The College of Optometrists

I was speaking to a fellow pre-reg today who told me he refered a 4 year old child who came in for his 1st ever eye exam, Rx was: 0.00/-4.50 DC VA:6/12 R+L to the HES for managment. No pathology, No BV anomaly.

Is it justified as optometrists to refer patients to the HES on grounds of refraction alone.

I would have prescribed the Rx and reviwed the Px in say approximately 6 weeks. If VA hadn't improved I would have then refered otherwise I would have continued to manage the Px providing the VA kept improving, ultimately to 6/5 R+L

Any comments/suggestions??

This is a very interesting question

and different people will give you different opinions!

As you say, under the terms of referal you could decide to treat the patient yourself by spex and (possibly) patching.

The advantages for the patients convenient deals with one practitioner only

Disadvantages No second opinion or other view available In-practice may not have tests or equipment for treating a young child. You only get one shot at this and any time 'wasted' in poor treatment may affect outcomes. The 'burdon' (and it is!) of good compliance falls on the practice. Compliance with kids and their treatments is notoriously difficult.

In my own view, the ethics are that I would refer - because I would not like to assume the obvious that the vision is purely due to astigmatic amblyopia (it could be due to something else - a brain tumour for example).

So I would get a second opinion at eye clinic. To me, that is not a cop out - it is simply being cautious and patient centred. The outcomes will affect the persons life and are thus very important. I would only treat someone like this within a team setting.

The person is being refered on the grounds of reduced vision - possibly amblyopia. That is good grounds. There was an optom fairly recently who was up before the GOC 'cos he failed to refer a kid with amblyopia. the child was finally refered three years later and the outcome was not so good. He did get off the charge - but not without a fight. His care plan was specs only - but the patient was not terribly compliant.

Perhaps I am wrong in my approach - but how would you build in safety and fall back into your care plan? Just suppose they don't comeback after 6 weeks - but troll in after a couple of years! =steve

Some interesting points raised there, thank you

Cheers Kappa

I find ethics in practice quite interesting.....

I have an elderly lady of 83 who loves wearing her contact lenses when going out.

Two years ago what with her dry eye and chronic blepharitis - I advised her to call it a day and return to glasses.

A very intersting conversation followed = she pleaded tht her only fun came from wearing her lenses out and they were important to her. What did it matter if they upset her eyes anyway? - she said. She could use comfort drops and if had a problem would rush in for help anyway. At her age - neovascularisation etc - would hardly matter, she said.

I thought about this - and i think she is right and I agreed with her -she is happily wearing her lenses upto today. So a less cautious approach can be justified.

But for yr friends little patient with poor vision -the opposite view I think is appropriate. This is because of the possibly tragic outcome if things went wrong. If one had oodles of experience and the College Cert in Bin V - then possibly yes - take it on. But a parent is bound to worry about their kid - and would like a second opinion. Besides - as I said -you never know and its Murphy's Law which rules Optometry! Further more high astigmatism is associated with various dystrophies and learning problems - so these may also need looking at.

= any way - all the best and good luck - steve

Personally when in community practice I would have taken the less cautious approach prescribing the full prescription (if I had got it by cycloplegic refraction or was very confident of my subjective on a four year old, but that's a whole different can of worms) and reviewed in six weeks. If the VA had improved then I would have monitored three to six monthly, if there was obvious amblyopia I could have considered patching.

If I did not have adequate children's tests I would not consider examining children, another issue entirely.

If I did not feel confident managing a child then I would refer, however if you have had a good view of the fundus with either direct or indirect ophthalmoscopy you've done as much as an ophthalmologist will do in the HES usually. They will not do CTs or MRIs unless they have a good reason and 6/12 with that Rx is not an unexpected result. I suspect if it had been an adult your colleague would have prescribed and not referred unless they found the VA did not improve with the RX.

The optometrist who faced a GOC hearing did not refer even though the VA was not improving.

As a HES optometrist I run community and Hospital clinics where children are managed refractively and orthoptically by an optometry and orthoptic team and do not see an ophthalmologist. The only benefit to refering to the HES in the vast majority of cases without pathology is that we have more time to manage them and the GOS fee system is not well designed to manage children.