Table 1.
Subspecialty - wise triage of ophthalmic clinical situations**
| Specialty | Emergency - See immediately | Urgent - See as soon as possible | Routine - Reschedule >3 months or Teleophthalmology |
|---|---|---|---|
| Comprehensive Ophthalmology | |||
| New/Follow-up | • Any acute/severe vision loss | • Blepharitis | |
| • Mild/moderate dry eye | |||
| • Watery eye | |||
| • Most conjunctivitis (triage via teleophthalmology) | |||
| Surgery | • Elective cataract surgery, Nd: YAG capsulotomy | ||
| • Laser refractive surgery | |||
| Cataract | |||
| New/Follow-up | • Cataract/Posterior capsule opacification | ||
| Surgery | • Cataract surgery for intractable high IOP (phacomorphic glaucoma, phacolytic glaucoma, angle-closure glaucoma), Cataract surgery for traumatic cataract with the ruptured anterior lens capsule | • Cataract surgery for cataract blindness when the patient is legally blind (i.e., combined effect of BCVA <6/60 in both eyes or field of vision constricted to 10 degrees or less of arc around central fixation in the better eye) | • Elective cataract surgery, Nd: YAG capsulotomy |
| Cornea/Refractive Surgery | |||
| New/Follow-up | • Microbial keratitis • Corneal trauma • Acute peripheral ulcerative keratitis • A neurotrophic cornea with ulceration • Therapeutic (bandage) contact lens patients • Corneal graft rejection • Ocular surface squamous neoplasia • Stevens Johnson syndrome |
• Minor trauma (e.g., abrasions, foreign bodies, recurrent corneal erosions) • Corneal ectasia with a moderate risk of progression (age <21 or documented progression>1D in 6 months) • Marginal keratitis (follow-up with teleophthalmology if appropriate) • Severe sight-threatening ocular surface disease • Routine post-operative patients |
• Blepharitis • Mild/moderate dry eye, any other ocular surface condition • Corneal ectasia with low risk of progression • Drug-induced keratopathies • Metabolic keratopathies |
| Surgery | • Urgent tectonic keratoplasty (perforations) • Therapeutic keratoplasty • Urgent primary care for chemical burns/thermal burns/Stevens Johnson syndrome |
• Keratoplasty for bullous keratopathy with a high risk of infection or pain • Keratoplasty in a patient <6/60 in both eyes with expected short term improvement • Cross-linking for progressive ectasia (either rapid progression or borderline thickness) |
• Laser refractive surgery • Routine corneal transplantation • Pterygium surgery • Collagen cross-linking for slowly progressive ectasia |
| Glaucoma | |||
| New/Follow-up | • IOP >40 mm Hg • Congenital and developmental glaucoma • Acute angle-closure • Acute neovascular glaucoma |
• After a change of glaucoma therapy where IOP is anticipated to change • Routine post-operative care for glaucoma filtration surgery/tubes • Anyone with IOP >30 mm Hg and glaucomatous visual field defect • Uncontrolled glaucoma |
• Stable glaucoma monitoring with no documented progression for 2 years • Ocular hypertension with no evidence of glaucoma and at low risk of developing glaucoma in the next 6 months |
| Surgery | • Acute uveitic glaucoma • Acute lens-related glaucoma • A new referral that the treating ophthalmologist considers urgent • Lens extraction surgery to ameliorate angle closure disease not controlled with laser or medical therapies • Glaucoma surgery for IOP lowering of any type in advanced glaucoma, rapid progression or very high IOP where clinically important progression is likely in the next 1 month, where conservative therapies have failed, are likely to fail or are contraindicated • Any surgery to manage acute sight-threatening complication of glaucoma surgery (e.g., bleb or tube infection) • Closure of cyclodialysis cleft leading to sight-threatening hypotony |
• Lens extraction surgery to ameliorate angle closure disease when the risk of progression of angle-closure or glaucoma over the next 6 months is unacceptably high. This includes the at-risk fellow eye of eyes blinded by angle closure disease • Glaucoma surgery for IOP lowering of any type in glaucoma where clinically important progression is likely in the next 6 months, where conservative therapies have failed, are likely to fail or are contraindicated |
