Table 1.
Coding protocol of the study
| Categories and sub‐categories | Definition and example |
|---|---|
| Primary reason for referral | |
| History |
Comments relating to a patient's background or profile, ocular or medical history, family ocular or medical history ‘On plaquenil – immunologist concerned about vision’ |
| Symptoms |
Ocular or visual, primary or secondary patient complaints ‘Unexplained RE blur for last 3 months’ |
| Signs | Observable evidence of disease or dysfunction |
| Miscellaneous | ‘Macular drusen’ |
| Acuity | ‘Recent reduced BCVA LE, no improvement with pinhole’ |
| Amsler | ‘Mild distortion on Amsler grid’ |
| Diagnosis |
Identifying statement of disease or illness ‘ERM RE’ |
| Imaging |
Testing that provides photographic or similar evidence of the eye and associated structures ‘Macula assessment’ |
| Diagnosed/suspected condition | |
| NAD | ‘Amblyopia?’ |
| Normal aging changes | ‘Age change evident’ |
| AMD | |
| Dry | ‘possible early dry ARM changes’ |
| Geographic atrophy | ‘Dry AMD RE macular RPE atrophic changes’ |
| Wet | Not applicable (no cases were referred) |
| Severity not specified | ‘ARMD’ |
| ERM | ‘Epiretinal Membrane left macular’ |
| CSCR | ‘Left CSR first diagnosed Jan 2012, symptoms past 12 years’ |
| Other | A diagnosis had to occur more than 15 times (5% of the total dataset) before it was coded separate from ‘other’ |
| Non‐specific | Cases where no definitive diagnosis was provided, for instance, if the referral form only stipulated clinical findings |
| CFEH reported diagnosis | |
| NAD | ‘The findings indicate no apparent abnormalities in either macula’ |
| Normal aging changes | ‘Normal aging changes in both eyes’ |
| AMD | |
| Early | ‘early age‐related macular degeneration in both eyes’ |
| Intermediate | ‘intermediate AMD in both eyes’ |
| Geographic atrophy | ‘The findings indicate late AMD with geographic atrophy in each eye’ |
| Neovascular | ‘There is advanced AMD in both eyes and a possible choroidal neovascular membrane in the right eye’ |
| ERM | ‘epiretinal membrane in the right eye with a distorted foveal profile’ |
| CSCR | ‘There are macular changes consistent with acute central serous chorioretinopathy in the right eye’ |
| Other | |
| Non‐specific | |
| CFEH recommendation summary | |
| Routine review |
Normal or low risk patients suitable for routine review with the primary care optometrist. ‘We suggest routine review within your practice and subsequent imaging at CFEH if you feel there is any change’ |
| Recall |
Patients at risk of disease progression though not showing present signs that required treatment and are most amenable to intermediate‐tier eye‐care. ‘We suggest routine review within your practice and subsequent imaging at CFEH in 6 months’ |
| Refer |
Cases with sight threatening pathology e.g. neovascular AMD or with high‐risk features for progression to vision threatening disease, or where examination and opinion from an ophthalmologist was needed. ‘As discussed on the phone, we recommend referral to an ophthalmologist within a week’ |
RE, Right eye; BCVA, Best corrected visual acuity; LE, Left eye; ERM, Epiretinal membrane; ARM, Age‐related maculopathy; RPE, Retinal pigment epithelium; ARMD/AMD, Age‐related macular degeneration; CSCR/CSR, Central serous chorioretinopathy; CFEH, Centre for Eye Health.