Article Date: 6/1/2006

referrals
A Complete Guide To Referrals
The who, what, when, and why of O.D. referrals.
BY TOM MILLER, O.D., F.A.A.O.

While optometry has enjoyed an enhanced scope of practice in recent years, there are still times when we need to refer patients to specialists. But do you refer your patients for the wrong conditions, or to the wrong specialists? Like any responsible health care provider, we recognize the need to refer and do so without hesitation and probably sometimes without need. Too often, perhaps, we may refer the wrong problems to the wrong professional. This can create an unnecessary hassle and extra costs to our patients and to society in general, as well as perhaps a subtle loss of prestige for ourselves. I'll provide some guidelines here to help you when you're considering referring a patient.

When You Need Laboratory Testing

Below are some examples of tests you may need to order to diagnose various conditions:

TEST: Erythrocyte sedimentation rate
Ischemic optic neuropathy
Giant cell arteritis
Third nerve palsy

TEST: C-Reactive Protein
Ischemic optic neuropathy
Amaurosis fugax

TEST: Fasting blood glucose   
Diabetes mellitus

TEST: Hemoglobin A1C
Diabetes mellitus

TEST: Rheumatoid factor    
Anterior uveitis secondary to suspected Juvenile rheumatoid arthritis

TEST: Human leukocyte antigen (HLA-B27):
Anterior uveitis, recurrent or bilateral
Behcet's disease

TEST: Fluorescent treponemal antibody absorption test (FTA-ABS):
Behcet's disease

TEST: Rapid plasma reagin (RPR) or Veneral disease research laboratory test (VDRL)
Anterior uveitis, recurrent or bilateral

TEST: Complete Blood Count (CBC) with differential    
Giant cell arteritis
Ischemic optic neuropathy
Diabetes

TEST: Lipid profile    
Pre-senile corneal arcus

The when, what and who

One reason we may refer a patient is that he or she needs a procedure we are not licensed to perform, such as invasive surgery. We may also refer because we do not want, or do not feel qualified, to provide a particular type of care, such as low vision or specialty contact lens work. And, unfortunately, it may also be due to artificially-induced restrictions placed on us by insurance companies.

What follows are a few examples of wise referral patterns to help ensure prompt treatment of conditions that can be easily identified by O.D.s. They all may be co-managed. You can often start testing and initial treatment prior to referring. The box on page 78, "When You Need Laboratory Testing," offers some examples of conditions for which an optometrist may order tests.

The best way to find appropriate referral sources is from fellow optometrists in your area. Usually excellent practitioners are well known in any particular locale. If possible, you should develop a one-on-one relationship with other providers. Always stay in the loop by communicating both the intention of the consult or referral and your expectations (i.e., I will see this patient back in six months for a repeat dilated retinal exam). Don't assume the other provider will know your intentions. Visit labs and imaging centers and ask them for paperwork necessary for ordering tests. (For information on making referrals to other optometrists, see "Keeping It In The Family," on page 16.)

Labs and imaging centers

Many ophthalmic medical problems warrant further testing to confirm a diagnosis. Before you refer to a specialist, know that we can provide a great service to our patients by ordering, and in many cases interpreting, these tests. Additionally, you can speed proper treatment by having the results readily available to a specialist provider to whom you're referring. These include conditions such as ischemic optic neuropathy, ocular ischemic syndrome, Lyme disease, recurrent uveitis and unexplained vision loss. With these conditions, the proper blood work-up can greatly enhance your patients' level of care and expedite the proper diagnosis.

Other conditions may require imaging to arrive at the proper diagnosis and to guide you to the proper specialty clinician. Pseudotumor cerebri, optic disc swelling, nerve palsy and trauma are a few that frequently demand specialized imaging.

Unless specifically prohibited, you should find a good lab and imaging center in you community to which to send your patients. This is typically a benefit provided to those with hospital privileges, but it is also available to any O.D. who takes the time to learn the protocol. The lab will usually welcome your business with open arms.