• Elective cataract surgery in glaucoma patient not blinded by cataract • Any lens extraction procedure combined with micro bypass glaucoma surgery where the lens extraction itself does not fall into high or medium urgency |
| Medical Retina | |||
| New/Follow-up | • Suspected or confirmed active CNV needing treatment • Intravitreal injections for Neovascular AMD, Diabetic macular edema, retinal vein occlusion, other CNV, macular edema. Treat and extend to maximum interval possible. • Active proliferative diabetic retinopathy requiring treatment (PRP laser or intravitreal-anti VEGF) • Malignant hypertensive retinopathy • ROP screening and laser and anti-VEGF treatment[22] |
Macular edema requiring treatment | • Non-neovascular (dry) AMD • Low-risk diabetic retinopathy screening • Non-proliferative diabetic retinopathy without macular edema • Stable treated proliferative diabetic retinopathy • Central serous chorioretinopathy • Macular telangiectasia without CNV • Retinal dystrophies • Screening for macular drug toxicity • Angioid streaks • Hypertensive retinopathy (non-malignant) • Choroidal folds |
| Vitreoretinal Surgery/Trauma | |||
| New/Follow-up | • Acute retinal detachment • Suspected retinal tears • Open globe injuries: Including IOFB • Acute endophthalmitis • Vitreous hemorrhage (dense, requiring vitrectomy) • Dropped nucleus requiring vitrectomy/lensectomy • Submacular hemorrhage requiring vitrectomy • Aqueous misdirection requiring vitrectomy • Complex surgery post-operative (minimize visits) • Diagnostic vitrectomy for infectious or oncological causes |
• Acute full-thickness macular holes • Severe vitreomacular traction syndrome • Myopic traction maculopathy with foveal detachment • Heavy liquid removal • Exposed scleral buckles at risk of infection |
• Epiretinal membranes • Silicone oil removal (unless developing complications such as emulsification) • Intraocular lens procedures • Symptomatic vitreous opacities |
| Surgery | • Surgery for the above, surgery for ROP and drainage in cases with appositional choroidal effusion, suprachoroidal hemorrhage, or flat anterior chamber | • Surgery for the above | • Surgery for the above |
| Uveitis | |||
| New/Follow-up | • Acute anterior uveitis, posterior uveitis, panuveitis • Intermediate uveitis with vision-threatening complications • Retinal vasculitis • Patients with uveitis of any form affecting an only eye (VA in fellow eye <6/60) |
• Chronic/persistent anterior uveitis managed with topical therapy only, teleophthalmology recommended where possible • Quiescent/stable forms of uveitis on stable systemic therapy (prednisolone dose <=7.5 mg/daily); teleophthalmology recommended where possible • It is highly recommended that patients receiving an intravitreal depot steroid injection for uveitis have at least 1 clinic review/in-person IOP check (ophthalmologist or optometrist) 3-6 weeks post-injection |
• Patients with an established history of recurrent, self-limiting episodes of acute anterior uveitis without sight-threatening complications (e.g., cystoid macular edema, steroid response) could be considered for teleophthalmology consult at the onset of a recurrence and for follow-up at 6-8 weeks, with clinical review if indicated • Uveitis cases in remission (quiescence without any treatment) |
| Surgery | • Vitreous biopsy and/or AC tap for infectious/inflammatory uveitis or malignant tumors | • Most uveitic cataracts | |
| Ocular Oncology | |||
| New/Follow-up | • Suspected malignant ocular tumors (e.g., retinoblastoma, uveal melanoma, metastases, intraocular lymphoma, etc.) • Confirmed malignant ocular tumors requiring acute treatment • Tumors previously booked for 3 months planned follow-up interval |
• Fundus tumors/lesions causing macular exudation (choroidal haemangioma, Coats, retinal capillary haemangioblastoma) • Tumors previously booked for up to 6 months planned follow-up interval |
• Stable choroidal naevi, CHRPE, iris cysts • Stable treated tumors • Tumors previously booked for over 6 months planned follow-up interval |
| Surgery | • Surgery for malignant tumors (including plaque brachytherapy for choroidal melanoma, enucleation, EUA and focal therapy, chemotherapy, etc) | Surgery for the above | |
| Oculoplastics | |||
