demonstrate a retinal break, but typically do not appear to have an operculum. Stage 3 and 4 holes are full thickness, with the main difference being whether or not the vitreous has detached. If detachment has occurred, the hole is stage 4. This image from 2007’s Review of Ophthalmology article “Revisiting Macular Holes” is a great example of the OCT presentation of the 4 different stages (in order A-D) followed by an image post-surgical repair (E):
When to manage: Stage 1 holes are typically not considered to be at surgical level. Therefore, management through patient education regarding the importance of reporting vision changes and monitoring with regular dilated fundus exams is an appropriate course of action. Many of these holes spontaneously resolve on their own. Here’s another great example of an early stage 1 hole:
When to refer: Once a true retinal break is apparent (stage 2-4), the patient should be referred for surgical treatment. Repair is successful in most patients, and the earlier the treatment, the better the prognosis for the patient.
Inflammation that affects the anterior, intermediate, and posterior segments of our patients can be daunting. However, with diligence, these patients can be managed with full success.
When to manage: Patients who present with panuveitis should be put on oral steroid treatment (often in conjunction with topical steroid therapy) and monitored closely. Typically, improvement is seen within a few days of beginning treatment, and full resolution is often achieved over a period of weeks.
This is one example of a patient who presented with bilateral panuveitis and reached full resolution, including 20/20 vision OD and OS, after treatment with a combination of oral and topical steroids:
When to refer: If your patient’s condition is unresponsive to treatment, you will need to refer for a probable steroid injection. Other patients to consider referring include those with whom you expect compliance issues and those who have developed macular edema that is not improving with oral therapy.
Note: a lab work-up is justified in these patients in order to pinpoint possible underlying systemic etiologies (for tips on ordering labs, check out this article); referral to a specialist to manage any underlying conditions may also be necessary.
**These guidelines can also be applied to patients with bilateral granulomatous uveitis**
3. Corneal ulcers
These lovely infections also have a tendency to make us docs squirm slightly in our chair. We all know the horror stories about penetrating ulcers, and the last thing we want is for that story to be about our patient. Luckily, in the majority of cases, ODs are absolutely able to manage these bugs.
When to manage: Almost all ulcers should be given an attempt at management since the topical antibiotics available are very effective. Keep these tips in mind when treating ulcers:
- Dosing is frequently needed every 1-2 hours at first, especially when dealing with large, central, multiple, or concerning ulcers.
- Consider waiting a few days to a week before adding a topical steroid so as to avoid slowing the healing process of the epithelial defect.
- If cost is an issue, consider using Polytrim – it has been shown to be as effective as some of our most recent antibiotics.
- Don’t be afraid to culture the ulcer and work with your local pharmacies to RX fortified antibiotics if needed. Just remember, cultures are most successful prior to beginning treatment.
When to refer: Ulcers that are not responding to treatment should be referred to a corneal specialist who can intervene surgically if the case were to progress to that level. Other times that a referral should be considered are when you question your patient’s compliance and when the stromal thickness at the ulcer site is significantly thinned, as this can be a sign of impending perforation. Be sure to note the thickness of the stroma in the affected area vs. the rest of the cornea to evaluate the likelihood of this complication.
4. Severe corneal abrasions or chemical burns
While extremely painful, these conditions do tend to heal quite nicely with proper treatment. Remember to neutralize the pH of the eye through sterile saline irrigation if a chemical burn has occurred.
When to manage: Like ulcers, almost all of these cases can be successfully treated by ODs. Utilization of bandage CLs, pressure patching, and atropine are helpful to manage the associated pain, and it may be necessary to prescribe a controlled oral pain medication if allowed in your state. These patients should be monitored daily until significant improvement can be appreciated, and delaying the addition of a topical steroid by a few days can give the epithelium a better opportunity to begin quickly healing. Steroids should not be avoided completely, however, as they help with patient comfort and reduce the chances of scarring after resolution. Expect sloughing off of the injured epithelium during the first couple of days of therapy, particularly if a bandage lens or pressure patch was used. Don’t worry, the cornea will recover. Artificial tears can provide extra comfort for these patients.
When to refer: If the stroma has been affected to a level that you are concerned about significant scarring, a corneal referral would be warranted. Like other conditions, poor response to therapy and patient compliance also serve as extremely justifiable reasons for a referral for these cases.
5. Angle closure
As one of the few acute ocular conditions that must be managed as soon as possible, angle closure can make many doctors, especially new grads, nervous. Management can be successfully achieved in almost every case if the doctor and staff are willing to be persistent (which can be a challenge as some presentations can be very stubborn to break). Just remember to avoid using prostaglandins in your cocktail of drops used.
When to manage: If the patient is in your office or has called with convincing symptoms of angle closure, it is important to act as soon as possible. If drops and/or Diamox is on hand, all ODs should attempt to lower IOP before allowing the patient to leave your office. It is very helpful to keep a few 250mg tablets of Diamox accessible in case they’re needed (you can start with a 250mg or 500mg dose, though Diamox can cause significant nausea, so I’d recommend using as small of a dose as possible). Make sure your Diamox is not extended release so that it will act faster, and avoid using a topical prostaglandin to lower the pressure in office. Once IOP is controlled, a same day or next day PI is warranted to prevent further attacks.
When to refer: Significant improvement in IOP can take over an hour, but in some cases, the pressure is not affected by topical or oral therapy even after this amount of time. These patients should be referred to an office who can do a same day PI. In cases where the IOP is successfully lowered with therapy in office, it is best to refer to have a PI performed within a day or two of the closure event to prevent recurrence.
6. Cystoid Macular Edema
Whether resulting from past intraocular surgery, poor compliance with steroid taper, or other underlying issues, CME can range from extremely subtle to marked and somewhat startling (especially when viewed through OCT). Regardless of initial severity, most patients are responsive to topical treatment.
When to manage: Presentation of CME should first be managed through topical therapy in most cases. NSAIDs, such as Prolensa or Ilevro, and steroids, such as branded Pred Forte or Durezol, should be utilized either alone or in conjunction to reduce the edema. Often, improvement is seen within one month, though full resolution may take longer. If the CME is significant, I recommend a combination of topical NSAID and steroid treatment.
When to refer: As with previous conditions discussed, CME in patients who have a history of poor compliance with therapy warrants a referral. These patients may do best with an injection from the start so that compliance is not a factor. Outside of these cases, CME that does not respond to treatment over a period of 2-3 months should be referred, particularly when vision is 20/40 or worse.
*Below is an example of an OCT from a patient who developed CME after discontinuing a high dose of Durezol without following his instructed taper schedule. This patient could have been managed with topical therapy with expectation of success, but his poor compliance prompted a referral to a retinal specialist.
As with all clinical matters, the ultimate decision concerning management is up to the individual doctor. Trust your gut and do what makes you most comfortable, but sometimes it is helpful to remember…
Why refer if the physician you are referring to would manage the patient in the same manner that you could?
Feel free to comment below with other cases about which you or another OD have had to make this challenging choice.