1. Mr. Kim Son Lett Consultant Ophthalmologist & Vitreo-Retinal Surgeon
Birmingham & Midland Eye Centre & BMI The Priory

2. Pre-Triage System
Red Need to be seen within a few hrs, further triaging.
Amber Need to be seen within 72 hrs, diverted to UCC slots.
Green No need for urgent assessment, referred to GP, optometrist or to OPD (via GP).

3. Red – Very Urgent Penetrating eye injury Acute post-op endophthalmitis
Severe chemical injury
Orbital cellulitis
GCA with visual symptoms
Sudden loss of vision <6hrs

4. Red - Urgent Painful red eye with visual loss
Retinal detachment with good VA
Corneal ulcer, esp. with CL wear
Blunt trauma with hyphaema & ↑ IOP
Corneal graft rejection
Painful diplopia

5. Amber Flashes & floaters, no loss of vision
Red eye without pain or visual loss
Retinal vein occlusions (OPD 4-6/52)
Diabetic retinopathy with vitreous haemorrhage
Wet AMD (preferably refer to Fast Track Macular Clinic)

6. Green – GP / Optometrist Mx
Bacterial & viral conjunctivitis
Allergic conjunctivitis
Blepharitis
Dry eyes
Lid lumps and bumps

7. Green – OPD Referral Cataract Chronic / gradual visual loss (months)
Open angle glaucoma, ocular hypertension
Watery eyes
Ectropion, entropion
Lid lumps & bumps
Non-acute diplopia

8. Trauma Burns Abrasions & lacerations Foreign bodies Blunt trauma
Acid, alkali, thermal, arc eye
Abrasions & lacerations
Lid, corneal and conjunctival, Penetrating Eye Injuries
Foreign bodies
Corneal, conjunctival, sub-tarsal, intra-ocular
Blunt trauma
Sub-conjunctival haemorrhage, hyphaema, choroidal rupture
Orbital Blowout Fracture, Traumatic Optic Neuropathy

9. Chemical Injury Emergency Alkali or Acid pH check Immediate irrigation
May result in limbal stem cell failure

10. Corneal Abrasion History provides diagnosis & indication of severity
Mostly doesn’t require A & E
Oc. Chloramphenicol qid 5/7

11. Foreign Bodies Can be removed if confident g. Chlor qid 5/7
Refer (PEARS?) if unable to remove or rust rings
Always check for subtarsal FB as well

12. Sub-conjunctival Haemorrhage
Spontaneous vs traumatic
Self limiting
No treatment
No referral required

13. Blow Out Fracture Assess for globe damage, Traumatic Optic Neuropathy
Orbital surgery only if tissue entrapment
Normally performed within 4/52

14. Cornea Dry eye Recurrent erosion syndrome Ulcers Shingles CL related
Acanthamoeba
Dendritic
Shingles

15. Dry Eyes Lubricants Look for blepharitis
Refer OPD only if unable to improve symptoms

16. Recurrent Corneal Erosion
H/O Index injury
Typically pain on waking / opening eyes
Oc. Simple / Lacrilube nocte 3/12
Refer OPD if no improvement

17. Bacterial Keratitis Esp in CL wearers Excess wear, poor hygiene
Urgent referral
Differentiate from marginal keratitis

18. Dendritic Ulcer Typically HSV 1, as with cold sores Self limiting
Treat with topical Acyclovir / Valgancyclovir 5x/d, 7/7
UCC referral

19. Herpes Zoster Ophthalmicus
Oral antiviral Rx if started within 72hrs onset of rash
Not always eye involvement
Hutchinson’s sign
70% chance eye involvement
Most eye involvement doesn’t require specialist Rx

20. Conjunctiva Conjunctivitis Episcleritis Scleritis
Bacterial, viral, allergic
Episcleritis
Scleritis

21. Bacterial Conjunctivitis
Purulent / mucopurulent discharge
Self limiting
OTC g. Chlor qid 1/52
No referral required

22. Viral Conjunctivitis Watery discharge Follicular reaction
Self limiting
No referral required unless corneal involvement

23. Allergic Conjunctivitis
Identification and avoidance of trigger allergen
Topical Sodium cromoglycate
Oral anti-histamines
No referral required unless persistent problem

24. Episcleritis Self limiting Mild – Moderate discomfort
Oral NSAIDs, eg ibuprofen
No referral required unless persistence
Steroid dependency

25. Scleritis Severe dull boring pain Brawny red appearance
Strong association with auto-immune and connective tissue disease
Urgent referral
Needs extensive management