| Alert: Due to the high risk of COVID 19 infection from the nasopharynx, avoid all nasal syringing, lacrimal surgery and nasal endoscopy. Treat thyroid eye disease medically first. If orbital decompression is still required, avoid medial wall/floor decompression which creates an entry into the paranasal sinuses. | |||
| New/Follow up | • Severe thyroid eye disease • Orbital tumors (sight threatening or malignant-suspected/known) • Orbital vascular lesions (carotid-cavernous fistula, progressive/sight-threatening vascular anomalies- e.g., extensive haemangioma, progressive vascular malformation e.g., acute bleed) • Orbital inflammatory disease (orbital/periorbital cellulitis, orbital abscess; sight-threatening orbital inflammation of any cause; acute dacryocystitis/lacrimal abscess, panophthalmitis) • Periocular malignancy (biopsy-proven or suspected) including melanoma (invasive and in situ), sebaceous carcinoma, squamous cell carcinoma, other high-grade malignancy (Merkel cell, adnexal carcinoma, etc.), high-risk basal cell carcinoma (medical or lateral canthal, recurrent, high-risk subtype, locally advanced i.e., orbital invasion) |
• Progressive benign orbital tumors • Moderately severe thyroid eye disease • Entropion (triage with teleophthalmology if appropriate) • Basal cell carcinoma (triage with teleophthalmology if appropriate) • Lacrimal: Recurrent/low-grade dacryocystitis, canaliculitis. Treat medically first, if requires surgery prefer percutaneous drainage, avoid DCR due to COVID-19 risk • Post-operative simple surgery • Pediatric ptosis with known/high risk of amblyopia (visual deprivation, failed amblyopia therapy) |
• Orbit: all other, including TED (stable mild-moderate) • Other eyelid malpositions: ptosis, brow ptosis, dermatochalasis, ectropion • Some low-risk BCC that has previously been examined (triage with telehealth if appropriate) • Benign periocular tumors (e.g.,chalazion/papilloma) • Lacrimal: All other |
| • Severe unilateral ptosis in an infant • Post-operative complex surgery • Recent trauma including eyelid and canalicular lacerations, orbital fractures and suspected orbital foreign body • Dacryocystocele (pediatric CNLDO with nasal involvement not resolving/acutely infected). Treat medically first, if requires surgery prefer percutaneous drainage, avoid DCR due to COVID-19 risk |
|||
| Surgery | • Surgery for the above | • Surgery for the above | • Surgery for the above |
| Genetics | |||
| New/Follow-up | • Most patients | ||
| Pediatric Ophthalmology | |||
| New/Follow-up | • Sight or potential life (systemic) threatening conditions • Cataracts causing amblyopia or under 4 months old • Reduced vision in both eyes • Reduced vision in one eye under age 7 years • ROP screening • Children on medication (drops or systemic) for glaucoma, uveitis, corneal disease • Post-operative within last 2 months |
• Patients having amblyopia treatment. Where possible, use teleophthalmology • Pediatric oculoplastic/adnexal cases • Reduced vision in one eye over age 7 years. Where possible, use teleophthalmology video/photos to triage • Examination under anesthesia where management is time-sensitive |
• Case by case triage |
| Surgery | • Cataract surgery in under<4 month age or where causing amblyopia • Retinoblastoma treatment • Pediatric glaucoma surgery where conservative therapies have failed • ROP treatment |
||
| Strabismus | |||
| New/Follow-up | • Triage of referrals on a case by case basis (accept suspected neurological strabismus) | • Triage of referrals on a case by case basis (except strabismus where amblyopia management is also required). Where possible, use teleophthalmology | • Most other non-acute strabismus cases |
| Surgery | • Acute trauma-related conditions requiring immediate surgery | • Most strabismus surgery and botulinum muscle injections | |
| Neuro-Ophthalmology | |||
| New/Follow-up | • Patient by patient triage needed (except acute optic neuropathies, suspected SOL or raised intracranial pressure, neurological diplopia, acute pupillary signs) | • Where possible, use teleophthalmology | • Stable patients or patients where management will not change outcomes |
| Surgery | • Optic nerve sheath fenestration for severe visual loss in idiopathic intracranial hypertension, Temporal artery biopsy | ||
**Adapted from the guidelines issued by the Royal Australian and New Zealand College of Ophthalmologists (RANZO)[5]