During the last 30 years, optometrists have made great strides in understanding systemic disease. Optometry school coursework now emphasizes the importance of systemic correlations with ocular pathology. Early efforts in this realm were widely concentrated on hypertension and diabetes; however, the focus has since been expanded to cover a full range of systemic illness.

Now, we offer a more comprehensive level of care and can interact with both general practitioners and specialists on our patients behalf. These interactions require that we not only communicate in terms that are understood by the medical specialist, but also clearly understand the information the specialist provides us. Most importantly, the benefit to our patients is much richer if there is open communication among specialists.

This article reviews common referrals and comanagement strategies between primary care optometrists and a variety of medical specialists.

Rheumatologists

Arguably, the most important specialty association an optometrist can establish is a solid relationship with a rheumatologist. Dry eye is typically at the forefront of most optometric practices, and rheumatologic disorders contribute greatly to the signs and symptoms of this condition. A rheumatologist will appreciate, and sometimes request, assistance with dry eye patients. This serves as a great opportunity to both comanage patients and attain an understanding of rheumatologic practice.

This rheumatoid arthritis patient presented with scleritis, which can cause severe ocular pain, increased light sensitivity and decreased acuity.

Rheumatoid arthritis, lupus and Sjgrens syndrome are common sources of concern. A rheumatologist may alter systemic therapy based upon the optometrists dry eye report, which should include comments on tear quality and quantity. Results of the anesthetized Schirmer test and lissamine green/ fluorescein staining examination help to complete the report. (Though many eye-care professionals doubt the validity of Schirmer testing, a positive result is of great interest to the rheumatologist.)

Plaquenil (hydroxychloroquine, Sanofi-Aventis) therapy is another common point of interest between a rheumatologist and an optometrist. This anti-malarial antibiotic has been found to have anti-inflammatory properties in many patients suffering from rheumatologic diseases.1 Plaquenil cumulatively binds to macular pigment, so the drug can cause vision loss due to toxicity. Corneal deposits are fairly common as well.1

Although the modern daily dosages of Plaquenil (200mg to 400mg) are not typically associated with toxicity, rheumatologists are generally aware of this potential complication and should instruct their patients to undergo an annual ophthalmic examinationsome even insist on an ocular examination at six-month intervals.1 The examination report is critical because it helps the rheumatologist decide whether to continue Plaquenil therapy. Include dilation, and emphasize color vision and central fields, either by Amsler grid or a macular program on a computerized visual field instrument, in your complete examination.

In addition to dry eye, ocular inflammation is a common finding in patients with rheumatologic disease. Include comments on the integrity of the patients cornea, conjunctiva and sclera in your report to the rheumatologist. Evaluation of the aqueous and vitreous humors for evidence of inflammatory cells is critical for a rheumatologic patient. Fundus findings should be related as well, considering that inflammatory disorders, such as sarcoid and lupus, can cause retinal vasculitis.2

 

Neurologists

It is important to establish a positive relationship with a neurologist before you need to refer patients to him or her. Patients with neurological symptoms may have life-threatening illnesses, and it is critical to have an immediate source of referral for neurological care. Remember that a neurologist may see critically ill patients all day and might have difficulty accepting new patients from an unknown referral source.

A complete optometric examination offers insight into a variety of neurological functions. Consider cranial nerve dysfunction and a patients mental status at each visit.

Also, headache is a common complaint encountered in the neurological realm. Make an appropriate neurological referral if either your therapeutic efforts or the efforts of the family physician have failed. Include emphasis on the patients history of illness, best-corrected visual acuity, color vision, extraocular muscle testing, pupillary reflexes, visual fields by automated screening mode (or at least thorough confrontation), and description of the optic nerve and retina in your report.

Additionally, the neurologist will be particularly interested in either the presence or absence of spontaneous venous pulsation and the color and quality of the disc. Be certain to note if the disc is elevated, edematous or inflamed. These basic observations help the neurologist assemble a clinical picture of a patient with a headache.

Retrobulbar optic neuritis is another common diagnosis that requires neurological referral. If this diagnosis is considered, ensure that your patient consults a neurologist who is intimately familiar with the Optic Neuritis Treatment Trial (ONTT) and its follow-up information.3 Oral steroids are initially contraindicated in favor of IV methylprednisone, followed by oral prednisone dosing. Remember that you are potentially responsible for the result of your referral, and it is important that you understand the neurologists approach.

In the case of a headache, your report to the neurologist should include the patients history, best-corrected acuity, and a thorough description of the optic nerve and retina. Be certain to include full-threshold visual fields and results of Ishihara color plates (performed monocularly). Specifically document either the presence or absence of an afferent pupillary defect, as required.

Sarcoidosis patients commonly present with granulomatous uveitis, as seen here.

