Currently most ophthalmic units receiving referral letters for minor operations from GPs book patients in to clinics before placing them on a waiting list.
As part of an initiative programme to reduce waiting times at King's College Hospital in London, GPs were given an opportunity to book patients with eyelid pathology directly onto the minor operations list over a 6-week period. We audited this data retrospectively.
There were 85 subjects (50 males and 35 females) with a mean age of 41.6 years (range 16–75 years). The referring diagnoses were divided into three categories: chalazion/cyst (80% of referrals); skin tag/papilloma (16%); and unknown aetiology (4%). When compared with the diagnoses made by the senior attending ophthalmologists, there was a 34% diagnostic discrepancy. The main discrepancy (65% of cases) occurred in the skin tag/papilloma group (referred initially as cysts). The unknown group contained skin tags/papillomas (66%), and cysts (34%).
Analysis of the final outcome revealed that 26% of patients did not require (or want) surgery; these patients were discharged. The proportion of those discharged was directly related to the length of time between referral and the appointment, which averaged about 3 months.
The clinical diagnosis of benign eyelid lesions at ophthalmic departments has been shown to be fairly accurate when compared to histological samples,1 in particular for chalazia (up to 94%). However, where discrepancy occurs the lesions often have a premalignant or malignant aetiology.2,3
The accurate diagnosis of ophthalmic conditions is clearly in the best interests of all parties involved, and would optimise the use of resources in the treatment of conditions considered suitable for management as ‘minor ops’. Improvement in this arena has been demonstrated by organising workshops in some units. Furthermore, it appears that including ophthalmology as part of vocational training is the best way of achieving this aim.4
The direct-access pilot scheme was not shown to be an efficient way of conducting the minor operations service. A picture of the lesion may help the ophthalmologist decide where and when to list the patient. In addition, targeted training/workshops for GPs, and a telephone interview with the patient a week prior to their visit in order to confirm the continued presence of a troublesome lesion, may reduce the day-of-surgery discharge rate.
REFERENCES
- 1.Ozdal PC, Codere F, Callejo S, et al. Accuracy of the clinical diagnosis of chalazion. Eye. 2004;18(2):135–138. doi: 10.1038/sj.eye.6700603. [DOI] [PubMed] [Google Scholar]
- 2.Deokule S, Child V, Tarin S, Sandramouli S. Diagnostic accuracy of benign eyelid skin lesions in the minor operations theatre. Orbit. 2003;22(4):235–238. doi: 10.1076/orbi.22.4.235.17248. [DOI] [PubMed] [Google Scholar]
- 3.Margo CE. Eyelid tumours: accuracy of clinical diagnosis. Am J Ophthalmol. 1999;128(5):635–636. doi: 10.1016/s0002-9394(99)00302-5. [DOI] [PubMed] [Google Scholar]
- 4.Jackson C, De Jong I, Schuluter PJ. Changing clinician practice. The RACGP/RACO National GP Eye Skills Workshop. Aust Fam Physician. 2002;31(3):285–290. [PubMed] [Google Scholar]