Primary care assessment and referral

Cataract is a common eye problem as people get older. General practitioners (GPs), Aboriginal health practitioners, optometrists and orthoptists are all primary care clinicians who may be your first point of contact for eye problems.

Cataract may be found as part of a routine eye test or because you are having trouble with your vision. Vision tests and an eye examination can identify whether you have cataract. These tests can be carried out by an optometrist or orthoptist, or by a specialist eye doctor (ophthalmologist). If you do have cataract, it is important for your clinician to understand how your visual problems are affecting your life, including the sorts of things that you can no longer do.

If cataract is not affecting your ability to carry out your usual activities, you may not need to consider surgery yet. Prescription glasses, or other equipment or aids might be worth considering – your optometrist, GP or low-vision service provider can advise you about the services available.

If cataract surgery is a suitable option for you and you are willing to consider surgery, your clinician can refer you to a specialist eye doctor for further assessment and to discuss possible surgery. Some specialist eye clinics will ask for specific information in your referral before they offer you an appointment. This might include eye test results from an optometrist, and information about other medical conditions and treatments from your GP or another clinician.

A patient with visual problems due to suspected cataract requires an ocular examination, preferably performed using a slit lamp biomicroscope or direct ophthalmoscope, and an assessment of how their visual problems are affecting their life. Optometry referral may be a suitable initial option for assessment of cataract.

Discuss the possible options to manage the patient’s symptoms and advise them that the presence of cataract alone is not an indication for surgery. Patients with lens opacities that do not cause visual symptoms or limit daily activities can continue to be managed and monitored in the primary care setting.

Consider referral for possible cataract surgery when patients have visual impairment that interferes with their ability to carry out their usual daily tasks, considering the possible impact on their ability to live independently. Ocular or medical comorbidities may affect the urgency of referral. Visual impairment can include reduced visual acuity, or disabling glare or contrast sensitivity. Vision-related activity limitations may include a loss of ability to work, drive, carry out daily tasks, or care for themselves or others – for example, an increased risk of falls in older people with risk factors. Box 1 provides information about assessment of vision-related activity limitation and some examples of assessment tools, see Cataract Clinical Care Standard full document.

Discuss the potential benefits and harms of cataract surgery, including the disadvantages of poor vision and the risks of complications. Assess the patient’s willingness to proceed with surgery if it is offered. Ophthalmology assessment can confirm whether patients with ocular comorbidity are more likely to benefit from surgery, or have an increased risk of complications.⁷

If referral is appropriate, check the referral criteria for the receiving service you are referring to, because requirements may differ between services. Ensure that all required information is provided; use a standardised cataract referral template if one is available. Both general practice and optometry assessment may be needed to provide the information required.^43-46 Improving the quality of the referral⁴⁶ can reduce delays for patients by helping ophthalmology services triage access to ophthalmology services and assess medical suitability for surgery.^42,47 Elements of a comprehensive referral that may be required by local referral guidelines are listed in Box 2, see Cataract Clinical Care Standard full document

If the patient does not to want to consider cataract surgery and there are no other indications for ophthalmology assessment, referral to an ophthalmology service may not be appropriate. Provide support for patients to reduce the impact of their visual problems, including refractive correction, tinted lenses to reduce glare, or use of suitable equipment to optimise vision and improve the patient’s capacity for activities of daily living.⁷ Refer to an optometrist, orthoptist, occupational therapist or vision clinic or other provider of low-vision services, if appropriate.

Primary care services making referrals should maintain awareness of any local referral guidelines or criteria for referral to ophthalmology or other eye services and have protocols to ensure that relevant information is included in the patient referral. Patient information about cataract and its management should be available for primary care clinicians to provide to patients. Information on any alternative community-based referral options should also be available.

Ophthalmology services receiving referrals should have guidelines that describe what information is required in referrals from primary care, and, where relevant, describe any criteria for accepting and prioritising referrals. This will usually be determined locally and take into account the availability of services, particularly in regional locations. Box 2 provides some of the components to consider in referral guidelines. Referral guidelines should be published online in an accessible, relevant location, and made readily available to referring clinicians and through Primary Health Networks, see Cataract Clinical Care Standard full document

A standardised referral template can be effective for improving the appropriateness of referral, as well as improving the quality of information needed to triage patients for ophthalmology appointments.^15,42,47