Referral patterns to an ophthalmic outpatient clinic by generalpractitioners and ophthalmic opticians and the role of theseprofessionals in screening for ocular disease

R J Harrison, J M Wild, A J Hobley

AbstractCase notes of 1113 consecutive new patients referredto a consultant ophthalmologist at a district generalhospital were reviewed to determine the sourceand efficacy of referrals and the current screeningpractices of general practitioners and ophthalmicopticians. General practitioners initiated referral in546 cases (49%) and ophthalmic opticians referral in439 (39%). Visual loss or visual disturbance was themost important single reason for referral (345 cases;31%), followed by suspected glaucoma (145 cases;13%), abnormalities ofbinocular vision (140; 12-5%),disorders of eyelids or ocular adnexa (127; 11%), andred eye (86; 8%). General practitioners referredmany more patients with disorders of the eyelidsand adnexa and ophthalmic opticians many morepatients with suspected glaucoma. Ophthalmicopticians were far more likely than general practi-tioners to refer patients with suspected glaucomacorrectly.A total of 180 patients (16%) were referred from

ocular screening, in 149 cases by ophthalmicopticians and in 10 by general practitioners. Seventypatients had glaucoma or incomplete features ofglaucoma, all of them referred by ophthalmicopticians. Of eight diabetic patients referred byophthalmic opticians, three had asymptomatic dis-ease and in two diabetes was diagnosed as a resultof ocular screening. No patient was referred forasymptomatic diabetic retinopathy from screeningby general practitioners. Ophthalmic opticians weremore likely than general practitioners to diagnoseretinopathy requiring photocoagulation.Use of a community based service to screen for

glaucoma could save unnecessary consultant out-patient appointments. A similar service could facili-tate detection of diabetic retinopathy at a stage whentreatment is most effective.

Burton General Hospital,Burton-on-Trent,Staffordshire DE14 3QHR J Harrison, FRCS,consultant ophthalmologist

Department of VisionSciences, AstonUniversity, BirminghamB4 7ETJ M Wild, PHD, lecturerA J Hobley, MSC, clinicaldemonstrator

Correspondence to: MissHarrison.

IntroductionSince 1948 sight tests have been available without

charge to the general public, initially through theOphthalmic Supplementary Service and since 1975through the General Ophthalmic Service. Most sighttests are undertaken by ophthalmic opticians (87-5% in1985-6)' and the remainder by ophthalmic medicalpractitioners. Ophthalmic opticians have a statutoryduty under the Opticians Act 1958 and the ensuingGeneral Optical Council rules to refer patients withinjury or diseases of the eye to a general medicalpractitioner, and under the NHS (General OphthalmicService) Amendment Regulations 1985 to inform thegeneral practitioner of any abnormality of the eyes.Evidence from studies suggests that the GeneralOphthalmic Service is a main source of referrals tothe hospital eye service, particularly with respect toglaucoma.24 Legislation within the current Health andMedicines Bill, however, proposes to abolish the freeNHS sight test for all but certain minority groups.Though the planned legislation was thwarted in theHouse of Lords, there is no evidence of change in thegovernment's attitude. If the bill is ultimately passedthe amount of screening now undertaken will almostcertainly decline.

This study aimed at investigating referral practicesto the outpatient clinic of a consultant ophthalmologistand at identifying the current screening practicesof ophthalmic opticians and general practitioners,particularly with respect to the diagnosis of glaucomaand diabetic retinopathy. An appreciation of thepattern of referrals and of the present effectiveness ofscreening will help guide any changes in practice thatmay become necessary should the free sight test beabolished.

MethodsFrom 1 November 1986 to 31 December 1987, 1437

patients were referred to a consultant ophthalmologistat Burton District Hospital Centre. On the basis of thereferral letters patients were allocated urgent, semi-urgent, or non-urgent appointments. The case notes of1113 of these patients were reviewed. The remaining324 patients had not been seen by the time the studywas concluded.Most of the patients were seen by a single consultant

ophthaliologist and the remainder by a clinicalassistant or one of several senior house officers. Thesample comprised all routine referrals from generalpractitioners, hospital doctors (mostly consultants),and community medical officers. A few emergencyreferrals were included if the patients had been seenoriginally in the clinic; those initially seen outsideclinic times or referred from the casualty departmentwere not included. Many outpatient attendances wereinitiated by ophthalmic opticians, who referred patientsvia the general practitioner. General practitioners wererequested to include a copy of the optician's report,usually on form GOS 18, with their referral letter.