Pulmonologists

Patients with sarcoidosis are often referred to a pulmonologist. Consider referral to a pulmonologist if you treat granulomatous uveitis in a sarcoid patient, especially if he or she has respiratory symptoms. Many of these patients have granulomas of the lung and require treatment with systemic steroids or other immunosuppressive agents. Sarcoid patients often have a long history of prednisone use, and the pulmonologist should be kept apprised of any ocular effects that may result, especially cataracts and glaucoma. Plaquenil and methotrexate therapies may be attempted; these demonstrate fewer ocular side effects than prednisone.4

Otolaryngologists

Ear, nose and throat specialists (ENT) can be a great resource. Depending on patient history, an ENT consultation may be quite beneficial for patients who suffer from headache. Pain that is localized to sinus regions, fever, nasal discharge, and changes in voice resonance may warrant a sinus work-up. The consulting ENT should be advised on the status of the patients extraocular muscle facility, any possible orbital congestion or proptosis, intraocular pressure, and either the presence or absence of papilledema. Similarly, spontaneous venous pulsation can help rule out orbital involvement and should be reported. Although rare, severe erosive sinus disease can affect these findings.

The ENT may be helpful in additional areas. For example, an ENT is usually proficient in the treatment of allergy. Additionally, many ENTs perform repair of orbital fracture and other oculoplastic surgeries. Consider the ENTs skills and interests prior to referral, as they may be required if local ophthalmologists are unavailable to perform the necessary procedures.

 

Mental Health Professionals

A referral to a mental health professional is perhaps one of the most difficult treatment decisions that you will have to make. Optometric education does not usually include much classroom or clinical material on mental health issues; however, many of your patients may require assistance in this area.

Patients who manifest anxiety and phobias are quite common, and many have yet to seek mental health consultation. Some have peculiar expectations or beliefs about prescription eyewear that may signal deeper mental disorders. Other patients may need help in coping with difficult ocular health diagnoses. Encouragement from the family optometrist can be a starting point for proper therapy.

Additionally, some patients may express seemingly bizarre symptoms that are centered on ocular comfort or vision. In these cases, it is especially important to rule out genuine organic causes, as an undiagnosed pathology can be tragic. For example, patients with age-related macular degeneration can experience unusual visual imagery or hallucinations as part of the pathologic process.5 In this instance, symptoms must be pinpointed before you consider any mental health referral.

Optometric examination and reporting should provide the information that a mental health professional may need, especially any associated neurological findings. Include comments on specific symptoms, cranial nerve function and visual fields (if indicated) in your referral. It is also helpful to note and comment on the baseline clarity of the crystalline lens because certain psychiatric medications can contribute to cataract formation.6 Take caution to avoid making specific mental health diagnoses that are beyond your capabilities.

 

Emergency Department Staff

Though emergency department referrals are relatively uncommon in optometric practice, there are occasions when this is the proper course of action. In addition to common causes of acute illness, including heart attack, stroke and diabetic coma, you must be aware of conditions that require urgent care, such as giant cell arteritis. These patients may manifest vascular inflammatory illness, such as polymyalgia rheumatica, along with acute vision loss and a swollen optic nerve, and their survival, as well as maintenance of vision in the unaffected eye, depends on rapid access to medical care.7 Inevitably, some of these scenarios will occur when the family physician is unavailable and/or when medical subspecialty care is not yet established.

Any referral to an emergency department should be preceded by a phone call to the attending physician. This simple courtesy may be self-evident, as it allows the receiving physician not only to start his or her own thought processes, but also to summon appropriate resources based on the nature of the referral. However, the phone call may also give the emergency department its prerogative to re-route a patient to another hospital, based on patient census or the skill set of the involved physicians. For example, a local hospitals emergency department recently declined to evaluate a very young patient of mine with an inflamed optic disc because the attending physician knew that his department lacked the expertise and resources to handle the case. In any case, a referring phone call is always better than having the patient present at the emergency department unannounced.

 

It is essential for optometrists to develop referral relationships with a variety of medical specialists. While your patients primary-care physician should be intimately involved in the process, direct referral to a variety of medical specialists can result in more rapid and efficient care. Familiarity with the local health-care system, including one-on-one relationships with medical specialists, can enrich your professional life and serve as a great aid to patient care.

Dr. Potter is chief of optometry and contact lenses with Millennium Eye Care, a multi-subspecialty optometry/ophthalmology practice in Freehold, N.J.

 

1. Marmor MF, Carr RE, Easterbrook M, et al. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy: a report by the American Academy of Ophthalmology. Ophthalmology 2002 Jul;109(7):1377-82.

2. Hughes EH, Dick AD. The pathology and pathogenesis of retinal vasculitis. Neuropathol Appl Neurobiol 2003 Aug;29 (4):325-40.

3. National Eye Institute. Clinical Studies Database: Optic Neuritis Treatment Trial (ONTT). Available at: www.nationaleyeinstitute.org/neitrials/viewstudyweb.aspx?id=47 (Accessed January 21, 2009).

4. Doherty CB, Rosen T. Evidence-based therapy for cutaneous sarcoidosis. Drugs 2008;68(10):1361-83.

5. Nixon PA, Mason JO. Visual hallucinations from age-related macular degeneration. Am J Med 2006 Mar;119(3): e1-2.

6. Shahzad S, Suleman MI, Shahab H, et al. Cataract occurrence with antipsychotic drugs. Psychosomatics 2002 Sep-Oct;43(5):354-9.

7. Kunimoto D. The Wills Eye Manual, 4th ed. Philadelphia: Lippincott, Williams and Wilkins, 2004:227-8.