Accident & Emergency/ General Ophthalmology/ Primary Care/ Urgent Care Clinic Protocol for Optometrists

Size: px

Start display at page:

Download "Accident & Emergency/ General Ophthalmology/ Primary Care/ Urgent Care Clinic Protocol for Optometrists"

Damian O’Brien’
5 years ago
Views:

1 Accident & Emergency/ General Ophthalmology/ Primary Care/ Urgent Care Clinic Protocol for Optometrists Protocol Summary Protocol for optometrists working in the Accident & Emergency, General Ophthalmology (Primary Care) and Urgent Care clinic Version: 4.0 Status: FINAL Approved: 5 th September 2017 Ratified: 5 th September 2017

2 Version History Version Date Issued Brief Summary of Change Author /03/2008 First version Scott Hau /03/2012 Second version Scott Hau, Seema Verma /11/2012 Third version Scott Hau /07/2017 New version - incorporating optometrists working in General Ophthalmology/PCC/UCC Scott Hau, Seema Verma For more information on the status of this document, please contact: Protocol Author Protocol Owner Department Scott Hau Scott.hau@Moorfields.nhs.uk Scott Hau, Senior Optometrist Dan Ehrlich, Head of Optometry Optometry and A&E Service Date of issue 5 th September 2017 Review due date 5 th September 2019 Approved by Optometry and A&E Service Ratified by CAEC Intended audience Staff in Optometry and A&E Service 2

3 1. Scope 1.1 This protocol applies to optometrists working in the Accident & Emergency (A&E), General Ophthalmology- Primary Care Clinic (PCC) and Urgent Care Clinic (UCC) at Moorfields Eye Hospital NHS Foundation Trust. 2. Purpose 2.1 The purpose of this protocol is to set out the steps that optometrists need to take when seeing patients in the A&E, PCC and UCC. 3. Training Three years of extended role experience - Conversant with the clinical skills and techniques required to assess the anterior and posterior segment - Undergo a minimum training period of 15 sessions during which all patients seen by the optometrist will also be seen by the supervising consultant. - The total number of sessions needed to train an optometrist up to a satisfactory level of competency is down to the discretion of the consultant. The consultant then signs off the optometrist once a satisfactory competency level has been attained (appendix 1) - After the training, the optometrist will be able to treat and manage patients independently for a range of conditions listed in the protocol (Table 1) - Ideally, optometrists working in A&E/PCC/UCC should be qualified to prescribe medications - Independent Prescribers (IP). For those who are not IP trained, there is an additional list of conditions for which they can treat and manage independently (Table 1) 4. Stakeholder Engagement and Communication 4.1 A&E Service, Optometry department 5. Approval and Ratification 5.1 Approved by the A&E/PCC Service and Optometry department. 6. Dissemination and Implementation 6.1 The protocol will be placed on the Trust Intranet 7. Review and Revision Arrangements 7.1 This protocol will be reviewed every 2 years. The next review date is September Document Control and Archiving 8.1 The current and approved version of this document can be found on the Trust s intranet site. Should this not be the case, please contact the Head of Clinical Governance 8.2 Previously approved versions of this protocol will be removed from the intranet by the Head of Clinical Governance and archived on the corporate governance shared drive. Any requests for retrieval of archived documents must be directed to the Clinical Audit Department (clinical.audit@moorfields.nhs.uk). 3

4 9. Monitoring compliance with this Policy Monitoring method Monitoring frequency Monitoring lead Rolling audit Annual A&E / optometry lead Monitoring reported to Clinical Governance Half Day 10. Supporting References / Evidence Base Moorfields Eye Hospital (MEH) Glaucoma protocol for optometrists 2015 MEH Medical Retina protocol for optometrists MEH St Ann s DTC cataract protocol for optometrists Consultation with A&E consultants MEH Non Medical Prescriber policy document MEH A&E Service Handbook 4

Accident & Emergency/General Ophthalmology/Primary Care Clinic/Urgent Care Clinic Protocol for Optometrists 1. Patient selection Patients will be seen in order of arrival by time.

