When to refer to an ophthalmologic review?

In daily clinical practice it may be necessary to refer the patient to a ophthalmological examination for the diagnosis, treatment or follow-up in the evolution of a possible pathology. Doubt can arise when deciding in which cases it would be advisable to refer and with what urgency it should be done.

Aspects such as adequate training and the experience of optometrist they are important to identify the cases that are susceptible of being remitted, but it is essential to take into account three aspects: the anamnesis, the functional examination and the structural examination.

El reason for consultation, personal history (pathologies, medications, surgeries, etc.) and the family background of the patient may be enough to alert us to a possible pathology, but it is necessary to contrast it with the rest of the examination.

El functional examination It includes those tests that provide us with information about the patient's vision. The structural examination allows to assess the anatomical and physiological integrity of the different ocular structures. Although sometimes there is no exact correlation between structure and function, it is important to evaluate these three areas in order to have a global vision of each case and be able to decide what to do.

In these lines, only, we will mention some ssymptoms or signs that can reach our work center and in which a referral to the ophthalmologist could be advised.

Sudden or important changes in refraction without justification can be caused by an ocular pathology

• An increase of myopia or unnatural changes of the astigmatism in an elderly person, along with a loss of visual acuity or visual quality can suggest the evolution of a cataract. The exploration through slit lamp will be key to the diagnosis.
• Important changes in the value of astigmatism in a young person they can suggest alterations in the cornea, as in the case of a keratoconus. A slit lamp examination, the keratometry and a corneal topography they will be of help in the diagnostic orientation.

An abrupt increase in farsightedness together with a decrease in visual acuity they can suggest alterations that involve a thickening of the retinaAs a central serous choriopathy or retinal detachment. Examinations that assess the posterior segment such as the ophthalmoscopy, retinography or the optical coherence tomography (OCT).

These three cases are some examples of unexpected changes in the patient's graduation, but there may be multiple causes that affect refraction and VA such as severe edema, keratitis, etc. Therefore, the global assessment of symptoms, history and functional and structural exploration is important.

Metamorfopsias

It is an unequivocal symptom for the remission of the patient, since they can be caused by any pathology that alters the structure of the central area of ​​the retina (DMAE, macular edema, macular hole, epiretinin membrane, central serosa, etc.).

In addition to the usual posterior segment tests (ophthalmoscopy, retinography, OCT), it can be helpful Amsler grid. It is a fast, simple and economic technique that allows evaluating metamorphopsies, scotomas positive (such as those caused by hemorrhage) and negative scotomas (such as those caused by a macular hole).

Myodesopsias

It is a frequent symptom in the daily consultation. In most cases they are due to a posterior vitreous detachment (DVP) that has no major consequences.

However, in a low percentage (approximately 10%), it can be associated with some more severe retinal pathology such as retinal detachment or a macular hole due to the traction caused, including a peripheral retinal tear that may lead to a retinal detachment. For this reason, in myodesopsies Sudden onset is always important assessment by a retinologist.

Red eye

Un Red eye It has different degrees of severity, but it should not be underestimated because sometimes it can indicate severe pathologies such as acute glaucoma, endophthalmitis o uveitis.

The clinical history that accompanies each case will help us to guide the diagnosis, but some symptoms and signs such as pain, decreased visual acuity, impaired pupillary response, hypopyon... should be sufficient for an urgent referral.

Total or partial loss of vision

Again, it is very important to contrast the information obtained during the anamnesis with the functional and structural examination. Listening to the patient can give us clues to the cause of that Sight loss. A painless loss may suggest some vascular problem such as a venous or arterial occlusion.

If there is no pain and it has the feeling of a curtain or a veil in an area of campor visual, may suggest a retinal detachment. In the case of being accompanied by pain linked to eye movement or with involvement of the pupillary response, there may be changes in optic nerve such as optic neuritis, ischemic optic neuropathy anterior (NOIA) or non-ischemic.

In both cases an examination of the posterior segment of the eye and due to the severity of the pathologies that may be associated with this symptomatology, remission to an ophthalmologic center is always necessary.

The patient can also refer episodes of fleeting amaurosis o transient vision losses previous that could indicate a vascular problem and that should be evaluated by the ophthalmologist.

Diplopia of sudden onset

A good anamnesis is important, since any sudden appearance of diplopia with general symptoms (such as headaches, dizziness, vertigo, nausea, impaired pupillary response, etc.) should be referred urgently, because although the cause of the diplopia is a paresis o muscle paralysis, the origin may imply a more severe pathology (for example: tumor, stroke, etc.)

If there are no associated symptoms and diplopia appears, occasionally, intermittently or sporadically, an adequate examination of the binocular vision and send in case of doubts.

Injuries, foreign bodies ...

There are some conditions that, although rare in an ophthalmological center, such as injuries or traumas, you have to be prepared. These conditions may be accompanied by more or less intense pain, tearing o photophobia.

Occasionally, small foreign bodies can be detected by slit-lamp examination and assess by fluorescein staining the possible corneal erosion caused. It is always advisable to refer to assess the need for a treatment.

Systemic diseases with possible involvement at eye level

There are pathologies or general systemic conditions in which a periodic ophthalmological examination is advisable, because they can have visual implications. Some examples are patients with Hypertension (HTA) or with Diabetes Mellitus (DM).

Depending on the degree of affectation of these diseases and the time of development, the frequency in the ophthalmological controls can be variable, but at least it would be advisable to carry out an annual review.

In the case of milletus diabetes, there are already protocols scheduled for revisions, according to some factors such as type, treatment, the years of duration that have elapsed since the diagnosis of diabetes, etc. Therefore, it is advisable to stress the importance of periodic reviews.

Ophthalmological family history

Despite the absence of a symptomatology that affects vision, some Ophthalmological family history and DMAE, glaucoma or the retinitis pigmentosa they would advise to perform a periodic ophthalmological examination for early detection.

Symptoms of visual loss not justified by the visual acuity found

Although the patient always wants to see better than he sees, sometimes there are patients who report not seeing well and yet have an AV of the unit (20 / 20). There may be pathologies that without affecting visual acuity initially affect aspects such as theampor visual. Some examples could be the retinitis pigmentosa or hemianopsies.

These are just some examples of visual complaints that may be amenable to an ophthalmologic review. However, there may be many more. In general, any decrease in visual acuity not justified, any inconsistency between the history of the patient, functional and structural examination, any finding that is not within normal and that generates doubts, should be sufficient grounds to advise an examination ophthalmologic