Vision at risk.

Our thanks go to AFP for the recent issue ‘Vision at risk’ (AFP October 2009). Numerous articles1–4 highlighted the difficulties experienced by GPs in the assessment, investigation and management of potentially catastrophic acute eye presentations. Although the articles were excellent, we feel that they only covered those presentations from the ‘severe’ end of the clinical spectrum, and failed to address the issue concerning eye presentations that arise in every day general practice – what to do with an eye presentation where there is a degree of clinical uncertainty. In a recent article by Statham et al5 10/11 of the patients that suffered a severe adverse event due to incorrect primary health care provider (PHCP) diagnosis and treatment had presented with a unilateral red eye, with a mean delay in referral to a specialist service of almost 8 days. Traditional teaching of PHCPs is to, ‘Beware the unilateral red eye – think beyond bacterial or allergic conjunctivitis’6 and to seek an appropriate ophthalmological opinion if symptoms fail to settle.7 To make explicit the dangers associated with the care of acute eye disease by PHCPs, may we suggest a list of ‘golden rules of acute eye presentations’ to AFP readers: • if there is any doubt in diagnosis or treatment, refer • if the condition is not improving in 12–24 hours, refer • if the patient reports eye (globe) pain, refer • if there is a concerning change in vision, refer • if the patient has only a single ‘good eye’ and develops symptoms in that eye, refer immediately • any diagnosis that requires treatment with steroid drops requires ophthalmic advice/opinion before commencing treatment.8 We would be extremely interested in the opinion of other PHCPs, and in particular our specialist ophthalmologist colleagues, to the list of recommendations. Robert Douglas, Tonia Mezzini Adelaide, SA