A patient presents to a general practitioner with red eye, who presumes that allergies are the culprit. This may sound like a case in which the GP will make a referral to an ophthalmologist for further evaluation and treatment. But, what if the GP refer right away, starts the patient on drops with a “wait-and-see” approach, and the patient’s condition worsens.

Because situations like this occur, it falls on the ophthalmologist to advise physicians on the right time to refer their red eye patients.

GPs need this guidance for two primary reasons, says Nathan E. Podoll, MD, assistant professor of Clinical Ophthalmology, Vanderbilt Eye Institute. First, if GPs are evaluating patients for multiple conditions, such as high blood pressure or chronic back pain, the vision issue may fall low on the list of priorities. Also, their resources and eye training are usually not extensive, says Dr. Podoll. “They probably don’t have a slit lamp. They use some sort of magnifying device, do fluorescein staining and that’s about it.”

Thus, GPs and physicians in other internal medicine subspecialties such as neurology, rheumatology and endocrinology should want to call their friendly neighborhood ophthalmologist as soon as conditions show signs that their red is beyond a simple conjunctivitis or isolated corneal abrasion. Here’s some advice to help them make that decision.

GIVE LECTURES

To reach those on the front lines of health care, consider holding red eye lectures in which you explain what to expect with a typical infectious conjunctivitis or corneal abrasion. “If your local hospital has a lecture series or grand rounds, you should volunteer to speak at that event to colleagues,” Dr. Podoll says. This could also include internal medicine residents and emergency room doctors, says Eddie Apenbrinck, MD, of Dr. Black’s Eye Associates in Indiana.

Your pre-existing referral sources, such as those GPs or family medicine physicians who are already consistently sending diabetic patients to you, should also be contacted. “Bring them lunch, share your business cards, and say, ‘Thanks for sending us diabetics. If you have patients with trauma or redness not going away, feel free to reach out with those as well,’” Dr. Podoll says.

POINT OUT THE WARNING SIGNS

Rather than focus on diagnosing a specific condition, Dr. Apenbrinck suggests updating the physicians on those warning signs that would warrant a red eye referral. Discuss the warning signs for when the patient may need a more organized treatment from an ophthalmologist. Red eye that results in minimal irritation or minor blurry vision from discharge is fine, Dr. Apenbrinck says, but if the patient exhibits change in vision, moderate to severe blurry vision, light sensitivity, pain with eye movement and/or pupil abnormalities, plead for an immediate referral.

Because red eye has such a broad differential diagnosis and could be present due to anything from allergy to autoimmune disease to infection, it increases the importance of obtaining a thorough patient history, Dr. Apenbrinck says. “The GP sees red eye and to them it looks the same no matter what. “They’re not exposed to it as much as we are in ophthalmology.” Included in the patient history should be duration, whether it has occurred previously (and at the same time of year), contact lens use and any other exacerbating factors.

REFERRALS’ CONDITIONS

Inform physicians to pay close attention to these factors in common red eye conditions.

• Trauma. “I have a low threshold to refer if a patient has red eye from trauma,” says Dr. Podoll. “That’s a scenario where it’s really tough to tell if it’s a simple corneal abrasion or if it’s accompanied by traumatic iritis, how deep the abrasion is or if there’s a foreign body.”
• Uveitis and iritis. These conditions go unrecognized too often, says Dr. Podoll, and it’s particularly important that ophthalmologists get involved. Along with redness, these conditions are typically accompanied by blurry vision, pain and light sensitivity.
• Chronic blepharitis or dry eye. These conditions are too often confused with conjunctivitis and treatment differs significantly, Dr. Podoll says. So, if the patient, before presenting, has prolonged symptoms that last throughout the day, the GP should refer right away.
• Contact-lens overwear. “If the patient is a contact lens wearer, I urge GPs to get the patient in here sooner rather than later due to the risk of contact lens being associated with corneal abrasions,” says Dr. Apenbrinck, especially if the patient experiences pain in addition to red eye. These patients also have a high risk of developing ulcers.
• Corneal abrasions. “I try to stress that an abrasion should heal quickly — epithelium turnover rate is pretty fast,” Dr. Apenbrinck says. “I would tell them to watch for a day or two, and, if the patient is not improving drastically by that time, it would be good idea to send them over.” The main concern, he says, is that it could be more than an abrasion and result in an ulcer.

WE LOVE REFERRALS

Dr. Podoll says he has no reservations about seeing a patient from a primarycare doctor, because they may not have much eye training and experience. “If it moves out of their comfort zone and it’s not straight forward, just send that patient along and we’ll be happy to take care of them and send them back to you for everything else.”

For Dr. Apenbrinck, this applies even when it doesn’t sound like an appropriate case for a referral. “If the GP is going out of their way to ask me to see someone, I try to get them in as soon as possible, even if it may not seem like something urgent.” OM