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First Stop in The Journey of Ophthalmic patients - A GP Survey

Authors: A. Ibraheim MBChB, D.O, FRCS, FEBO, FRCOphth. A. Rehman FRCS

Correspondence: A.Ibraheim (Consultant Ophthalmologist And Honorary Senior Clinical Lecturer (Sheffield University)

Abstract:

A regional survey was carried out involving 150 G.Ps who refer their patients to our eye department based at Barnsley. The purpose was to collect information on their management of the ophthalmic patients. A comprehensive questionnaire was sent to them. 67 completed forms were received between January and March 2007. The area of interest included the visual acuity measurement, ophthalmoscopy, use of dilation drops, management of diabetic patients, initiation of minor surgical or medical treatment, when to refer to optician and when to refer to eye specialist. Result: 85% carry out visual acuity measurement, 39% are not confident of their findings, 66% cannot tell if the macula is normal, while 24% unable to tell if the disc is normal.13.5% only use dilating drops. 3% do not initiate any treatment to any eye condition. 56% carry out minor surgery. 73% refer diabetic to screening centre, 27% refer direct to consultant or optometrists. Up to 48% of their referrals to the optician should have been to a consultant clinic. Conclusion: there are many area of shortcomings in the current practice of our sample that could be improved upon through, local educational courses, training, and issuing guidelines, and better communication between Hospital and GPs.

Key words. General practitioner. Ophthalmic disease. Optometrists referrals

Aim:
A study was undertaken to investigate the current practice within our GP community with regard to their ophthalmic patients, in order to identify areas requiring education, training and guidelines.

Introduction:

The publication of the UK government’s Patients Charter and the New NHS Charter has created an increasing importance on the need to run an efficient outpatient with a shorter waiting time and more efficient utilization of the available resources1. G.Ps, most f the time are the first stop in the journey of the patients. Therefore the way the patient is being managed at this stop has greatest impact on the services provided by the secondary care2. G.P may be considered as gatekeeper to ensure appropriate referral of their patients to secondary care providers. The advent of primary care groups and Trust has created the opportunity to develop services in more cost-effective and appropriate ways. Inappropriate referral’ can be interpreted as pejorative and carrying a sense of blame. It is more helpful, and more accurate, to think in terms of ‘avoidable’ referrals. Avoidable referrals are those which would not be required if an aspect of the health care system were organized differently3.
‘Specialty / Subspecialty area’ – Myths and facts
The term specialty/subspecialty my give the impression of (hands off / leave it to me) to some GPs. Therefore wholesale referral is justified! Of course this perception must be dissipated as GP colleagues can do quiet a lot themselves in term of management and care in these specialty areas, as we will see from this study.4

Method:

A 2 page A4 questionnaire of the tick box design were sent by post to about 150 G.Ps who refer their patients to our ophthalmic department at Barnsley. These GPs cover mainly Barnsley, Rotherham, and part of Sheffield. To encourage replies G.P’s name remained anonymous and stamped addressed envelope was included. It was intended to keep the information provided confidential, anonymous and untraceable to the source of origin. Reassurance of this was included in the letter accompanying the questionnaire. The data collected over a three-month period were analyzed as shown below in this article

Results:

85% of our sample does check the visual acuity of their ophthalmic patient. 15% they do not carry out this fundamental basic test( see table 1). Of the whole sample only 10% use pinhole as well. Of those who do measure the visual acuity 39% are not confident of their finding. Therefore 54% may not be able to make a sound judgment on the finding of their ophthalmic patients.
When our sample were asked about ophthalmoscopy at their practices 21% are not able to tell what a normal disc looks like i.e. they can not differentiate normal from abnormal disc. But the majority (76%) is able to do so. On the other hand,70% of them are unable to tell if the macula is normal. Only 30% are able to identify abnormal looking macula. Their answers to the next question whether or not dilating drops are used in the assessment of their patient may explain in part why one third cannot assess the macula. Only13.5% do dilate pupil as part of over all assessment of their ophthalmic patients while the other 86.5% do not dilate, ‘see table 1’. The reasons given for not dilating the pupil were fear of precipitating glaucoma in 25%. In another 25% they do not think dilating the drops will add to their information while a 48% do not keep the dilating drops in their stocks.
So far we have noticed that the GPs in our sample are rather conservative in conducting basic test for the assessment of their ophthalmic patients, but are bolder with clear tendency to actively intervene when it comes to initiating treatments, such as medical treatment of eye conditions and some minor surgical procedures. 97% of them do initiate treatment to some ophthalmic patients such as acute discharging eyes, blepheritis, dry eyes, and itchy eyes, ‘see table 2’. 43.5% will initiate treatment for recurrent iritis. But we did not expect them (40.5%) to treat even acute painful eye conditions.
One important area we tried to explore was the handling of the diabetic patients. 91% will refer all diabetic mainly to secondary care and to lesser extent to optometrists, event if they were asymptomatic and in the absence of diabetic retinopathy. 2% only will refer if patients show diabetic retinopathy, while 6% feel confident to only refer diabetic with sight threatening condition.
Another area of interest the study probed in was the pattern of referral to the optometrists. We noticed a significant number of referral that should have been directed to the consultants instead they went to the optometrists prolonging the journey and in some instances might have compromised the appropriate treatment. e.g. 22.5% would refer to the optometrists flashing lights, 30% will refer children with squints, 31.5% will refer field defect or patches in the field of vision, 18% will refer diplopia, 15% will refer deterioration in the vision of patients with only one seeing eye, and 26% will refer known patients with age related macular disease who developed deterioration of vision to the optometrists ‘see table 3’.