5 Accident & Emergency/General Ophthalmology/Primary Care Clinic/Urgent Care Clinic Protocol for Optometrists 1. Patient selection Patients will be seen in order of arrival by time. For patients brought back for Patient Review Clinic (PRC) in A&E, they should be seen first. 2. Symptoms & history Take full patient symptom and history including, presenting complaint, history of presenting complaint, previous ocular history, medical and system review history, drug history, allergies, and social history. 3. Clinical investigations Check vision/visual acuity/pin-hole acuity have been done recheck if necessary Clinical investigations should be tailored to the type of ocular complaint the patient has and may include any one or a combination of the following tests: - Pupils to check for RAPD - Measure IOP - Corneal sensation - Tear ph - Palpate lymph nodes - Colour vision - Gonioscopy - Confrontation +/- red desaturation - Cover test/motility/saccades - Exophthalmometer measurement - Cranial nerve examination - Pachymetry - Topography - Slit lamp examination of the anterior segment - Pupil dilation - Dynamic anterior vitreous examination - Slit lamp & Volk lens examination of the fundus - Binocular headset indirect ophthalmoscopy - Posterior segment OCT - BP/Blood sugar level - Orthoptic assessment - Ultrasound B-scan - Visual field examination 5

6 4. Performing minor procedures - Further clinical investigations and/or performing minor procedures such as corneal foreign body removal and corneal scrapes are sometimes required before a diagnosis can be achieved. - Optometrists must be appropriately trained by the consultant ophthalmologist before they can perform the procedure 5. Special investigations The following additional tests may also be ordered after discussing with the consultant: - Haematological investigation - CT scan of the brain and orbit - Chest X-Rays 6. Conditions that can be managed by optometrists independently in A&E/General Ophthalmology/PCC/UCC Table 1 indicates the list of conditions that can be managed and/or referred on to other subspecialty services independently by optometrists without the need for obtaining a medical opinion in A&E/General Ophthalmology/PCC/UCC. The table includes separate categories for both Non-prescribing and IP optometrists If the patient presents with atypical symptoms or the condition is not suitable to be seen only by the optometrist then the optometrist will need to discuss the case with the consultant ophthalmologist. 6.1 Managing patients without medical supervision If there is no senior medical supervision, such as in Optometric-led UCC or outreach PCC clinics then o if there is prior warning where possible inappropriate patients should be rebooked. or o the optometrist will need to discuss the case with the fellow on call or with an ophthalmologist in clinic/ A&E. Table 1 Condition Nonprescribing optometrists Prescribing optometrists Independent Prescribers Drug category for prescribing optometrists Comments Eyelids/skin Blepharitis Topical Lid hygiene Trichiasis Refer to Adnexal if secondary to other causes Stye Topical if required Chalazion Refer for I/C if persistent Herpes Simplex Topical antivirals Discuss with to lid margin ophthalmologist Herpes zoster (no keratitis) Systemic antivirals Discuss with 6

7 consultant if there is eye involvement Dry eyes Topical Severe tear deficient dry eyes secondary to Sjogrens or other autoimmune conditions will need referral to EXD for specialist management Conjunctivitis Bacteria Topical Adenoviral (without keratitis) Topical Consider swab for other causes if persistent Adenoviral keratoconjunctivitis Topical steroids especially if visual acuity is reduced Acute allergic antihistamine/mast cell stabiliser - Systemic antihistamine Toxic (drug toxicity etc) Un-inflamed pinguecula/pterygium Inflamed pinguecula/pterygium Contact lens related papillary Seasonal allergic conjunctivitis (Topical only) if severe epitheliopathy Refer to EXD if vision is severely impaired Avoid offending antigens discuss with consultant for drugs that have been prescribed by other Services e.g. glaucoma medications For pterygium, refer to EXD if threatening visual axis (nonpharmacological advice) (nonpharmacological advice) Topical steroids Conjunctival trauma Conjunctival abrasion Topical antibiotic Sub-tarsal foreign body Topical antibiotic Cornea Epithelial basement membrane dystrophy (topical only) antihistamine/mast cell stabiliser steroids (short course) in severe cases Topical antihistamine/mast cell stabiliser Refer to EXD if recalcitrant 7

8 Bullous keratopathy (topical Topical Refer to EXD only) Keratoconus Refer to EXD Recurrent corneal erosion (topical only) cycloplegics antibiotic - Debridement - Bandage Refer to EXD if recalcitrant Contact lens related problems (not infective keratitis) Contact lens related bacterial keratitis (<1mm ulcer), round well defined infiltrate, no hypopyon, no perineural, no ring infiltrate Contact lens immune/sterile related keratitis Herpes Simplex keratitis (epithelial disease) (topical & nonpharmacological advice ) contact lens - quinolones cycloplegics, quinolones antivirals Use quinolones as per A&E Service guideline Use quinolones as per A&E Service guidleine Peripheral corneal disorders Dellen Marginal keratitis Ocular Rosacea blepharokeratoconjunctivitis Corneal Trauma Corneal superficial foreign body (nonpharmacological advice) (nonpharmacological advice) steroids steroids - Systemic cycloplegics Corneal abrasion Identify cause Discuss with consultant with recurrent cases as may need EXD referral Discuss with ophthalmologist for severe cases and refer to EXD if recalcitrant 8

