Cornea

Scope

  • Keratoconus
  • Corneal dystrophies – Symptomatic (e.g. Fuchs')
  • Symptomatic Pterygium
  • Scleritis
  • Severe dry eye syndrome – incl. graft vs host disease
  • Suspected neoplasms of ocular surface (not the lids)
  • Contact lens related problems
  • Anterior segment complications from previous ocular/cataract surgery and other 2nd opinion
  • Secondary anterior segment/cornea complications from herpes/shingles
  • Previous chemical injuries needing further assessment
  • Recurrent corneal erosions
  • Symptomatic Corneal scars

Out of scope

  • Corneal abrasions / erosions
  • Corneal ulcer – urgent referral needed
  • Bacterial / viral – herpes/shingles – urgent referral needed
  • Mild to moderate Dry eye syndrome, if not possible to manage in primary care then refer to general clinic
  • Acute chemical injury - urgent referral needed

Assessment

Signs & Symptoms

  • Blurred vision
  • Reduced vision
  • Glare
  • Reduced colour sensitivity
  • Monocular diplopia
  • Marked discomfort

History and Examination

  • Previous medical history including medications/allergy list & family history
  • General Ophthalmic Services (GOS)
  • Serial eye test results – when available – especially in Keratoconus
  • Body Mass Index (BMI)
  • Mobility
  • Interpreter required

Red Flags

  • Corneal abrasions / erosions
  • Corneal ulcer
  • Bacterial / viral – herpes/shingles
  • Acute chemical injury

Urgent Care Services:

North Devon District Hospital: Attend ED

Investigations

  • GOS
  • Previous records/information from other providers including:
    • letters,
    • laser surgery records, and
    • investigations (such as topography)

Management

Keratoconus
  • Management: Community optometrist management is not recommended as treatment (collagen cross linking) to prevent progression is available
  • When to refer: Routine referral to Cornea service for corneal topography to confirm diagnosis and agree further management. Late community optometrist management may then be possible
Corneal dystrophies – Symptomatic (FUCHS')
  • Management: mild cases can be managed by community optometrist if confident of the diagnosis until the patient is symptomatic
  • When to refer: reduced vision – below driving standard
Pterygium
  • Management: lubrication to control irritation
  • When to refer: Routine referral if significant growth across limbus and severe symptoms warranting surgery
Recurrent corneal erosions
  • Management: topical lubrication is usually helpful
  • When to refer: when symptoms are not controlled by lubrication
Severe dry eye syndrome – including graft vs hose disease
  • Management: not suitable for primary care management, however preservative free lubrication may be commenced until secondary care appointment has materialised
  • When to refer: refer to secondary care
Suspected neoplasms of ocular surface - not the lids
  • Management: not suitable for primary care management
  • When to refer: refer to secondary care – 2 weeks pathway if suspected
Contact lens related problem
  • Management: stop contact lens wear and send separately as well as the contact lens cases for culture and sensitivity and request analysis for bacteria and acanthamoeba if infection is suspeced
  • When to refer: refer to secondary care – urgent care if suspected infection
Anterior segment complications from previous ocular/cataract surgery and other 2nd opinion
  • Management: not suitable for primary care management
  • When to refer: refer to secondary care
Previous chemical injuries needing further assessment
  • Management: not suitable for primary care management
  • When to refer: refer to secondary care

Referral

Referral Criteria

Before a referral is made the referrer must confirm that:

  • The patient understands that the purpose of the referral is for assessment to determine appropriate management.

Referrals must include the following history and examination:

  • GOS
  • Previous medical history including medications/allergy list & family history
  • Serial eye test results – when available – especially in Keratoconus
  • BMI
  • Mobility
  • Interpreter required

Referral Instructions

e-Referral Service Selection

  • Specialty: Ophthalmology
  • Clinic Type: Cornea
  • Service: DRSS-Northern-Ophthalmology- Devon CCG- 15N

Referral Forms

DRSS (GP) Referral Form

Opticians Referral Form

Supporting Information

Patient information

Patient information from the Royal College of Ophthalmologists

Pathway Group

This guidance has been signed off by NEW Devon CCG

Publication date: January 2017

 

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