Lastly the survey shows lack of information about our long established services in the eye department such as cataract clinic, medical retina clinic, glaucoma clinic etc. 46% they are not aware of cataract clinic service. While 72% are not aware of medical retina clinic and 36% are not aware of the glaucoma clinic.

Table One

Task	Yes response (%)
Visual acuity testing	85
Use of pinhole	10.5
Confident with your findings	61
Able to tell if disc is normal or not by ophthamoscopy	76
Able to tell if macula is normal or not by ophthamoscopy	30
Do you dilate the pupil	13.5

Table Two

Eye conditions treated?	Yes response
Acute red eye with discharge	98.5
Blepharitis	95.5
Dry eye	94
Itch eye	97
Recurrent iritis	43.5
Acute painful eye	40.5
Minor surgical procedures	56

Discussion:

The result shows only 10% who includes pinhole test in their visual assessment while 15% do not carry out visual acuity measurement at all, and 39% do not feel comfortable with their measurement. Therefore according to this study a total of 54% would make their judgments whether to refer or to treat in the absence of valuable information provided by visual acuity measurement. It would seem to us that this group of G.P is more likely to refer ‘avoidable ophthalmic referral’ to secondary care than the other half of the sample. Measurement of visual acuity in the GP premises we think could be done routinely. The nurse in the GP practice can become very capable to carry out the test with efficiency before the patient gets into the GP consulting room. Even if the GP decided to refer the patient to secondary care it is still valuable piece of information to the ophthalmologists, as it will assist in prioritizing the appointment i.e. whether to go on urgent, soon or routine list5. On the other hand there are many occasions where the GPs who carry out visual acuity and pin hole testing can comfortably make a safe and appropriate decision themselves e.g. cases of refractive errors like a young patient seen by a GP due to blurring of vision in the absence of other signs and symptoms and was found to have a visual acuity of 6/24 improving to 6/6 with pinhole. The GP can simply sort out this error of refraction once and for all by referring to an optometrist for a pair of glasses. Otherwise without this simple test the GP will have no choice but to refer such patient (avoidable referral) to the secondary care provider. Also there are group of patients who could have been seen before by ophthalmologists but discharged and only to be re-referred if there would be significant deterioration of vision, typical example is, patients with very early lens opacity or patients with dry age related macular disease. Without measuring the visual acuity the GP has to rely on the patient subjective expression. But then some patients will be missed who either by nature do not complain or may put their deterioration of the vision down to ‘normal’ age changes. Here the GP who carry out visual acuity testing can be of great help to such patient , as early detection of deterioration my help the patient to have early intervention by secondary care provider.6
As a complementary tool to the visual acuity assessment here comes the role of routine ophthalmoscopy for ophthalmic patients. While we appreciate that GPs are often described as ‘generalists’ and are not trained to detect minute changes in the macula or the optic disc, it is equally true they are expected to know what a normal organ or part of an organ look like such as the macula or the optic disc. According to our study 76% are confident in assessing the disc with ophthalmoscopy. This seems much better than a similar study in South Devon, that showed only 38% who are confident with their ophthalmoscopy.7 but our sample shows a reversal of the percentage when it comes to assessing the macula. Only 30% are able to tell if the macula is normal or not with the direct ophthalmoscope. One of the reasons for this reversal seems to be that 86.5% of our sample does not use dilating drops. Therefore we would not be surprised if this group of GPs again refers more ‘avoidable’ cases to the secondary care. Even in traditional high-risk groups (shallow, flat anterior chamber) the risk of precipitating acute glaucoma with mydriatic eye drops has been found to be very low12. The presence of chronic glaucoma constitutes no additional risk10
It should not be too difficult to improve on the skill of such GPs through vocational training, continued medical education and regular audits. This does also apply for those GP colleagues who are too reluctant to use dilating drops (for fear of inducing glaucoma) GPs who do not dilate will deny themselves of a great deal more of valuable information about their ophthalmic patient such as those with diabetes. The sensitivity of detecting retinopathy is doubled with dilation8. Filling the gap in the knowledge in this area through sandwich courses and self directed education will change the attitude of GPs who are obsessed about glaucoma9, or those who do not thing dilation would add to their information (39%). The risk of inducing acute glaucoma following mydriasis with tropicamide alone is close to zero10. The risk with long-acting or combined agents is 1 in 3380 according to Rotterdam study11.