9 Episcleritis (topical only) antibiotic lubricant steroids - Systemic NSAID Consider referring to uveitis clinic if recurrent Glaucoma Ocular hypertension Manage patient according to NICE guideline POAG prostaglandin analogue Beta blocker if no contraindication - Alpha agonists carbonic anhydrase inhibitors Anterior uveitis (first episode & recurrent episodes with established diagnosis and under the Uveitis clinic ) Orbit Preseptal cellulitis (+/- infected chalazion) corticosteroids cycloplegics - Systemic Augmentin 375 mg (Coamoxiclav 250/125), Augmentin 625 mg (Coamoxiclav 500/125) Discuss with ophthalmologist and refer to Glaucoma Discuss with ophthalmologist if equivocal Chemical injury Grade I (nonpharmacological Clear cornea, no only antibiotic limbal ischaemia or advice) steroid epithelial defect (for inflamed eyes) Posterior segment Asteroid hyalosis Perform 360 degree indentation with binocular indirect Photopsia/floaters/posterior ophthalmoscopy or vitreous detachment (nonmyopes or myopes < 7 D) with a 3 mirror Goldmann gonio lens. The optometrist will need to be signed off 9

10 Non proliferative diabetic retinopathy Macular drusen with good VA and no metamorphopsia Dry Age related macular degeneration by the consultant once the adequate level of competency in performing indentation fundus examination has been achieved Appendix 2 Emphasise to patient the importance of good glucose control. Letter to GP, arrange local MR FU Refer to MR if the reduction in VA is affecting quality of life Epiretinal membrane with good VA Refer to VR if the VA is affecting patient s quality of life Fundus photo and Flat choroidal naevus less give appropriate than 1 disc diameter patient advice Central serous retinopathy Refer to MR Macular hole Refer to MR Non-ischaemic branch and Refer to MR central retinal vein occlusion Early adult age related cataract Refer if quality of life is affected and patient wants surgery Refer for YAG capsulotomy Posterior capsular opacification Strabismus Refractive-managed squint Refer to Strabismus Concomitant squint Refer to Strabismus 7. Treatment and management The optometrist makes a diagnosis from the investigations carried out as per above Document management plan in patient s notes Explain fully the diagnosis to the patient give appropriate advice about the condition and treatment to the patient Ask the consultant to sign a prescription if topical POM treatment is required unless the practitioner is an Independent Prescriber. If there is no medical supervision in the clinic (see 6.1 above) then the non-prescribing optometrist will need to ask an Independent Prescriber optometrist to sign for the prescription All prescriptions are to be issued on OpenEyes if possible Discharge patient from A&E/General Ophthalmology/PCC/UCC or refer to another subspecialty Service within the Hospital Type GP letter on PAS or on OpenEyes Record number of patients seen per session in log book 10

11 11

12 Appendix 1 Non prescribing optometrist Consent of consultant ophthalmologist to the optometrist managing certain conditions independently in A&E/General Ophthalmology/PCC/UCC as defined in Table 1: Signed: (Optometrist) Print name: Date: / / Signed (Consultant Ophthalmologist) Print name Date: / / Prescribing Optometrist (Non Medical or Independent prescriber) Consent of consultant ophthalmologist to the optometrist managing and treating the additional conditions independently in A&E/General Ophthalmology/PCC/UCC as defined in Table 1: Signed: (Optometrist) Print name: Date: / / Signed (Consultant Ophthalmologist) Print name Date: / / 12

13 Appendix 2 Consent of consultant ophthalmologist to the optometrist in examining patients (non myopes or myopes < 7D) independently with photopisa and floaters in A&E/General Ophthalmology/PCC/UCC: Signed: (Optometrist) Print name: Date: / / Signed (Consultant Ophthalmologist) Print name Date: / / 13

OPHTHALMOLOGY REFERRAL GUIDE FOR GPS

OPHTHALMOLOGY REFERRAL GUIDE FOR GPS A guidebook to support general practitioners in the management and referral of a range of common eye problems. Contents 3 Introduction 4 Ophthalmic Workup 6 Acute Visual