26. Lids Blepharitis Chalazion, stye Ectropion, entropion
Anterior, posterior
Chalazion, stye
Ectropion, entropion
Pre-septal cellulitis

27. Anterior & Posterior Blepharitis
Lid hygiene
Hot compresses
Treat associated dry eye
No referral required

28. Chalazion Hot compresses I&C if refractory
Prescribe oral Abx if infected
No referral to A & E

29. Senile Ectropion & Entropion
Ensure lubrication of ocular surface
No acute management in A & E
Refer routinely

30. Pre-Septal Cellulitis
Need to differentiate with orbital cellulitis
Pt not systemically unwell
No orbital signs
Needs oral Abx (GP)
Refer if in doubt

31. Orbital Cellulitis Potentially sight / life threatening condition
Pt systemically unwell, pyrexial
Orbital signs
Emergency referral
Need admission and IV ABx

32. Neuro-ophthalmology IIIrd, IVth, VIth nerve palsies Optic neuritis
Papilloedema
Giant cell arteritis

33. 3rd, 4th, 6th Palsy
Majority will be microvascular in elderly diabetic hypertensive population
Consider duration
Beware of painful nerve palsy esp 3rd PCA aneurysm
Beware of assoc headache esp 6th GCA

34. Disc Swelling Physiological Hypermetropes Optic cup SVP Vessel changes
Exudates
Haemorrhages
Hyperaemia
Retinal folds
VISUAL SYMPTOMS?

35. Optic Neuritis Mostly due to demyelination Unilateral vs bilateral
Child vs adult
2/52 ↓, 2/52 ↔, 2/52 ↑
Reduced vision, colour vision, RAPD
Uhtoff’s phenomenon
Pain esp ocular movement
Haemorrhages
Hyperaemia
Venous distension
Swelling
Or no physical signs

36. Papilloedema Due to raised ICP Bilateral Reduced vision Obscurations
Blind spot enlargement
Haems
Hyperaemia
Tortuous congested vessels
Exudates
Cup obliteration
Retinal folds

37. Giant Cell Arteritis Temporal headache and tenderness Blurred vision
Jaw claudication
Polymyalgia
Associated with RAOs
Emergency referral to Eye Cas ONLY if visual symptoms eg. Amaurosis
Otherwise refer urgently to Rheumatology / Physicians

38. Glaucoma Open vs Closed angle 1̊ vs 2̊ Neovascular What IOP is urgent?
<30mmHg refer to outpatients
>30mmHg D/W on call team

39. Acute Angle Closure Glaucoma
Typically presents midday onwards
Fixed, semi-dilated pupil
High pressure, corneal oedema
Closed angle – may need to examine fellow eye
Emergency referral
Needs medical treatment then laser iridotomy
More extensive surgery may be necessary

40. Vitreo & Medical Retina
Posterior Vitreous Detachment
Vitreous haemorrhage
Retinal tears and holes
Retinal detachment
Wet AMD
Vascular occlusions
Proliferative diabetic retinopathy

41. Posterior Vitreous Detachment
Only 30-50% PVD symptomatic
Symptomatic PVD refer to UCC, depending on duration
Most are not associated with retinal detachment

42. Vitreous Haemorrhage
Check for systemic associations eg. DM, HT, Sickle
Examine fellow eye
If present, UCC referral (duration dependent)
In absence of systemic disease, PVD with VH has 70% incidence of retinal tear
Urgent referral to Eye Cas

43. Retinal Detachment Is the macula on or off? VA Clinical exam
If on, emergency referral
If off, Eye Cas, UCC or clinic depending on duration
Check for symptoms of chronicity
Not all detachments are an emergency!

44. Wet Macular Degeneration
Sudden onset reduction of vision, distortion
H/O dry AMD
Optician can diagnose
Fast track macular service

45. Venous Occlusions No emergency treatment available
Refer via fast track system
Need long term treatment

46. Arterial Occlusions Irreversible retinal damage from 4hrs of onset
Immediate emergency treatment up to 8hrs from onset
Aspirin
ocular massage
rebreathing into bag
Beyond this time no heroic measures
Check for GCA symptoms
Stroke/TIA pathway

47. Proliferative Retinopathy
Most commonly diabetics
Also Sickle, prior RVOs and rarely RAOs
Refer to UCC unless also VH

48. The Future 6-9% annual increase in demand
<30% of attenders are genuine 4hr cases
PEARS / MECS
Rapid access clinics
Allied professionals in house
Nurses
Optometrists
Orthoptists
GP surgeries open all hours!