Even if GPs are too obsessed about precipitating glaucoma (theoretically could only happen in high risk group. The latter only constitute 2.2% of population)11 is not good enough excuse not to dilate the vast majority who are broadly risk free. A simple and quick test will help GP to identify patients who wear longsighted glasses (supposedly at high risk). By moving the glasses the patient use for distance against object 2 meters away. If the object of regard appears to be moving with the movement of the glasses then that patient is not hypermetropic (but myopic hence can safely be dilated even by obsessed GP), and if the object appears to move in the opposite direction, the patient is hypermetropic. At least with this test the GP will be able to dilate a vast majority of his patients without the fear of precipitating glaucoma. Otherwise routine use of 0.5% tropicamide is safe for all patients regardless to what glasses they wear. Of course it is advisable to ask the patient to seek medical attention if the symptoms of acute angle closure glaucoma (red painful eye, blurry vision, nausea and vomiting) occur13. In fact some could argue-and rightly so- that anyone whose angle may be provoked into closure by a mild mydriatic (incidence between 1/3380 to 1/20000)10is at risk of spontaneous angle closure glaucoma. The fact that it has been precipitated in a healthcare setting, rather than occurring in the community, is of some benefit. The patient is likely to be within easy access of specialist care14.
It is reassuring to see that 97% of the sample is themselves able to treat a spectrum of eye conditions such as conjunctivitis, itchy eyes, dry eyes, blepheritis etc. A good 56% of the sample carryout minor surgery too at their premises such as removal of skin tag or meibomian cysts. We are sure these activities could easily be extended to involve most of the other 44% who do not carry out surgery. It will remove significant number of these minor cases from our list in hospital thus relieving consultant time and enabling them to fill those minor cases slots with perhaps extra cataract cases.
According to our study the sample are not doing well when it comes management of diabetic patients. Only 73% would refer their diabetic patients to our long established diabetic screening centre. While the other 27% would either refer direct to the consultant (19%) i.e. with high rate of inappropriate referral or to the optician (8%) who are not trained for diabetic screening in our area. The latter could simply prolong the journey of the patient. 27% as a figure may look modest but it is not when it is realized that there are about 12 to 16 thousands diabetic looked after by our sample. Ideally all the diabetics should be registered and followed up in the screening centre. Those who need specialist opinion will be then referred from the screening centre to the eye clinic for further management. Some G.Ps perhaps are not a ware of the screening centre services therefore communication and exchange of information between secondary care provider and the GP community is all that is required to address this shortcoming. Also GPs should be made aware of the exact role of the optometrists and their limitations.

Our survey probed the pattern of GP referral of their ophthalmic patients to the optometrists. We are surprised to see that 28.5% of the participants in the survey will refer any eye problem as first line to the optometrists. 30% will refer all children with squints to the optometrists. The optometrists may help in some eye problems in the first group of referral such as screening for glaucoma, changing glasses but they have not got much to contribute in children with squint. All the optometrist will do is to re-refer to the secondary care provider for proper management. Therefore it is unnecessary delay in the management of these children with squint, which is time sensitive condition.
The same is true for cases with diplopia (18% will refer to optometrists), flashing lights with floaters (22.5% will refer), shadows in the field of visions (31.5% will refer), known cases of age related macular disease who developed distortion or further deterioration of vision (25.5% will refer to optomerist). Patients in all these examples should be referred directly and promptly to the consultant clinic and not to the optometrists. As referring them to the optometrists is complete waste of valuable time, and inconvenience to the patients who may be quiet elderly with co-morbidities too. More importantly is that it may reduce significantly the chance of benefit from early intervention particularly so for patient with macular diseases.
This attitude of our participants may reflect the misunderstanding of the role of the optometrists and the contribution they can offer to such patients. Again this could be solved by education and local courses for the GPs.
The study shows also that some of our participants are not familiar with the kind of services we as eye department are offering e.g. 82% of the sample are not aware of our well established medical retina clinic, and 66% are not aware of our paediatric clinic.

