Retinal referral urgency

Correctly diagnosing retinal disease can be difficult in general practice; some GPs do not feel confident with the direct ophthalmoscope and it is not ideally designed to pick up subtle macular changes.  It may be reassuring that few ophthalmologists are comfortable with one either, relying instead on stereoscopic slit-lamp lenses. It is usually  worthwhile referring to an optician who may be better able to triage chronic blurred vision.  More so as many cases turn out to be uncorrected refractive error.  The obvious exception is a patient with acutely blurred or distorted vision, or if there are symptoms of retinal detachment (flashing lights, floaters, field defect).   These patients require urgent, direct, hospital referral.  The main list on this page is organised by priority of referral, but for situations where the GP has made, or been given a diagnosis, an alphabetical list is provided at the bottom of the page, with links to the main list. There are additional clinical notes on many of the conditions, as indicated in the main list.  

This information is offered as a guide only, as clinical situations vary. The following generalisations are based on my own experience, rather than a locally or nationally agreed consensus.



Retinal referral urgency

Immediate

Central retinal artery occlusion (or branch retinal artery occlusion with macular involvement) of < 24 hours duration. 

Retinal detachment (keep nil by mouth ) (see GP clinical notes)

                                                                                        

Within 24 hours

New or exudative age-related macular degeneration with suspected neovascularisation (see GP clinical notes)             

Branch retinal artery occlusion not involving the macula                              

Retinal tears (see GP clinical notes)                                                                                          

Central retinal artery occlusion >24 hours duration    

Posterior vitreous detachment with flashes and floaters (see GP clinical notes)

Vitreous haemorrhage

Urgent (within one week)

Proliferative diabetic retinopathy (see GP clinical notes)                                                           

Toxic maculopathy                                                                                 

Branch retinal vein occlusion (see GP clinical notes) 

Central retinal vein occlusion (see GP clinical notes)

 Soon (within one month)                                                                     

Severe non-proliferative diabetic retinopathy (see GP clinical notes)  

Diabetic maculopathy (see GP clinical notes)                                    

Pseudophakic macular oedema                                                                      

Central serous retinopathy 

Retinal macroaneurysm

 

Routine                                                               

Mild to moderate non-proliferative diabetic retinopathy or background diabetic retinopathy (see GP clinical notes)                    

Hypertensive retinopathy (treat hypertension urgently)                                                                            

Retinitis pigmentosa or other pigmentary retinopathy                             

Best disease                                                                                       

Stargardt disease                                                                    

Choroideremia                                                                                           

Gyrate atrophy                                                                                   

Choroidal naevus                                                                                   

Macular telangiectasia                                                                         

Atrophic (dry) age-related macular degeneration where choroidal neovascular membrane has been excluded (see GP clinical notes)     

Lattice degeneration with atrophic round holes but no tears (see GP clinical notes)

Macular hole (see GP clinical notes)

Epiretinal membrane (see GP clinical notes)

Alphabetical list of retinal disease (click on link for referral urgency).

Age related macular degeneration
    exudative (wet)
    atrophic (dry)
Best disease
Branch retinal artery occlusion
    macular involvement
    macular sparing
Branch retinal vein occlusion
Central retinal artery occlusion
    <24 hours duration
    >24 hours duration
Central retinal vein occlusion
Central serous retinopathy
Choroidal naevus
Choroideremia
Diabetic retinopathy
    background diabetic retinopathy
    mild / moderate non-proliferative retinopathy
    severe non-proliferative retinopathy
    proliferative retinopathy
    maculopathy
Epiretinal membrane
Gyrate atrophy
Hypertensive retinopathy
Lattice degeneration (hospital referral not always required - see GP clinical notes)  
Macular hole
Macular oedema after cataract surgery (pseudophakic macular oedema / Irvine Gass syndrome)    
Macular telangiectasia
Posterior vitreous detachment
    asymptomatic (hospital referral not usually required - see GP clinical notes)    
    symptomatic
Retinal detachment
Retinal hole (see GP clinical notes)
Retinal tear
Retinal macroaneurysm
Retinitis pigmentosa
Stargardt disease
Toxic maculopathy
Vitreous haemorrage