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Referrals between the many and varied branches of ophthalmology sometimes underline how sub-specialised we have all become nowadays. The old era when everyone was an ophthalmic jack of all trades is gone, for better or for worse, and instead of one ophthalmologist bodging their way through trabeculectomies, retinal lasers, enucleations, buckles and various squint surgeries we now live in a world where, say, a strabismologist will use one of many intricate techniques to correct fine gradations of squint as opposed to using one of the two ‘large or small correction’ operations that they might have been used to in yesteryear.

This parting of the ways within our specialty is in the process of creating a new language when we refer patients to each other that might benefit from a glossary all of its own:

Referrals to glaucoma:

The pressure has been a little high for the past few visits and we have tried many different drop combinations without success: The pressure has been more than 40 for the best part of a year, the disc is now fully cupped and we have finally realised the totality of what’s gone on. Please do something.

Please see this very nice gentleman with a cupped disc who might have glaucoma: The disc looks funny and the registrar asked me specifically about it right in front of the patient. It’s probably normal but I am in a bit of a bind now so I would appreciate the help.

Please see this gentleman with a cupped disc who might have glaucoma: The disc looks funny and the registrar asked me specifically about it right in front of the patient, who then became aggressive and asked me all kinds of questions about what glaucoma was that I was not properly able to answer and if you don’t see them before I see them again in six weeks it will cause me diplomatic issues.

Referrals to medical retina:

This patient whom I saw in the private hospital presented with possible AMD please see: They came with distortion and after receiving their fee I very obviously couldn’t see what’s going on without an OCT scan, which we don’t have here, and I can’t very well send them to specsavers now can I?!

I think this patient might qualify for treatment for their DMO: Their macular thickness is over 700 microns and has been for three years now.

I think this diabetic patient needs more laser due to persistent vitreous haemorrhage: There is no space to laser. None. It’s all filled in but as I know bleeding equals laser and that’s pretty much the end of my algorithm can you please take over?

Referrals to VR:

I think it might be best if you do this phacoemulsification on account of the phacodonesis, dense cataract and anxious nature of the patient: This is going south; we both know it. Come on man please save me a coronary and do it for me; my nerves are already shot as it is.

Please see this patient with an epiretinal membrane who might benefit from having it removed: This is an internal referral from inside the hospital. It will not need removal. But as only you can do this particular operation I can then absolve myself for responsibility for all the other aspects of his care so thank you.

I would be very grateful if you could see this lady with what appears to be a chronic retinal detachment without a demarcation line: I think it’s a schisis but if I call it that you won’t see it. I am so sorry to send this to you but it’s been years since I saw enough of these to be able to properly distinguish them so please please can you deal with it.

Referrals to cornea:

Please see this lady with bacterial keratitis who is not improving on current therapy: Every time I see her she gets worse and I think the registrar is starting to suss out that I don’t know what I’m doing here. I’ve even started doxycycline as I read somewhere that it’s helpful and the only stage left is citric acid please take her away from me!

Please see this man with a corneal dystrophy for possible graft: See there that I didn’t tell you what one it is? That’s because I have no clue. Vaguely somewhere I have a memory of Congo red and something called lattice though this is neither red nor stringy so if I keep things vague you might not totally know that I am unaware of what it actually is.

Perhaps this patient might benefit from a combined phaco / graft procedure? I can’t see anything here. It’s all blurred. If I try this phaco myself I will need a some form of benzodiazepine beforehand. Please take a look and even if you don’t think this is a goer there is a chance you might do the phaco anyway and my problem will evaporate.

Referrals to strabismus:

This patient has been seen by the orthoptic team who feel they might benefit from a recess / resect: Look, I just read the end of the report; the symbols are all double Dutch to me as they are to almost everybody.

This patient has a squint that I would appreciate your help with: Yes, I failed the squint station in Part 2 FRCOphth but as I knew I would never do squint ever again my limited knowledge has been atrophying ever since. I did try to do the cover test thing as the nurse was there and the eyes did jerk funnily but quite what that meant I have no clue. I thought that by saying ‘hmmm’ and shaking my head sadly it might convey to the patient that I did in fact know what was going on and thought an even bigger expert would be the icing on the cake here, hence my referral.

Please can you see this young lady with diplopia that the orthoptists seem to think has normal ocular motility: I think she’s insane, please help me. When I tried to tell her it was all okay and tick discharge she launched a stinging verbal assault on me and my registrar.

Referrals to paediatric ophthalmology:

This delightful child has a condition that I would appreciate your help with: I think I know what’s going on but they are a child and I get a bit funny with children as they do get odd things and they do fall within your remit so haha checkmate they’re your patient now.

This delightful child was seen with their parents: The parents are sensible.

This delightful child was seen with their anxious parents: The parents are a nightmare.

This child was seen with their parents: The child is a nightmare.

This anxious child was seen with their parents: The child screamed through the whole consultation and tried to assault me with a Goldmann Tonometer.

All specialties:

This patient was seen by ‘named individual’ in eye casualty / theatre / clinic: It’s a mess up. A total mess up. You will realise as soon as you see the patient so just know it WAS NOT ME that did this. Okay?

I hope you find this glossary useful in interpreting the hidden messages that abound in interspecialty referrals within ophthalmology. As the gaps between the specialties widen yet further the potential for misunderstanding grows exponentially and one day there might even be a need for a glossary for interactions between different branches of the same subspecialty. Unless of course COVID-19 resets the clock and we all find ourselves trying to do trabeculectomies and corneal grafts with a choice between four different twisted bits of metal for both procedures again.

Good luck!

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CONTRIBUTOR
Gwyn Samuel Williams

Singleton Hospital, Swansea, UK.

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