1. Squint: All children over 3 years with squint or suspected squint must have a full eye examination by an optometrist.
This exam must include assessment of visual acuity, assessment of the squint and ocular motility, cycloplegic refraction and fundus examination. If significant hypermetropia is present, children should be given their full cycloplegic correction and reviewed after 6 to 8 weeks.
Children under 3 years with a suspected squint or visual problems should be referred directly to the hospital eye service.
Squint in Babies:
Babies have unstable ocular alignment up to the age of around 4 months, so often have an intermittent squint especially when tired. If a baby carries on showing signs of an intermittent or constant squint after 4 months of age they should be referred to the Hospital Eye Service (SCI-GW: RHSC >> Ophthalmology). If there are concerns about a constant squint at less than 4 months of age, the red reflex should be checked and baby referred urgently only if the red reflex is abnormal; for all other on-going squints please refer once the infant is over 4m.
Please also see flowchart for referral of children with suspected strabismus and/or amblyopia
2. Reduced visual acuity in school age children: Any school age child with reduced vision should be assessed by an optometrist who will refer onwards to the hospital eye service if required.
3. Children with developmental delay (including trisomy-21 (Down’s syndrome) or behavioural problems: All newborns are screened for congenital cataracts at birth and again at 6 weeks of age. Children with behavioural problems or developmental delay who are suspected of having a squint or reduced vision should be referred to a community optometrist in the first instance if they are over 3 years and directly to the hospital eye service if they are under 3 years. All children with Down’s Syndrome should be referred to the hospital eye service for a full eye examination between 18 months and 2 years. See detailed guidance for Down’s Syndrome (dsmig.org.uk)
4. Children with permanent childhood hearing impairment: Children with permanent conductive or sensorineural deafness or who wear hearing aids should be referred to the hospital eye service for an eye examination. For more information see sense.org.uk
5. Tarsal cyst (chalazion): The vast majority of tarsal cysts resolve spontaneously. Children with tarsal cysts that have been present for 6 months or more may be referred for consideration of surgery under general anaesthesia. Surgery will only be considered if at least 3 months of moist heat and massage has failed.
6.Watery / sticky eyes in infants: Watery/sticky eyes due to blocked tear ducts are common and resolve by 18 months of age in 95% of children*. Conjunctival swabs for culture and sensitivity should not be performed and routine use of topical or systemic antibiotics is not indicated unless there are signs of secondary conjunctivitis (redness with yellow/green discharge) or cellulitis of the eyelid. Lacrimal sac massage can aid resolution and should be the first line of treatment. Referral for surgical probing should not be made until the child is over 1 year old.
*Rarely, watery eyes are due to congenital glaucoma but in this situation the eye(s) is enlarged, the cornea is usually cloudy and the infant is typically light sensitive.
7. Dyslexia: In dyslexia the brain has difficulty understanding language including written words. Most children with dyslexia have no visual problems but should be assessed by a community optometrist to rule these out. Coloured overlay assessment is not available in the NHS Lothian Children’s Hospital Eye Service.
Urgency of the condition
This table has been developed as a tool to assist with ophthalmology referrals. However diagnoses are not absolute and if there are atypical features please contact the triage nurse for advice regarding referral.
Please phone the triage desk Monday to Friday between 08.30 and 16.30 (PAEP) or 9.00 to 17.00 (St John’s). If you have an emergency/urgent query out with these hours contact the on call ophthalmologist through the RIE switchboard.
Emergency – same day
Urgent – <1 week
Soon – 1-3 weeks
Routine – 6-8 weeks
Emergency referrals include: retro-orbital haemorrhage, acute angle closure glaucoma, penetrating eye injury and severe chemical injury.
| Condition | How Soon | Additional Information |
| Paediatrics | | |
| Cataract in a child | Urgent | |
| Suspected retinoblastoma | Urgent | |
| Neonatal conjunctivitis (within 28 days of birth) | Urgent | Refer to secondary care (Sick Children’s) |
| Acute reduction in vision | Urgent | |
| Squint –<3 years of age refer to ophthalmology>3 years refer to optometrist | Routine | |
| Diagnosis of permanent sensorineural/conductive hearing loss | Routine | See paediatric referral section |
| Children with Down’s syndrome | Routine | Refer for vision assessment between 18 months to 2 years |
Who to refer:
Please see Lothian GP and optometry ophthalmology referral pathway.
Urgency of the condition for details on how soon patients should receive an appointment.
Please see condition specific information for descriptions and management of many common ophthalmological conditions.
Patients who present with a problem with their only seeing eye should be advised to see an optician/ophthalmologist for review.
Who not to refer:
Amaurosis fugax – please refer to the neurovascular clinic. Please assess vascular risk factors including blood pressure, cholesterol and diabetes.
Giant cell arteritis (GCA) – if there are no visual symptoms please discuss with the rheumatology department.
Some routine conditions can be managed in primary care (GP and optometrists) e.g. conjunctivitis, abrasions, allergy and dry eyes. Additionally, herpes zoster ophthalmicus without eye involvement can often be managed in primary care. Consider getting an assessment by an experienced optometrist. Optometrists can provide appointments for patients as part of the General Ophthalmic Services Contract and are required to see emergency patients in a timely manner.
How to refer:
We require a referral letter for EVERY patient.
The preferred referral process is via SCI Gateway. If sending/forwarding a referral via SCI gateway please include past medical history, allergies and medications
If you do not have access to fax or SCI Gateway e.g. if you have arranged an appointment out of hours please send a written referral letter with the patient to bring to their appointment.
Only if SCI Gateway is unavailable should a letter be typed or handwritten. Please write legibly and include your examination findings.
If you have arranged an appointment in the acute referral clinic and you are referring from within another hospital in Lothian please use TRAK to type the referral letter.
For optometry specific referral forms please see Information for optometrists
- Low Visual Aid Clinic 2021
- Patient Support Service
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- Ophthalmology -PIL Local Anaesthesia Apr17
- Optometry LEHN GP Reply Form
- Optometry Poster – look no further than optometrist
- Optometry Lothian Eye Network Triage Form V2 Jan18
- Optometry IT support info
- GP referral to optometry for Cataract & Other conditions
- Optometrist Cataract Referral Form OPT 003 (Electronic)
- Optometrist Cataract Referral Form OPT 003 (printable)
- Opthal Squint Amblyopia Flowchart 2018
- Optometrist General Referral Form OPT001 (Electronic)
- Optometrist General Referral Form OPT001 (Printable)