Testing tips

Time for Imaging

Plain film x-ray
Suspected orbital fracture
Chest x-ray
Anterior uveitis (recurrent or bilateral)
Behcet's disease

Computerized Tomography (CT) Scan
Suspected orbital fracture with muscle entrapment
Papilledema
Orbital Cellulitis
Graves orbitopathy
Orbital tumors
Demyelinating optic neuropathy
Sinusitis

Magnetic Resonance Imaging (MRI)
Recent closed head trauma
Pseudotumor cerebri/papilledema
Orbital tumors
Internuclear ophthalmoplegia
Optic atrophy
Acquired hemianopic or quadranopic field loss
Third nerve palsy
Chronic headache

Magnetic Resonance Angiography (MRA)
Suspected carotid/ophthalmic artery stenosis or dissection
Suspected intracranial & orbital aneurysms
Third nerve palsy

While proper and prudent referral for lab work or imaging is greatly beneficial in enhancing overall patient care, it's important that you are educated about what test to order and when to order it. Improper testing is not only expensive but can potentially delay proper treatment. See the box page 80 ("Time for Imaging") for a list of some common conditions that warrant imaging.

Follow-up is crucial

With all referral cases, it is vitally important from both a legal and a practice management standpoint to follow-up with the patient after he or she has seen the specialist. It's good practice to schedule the testing appointment while the patient is still in your office. Also, you should ensure that the specialist sends all of the patient's testing information to your office. If the specialist informs you that the patient missed the appointment, you need to contact the patient by some means. Many experts recommend a certified letter outlining the seriousness of the condition along with the possible outcome (sight loss, blindness, death, etc.).

Take charge

For the benefit of your patients and your practice, step up to the plate and take command of your patient's eye health. Our mission has evolved from that of a sight tester and eyeglass prescriber to that of a true "doctor of the eyes." Before automatically sending a patient to another clinician, it would often behoove us to fully investigate the problem, gathering all clinical information. At times, this will include requesting laboratory or imaging procedures.

No one will take better care of your patients than you will. Don't assume other practitioners will always do the right thing — be the captain of your patient's eye health. You will reap the rewards in both personal satisfaction and increased income from the referrals made by happy patients. Managing your patients' ocular care will greatly elevate you in their eyes. In this day of rushed, sloppy, inefficient and frequently haphazard medical care, they will appreciate your effort and concern probably more than you will ever know.

Find a good lab and imaging center in your community to which to send your patients.

Dr. Miller is in solo practice in Fayetteville, N.C. He graduated Southern College of Optometry in 2000 after serving in the U.S. Marine Corps. He was North Carolina's Young O.D. of the Year in 2002. E-mail him at tomeyeman@nc.rr.com.

 

 

When and Where to Refer

REFER TO AN INTERNIST 
Mild diabetic retinopathy
Mild hypertensive retinopathy
Suggestive ocular signs of HIV/AIDS
Ocular conditions suggestive of Lyme's Disease
Myasthenia gravis

REFER TO A NEUROLOGIST OR NEURO-OPHTHALMOLOGIST
Optic neuritis suggestive of M.S.
True papilledema
Possible brain lesion or aneurysm shown on neuro-imaging
Pseudotumor cerebri
Unexplained anisocoria
Unexplained nerve palsy

REFERRAL TO A CARDIOLOGIST (OR INTERNIST)
Ocular ischemic syndrome
Hollenhorst plaque
Retinal artery occlusion (for carotid artery evaluation)
Amaurosis fugax

REFER TO A RHEUMATOLOGIST
Chronic uveitis with positive RH factor or antinuclear antibody (ANA)

REFER TO A PEDIATRICIAN
Cellulitis in children
Severe allergies
Suspect Attention Deficit Hyperactivity Disorder (ADHD)

REFER TO A RETINAL SPECIALIST
Arteritic ischemic optic neuropathy
Retinal/Iris neovascularization
Chronic idiopathic central serous chorioretinopathy (ISCR) requiring laser treatment
Retinal tears or detachments needing repair

REFER TO A GLAUCOMA SPECIALIST
Advanced glaucoma needing surgery

REFER TO A CORNEAL SPECIALIST
Keratoplasty
Severe central corneal ulcers

REFER TO A GENERAL OPHTHALMOLOGIST
Cataract surgery
Yag capsulotomy

 



Optometric Management, Issue: June 2006