If the G.Ps are aware of these subspecialty clinics, their occasional referrals to tertiary centre, where they thing all such cases need to go, will be reduced. This will safe patients unnecessary long trips and perhaps a longer wait too. If GPs knew the availability of the subspecialty clinic, patients would then be referred directly to the appropriate clinic instead of going to the general pool, which may again prolong the journey of the patient before eventually seen in the subspecialty clinic.

Conclusion:
The study though not extensive but highlighted several key points that could be improved upon by simple communication, issuing guidelines, arranging short annual refreshing courses with some training session to acquire basic ophthalmic skills such as ophthalmoscopy. Our GP colleagues are in fact keen on such initiatives as indicated by our survey. 86.5% of the sample will be interested to attend a half-day educational course in the ophthalmic unit even higher than in other reported studies7. We recommend similar surveys in other regions to identify any shortcomings and address them accordingly. These surveys may be repeated every couple of years to monitor the implementation of the recommendations. We believe this kind of activity will help to make our services more efficient and cost effective.

Acknowledgement: We would like to thank all GPs who participated in the survey. Our special thank to Mary our secretary who helped us in organizing the letters.

Tables

Task Yes No
Visual acuity testing 85% 15%
Use of pinhole 10.5% 89.5%
Confident with your findings 61% 39%
Able to tell if the disc is normal or not by ophthalmoscopy 76% 24%
Able to tell if the macula is normal or not by ophthalmoscopy. 30% 70%

Do you dilate the pupil 13.5%
86.5%

References

1-Department of Health, NHS Executive, Communications Unit , London: Series number BN33/98, 1 January
2- Sheldrick J.H, Wilson A.D, Vernon S.A, and Sheldrick C.M: Management of ophthalmic disease in general practice.Br J Gen Pract. 1993 Nov; 43(376):459-62
3- Rosalind Eve, Kate Gerrish, Penney Mares, Helen Metacalf, and James Munro: More than one way to skin a cat. Centre for Innovation in Primary Care/ March 2001
4- Everitt. H, Little.P: How do GPs diagnose and manage acute infective conjunctivitis? A GP survey. Fam Pract. 2002 Dec;19(6):658-6
5- Latham.K,and Misson.G: Patterns of cataract referral in the West Midlands. Ophthalmic Physiol Opt.1997 Jul;17(4):300-6
6- Royal College of Ophthalmologist guidelines on Age related macular disease
7- Featherstone P.I, James. C, Hall M.S, and Williams.A: General practitioners' confidence in diagnosing and managing eye conditions: a survey in south Devon. Br J Gen Pract. 1992 January; 42(354): 21–24.
8- Klein .R, Klein B.E, Neider M.W, Hubbard L.D, Meuer S.M, and Brothers R.J: Diabetic retinopathy as detected using ophthalmoscopy, a nonmydriatic camera and a standard fundus camera. Ophthalmology 1985;92: 485-91
9-Adaamson .E, and Herman .W: Patterns of medical care for diabetics in the San Francisco Bay area. Atlanta: Centers for Disease Control, 1988.
10- Pandit R.J, and Taylor R: Mydriasis and glaucoma: exploding the myth. A systematic review. Diabetic Med. 2000;17: 693-9.
11- Wolfs R.C, Grobbee D.E, Hofman.A, and de Jong P.T: Risk of acute angle-closure glaucoma after diagnostic mydriasis in nonselected subjects: the Rotterdam Study Investigative Ophthalmology Visual Sci.1997;38: 2683-7
12- Liew .Gerald , Mitchell .Paul , and Wong TienYin: Funuscopy to dilate or not to dilate. doi:10.1136/bmj.332.7532.3 BMJ 2006;332:3 (7 January)
13- . Patel K.H, Javitt J.C, Tielsch J.M, Street D.A, Katz. J, and Quigley H.A, et al: Incidence of acute angle-closure glaucoma after pharmacologic mydriasis. Am J Ophthalmology 1995;120: 709-17.
14- Kanchan J. Bhan, Bastawrous. Andrew, and Davey Keith. G: Funduscopy to dilate or not to dilate. doi:10.1136/bmj.332.7534.179.BMJ 2006;332:179 (21 January),.

First Published November 2008

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