Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • acute or unexplained visual loss
  • swollen bilateral optic nerves
  • acute onset double vision
  • acute onset unequal pupil (anisocoria) especially if associated with pain/headache
  • history +/- serological results suggestive of Giant Cell Arteritis (GCA)

Please contact the on-call registrar to discuss your concerns prior to referral.

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network 

Southern Adelaide Local Health Network

Exclusions

  • explained neurological visual field impairment
  • post-stroke return to driving assessment

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • unexplained neurological visual field impairment
  • asymmetry of pupil size or reaction with ptosis within 6 weeks onset
  • recent onset diplopia

Category 2 (appointment clinically indicated within 90 days)

  • asymmetry of pupil size or reaction without ptosis
  • suspected papilloedema on fundus examination

Category 3 (appointment clinically indicated within 365 days)

  • all other neuro-ophthalmology referrals not meeting the above criteria

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • relevant past medical/surgical history
  • current medications, allergies
  • ocular history, including:
    • symptoms and duration of clinical presentation
    • surgery and medical management
    • diabetes history
    • medication management
    • other eye conditions, for example unilateral vision
  • eye and vision examination both eyes:
    • best corrected visual acuity
    • automated visual fields examination
  • relevant social information including:
    • employment/education associated implications
    • carer for partner/family member
    • lives alone, unable to manage daily activities due to vision loss
  • optical coherence tomography (OCT) where possible
  • optometrist report less than 3 months old at time of referral

Additional information to assist triage categorisation

  • complete blood examination (CBE)
  • urea, electrolytes, and creatinine (UEC)
  • liver function tests (LFTs)
  • c-reactive protein (CRP)
  • erythrocyte sedimentation rate (ESR)
  • vasculitis screen
  • glycated haemoglobin (HbA1c) % if appropriate
  • computed tomography (CT) or medical resonance imaging (MRI) brain where possible

Clinical management advice

Pupil size asymmetry is a common occurrence in the general population and can be caused by either harmless or serious factors. Benign causes of asymmetry can include:

  • essential anisocoria, which is present from birth and usually results in less than a 1mm difference in pupil size in light and dark conditions, affecting up to 10% of individuals.
  • contact with certain medications or poisons can impact pupil reactions and size, as can eye trauma or surgery, which can result in dilation, constriction, or abnormal shaping of the pupil.

Important causes of asymmetry can include:

  • third nerve palsy, where sudden onset leads to reduced pupil constriction to bright light and may be accompanied by limited eye movement or ptosis,
  • Horner's syndrome, which causes reduced pupil dilation in low light and may also be accompanied by ptosis.

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

  • full name, including aliases
  • date of birth
  • residential and postal address
  • telephone contact number/s – home, mobile and alternative
  • Medicare number, where eligible
  • name of the parent or caregiver, if appropriate
  • preferred language and interpreter requirements
  • identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

  • impact on employment
  • impact on education
  • impact on home
  • impact on activities of daily living
  • impact on ability to care for others
  • impact on personal frailty or safety
  • identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery, where surgery is a likely intervention.
  • Choice to be treated as a public or private patient.
  • Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.