Biographical data were obtained from the case notes,including sex, age at time of attendance, and source ofreferral-that is, general practice, ophthalmic opticalor ophthalmic medical practice, hospital doctor, orcommunity medical officer. The referral letters wereanalysed for reports of symptoms and the primary andsecondary reasons for referral. The reason for referralwas classified by using a system devised for the studywhich was based on symptoms and anatomical loca-tion. Referral data were also analysed for the types ofexaminations undertaken by the referring agent-for example, assessment of visual acuity, ophthalmo-scopy, assessment of binocular vision, visual fieldexamination (including type of visual field test),measurement of intraocular pressure, and fluoresceinstaining of the cornea. The ocular diseases ofeach patient were classified according to the Inter-national Classification of Diseases (9th revision) andthe extended five digit code "Classification of disordersof the eye" proposed by the International Council ofOphthalmology. Finally, the clinical action taken bythe ophthalmologist was recorded.

In the assessment of the role of ophthalmic opticiansand general practitioners in screening for ocular diseasepatients were classified as those with or withoutsymptoms based on information in the referral letterand the history taken by the ophthalmologist. Patientswere deemed not to have symptoms if they wereunaware of any ocular abnormalities apart from thoseattributable to refractive error, and referral of these

16BMJ VOLUME 297 5 NOVEMBER 19881162

patients was considered to be a consequence ot someform of ocular screening. The few older children withsquint could be classified as having asymptomaticdisease if a reliable history was obtained, but youngerchildren could not be classified in this way.

Diagnosis ofglaucoma and borderline conditions-Thecriteria for diagnosis of ocular hypertension wereintraocular pressure >21 mm Hg, no evidence of angleclosure, and normal visual fields. Borderline findingswere suspicion of disc cupping but no definite glauco-matous field loss. If anatomically narrowed anteriorchamber angle was present this was noted in relationto either raised intraocular pressure or borderlinefindings. Glaucoma was defined as glaucomatous fieldloss together with optic disc cupping or raised intra-ocular pressure, or both.

ResultsOfthe 1113 patients whose case notes were reviewed,

467 were male and 646 female. As expected, the agedistribution (table I) was bimodal with a greaterproportion of children and elderly patients.

REFERRAL PATTERNS

Refering agents and reasons for referralGeneral practitioners initiated the referrals of 546

patients (49%) and ophthalmic opticians the referrals(initially to the general practitioner) of 439 (39%). Ofthe remaining patients, 88 (8%) were referred by otherhospital doctors, 23 (2%) by community medicalofficers, and four referrals were initiated by ophthal-mic medical practitioners (see table II). The referralsinitiated by general practitioners originated from 40practices, 10 of which accounted for 287 patients(53%). Referrals initiated by ophthalmic opticiansoriginated from 24 practices, seven ofwhich accountedfor 275 patients (63%).

Table II lists the referring agents and the reasons forreferral. Visual disturbance or loss was the mostimportant reason for referral (345 cases; 31%), fol-lowed by suspected glaucoma (145; 13%) and abnor-malities of binocular vision, mainly squint (140; 13%).

TABLE i-Age-distribution ofpatients studied

Age (years): 0- 10- 20- 30- 40- 50- 60- 70- 80- ¢90 Unknown TotalNo of patients: 200 67 58 69 106 109 208 173 103 8 12 1113

Disorders of the eyelids or ocular adnexa accounted for127 referrals (11%) and red eye for a further 86 (8%).Reasons for referral differed substantially among the

referring agents. General practitioners referred 107(84%) of the patients with disorders of the eyelids orocular adnexa and 66 (77%) of the patients with redeye, whereas ophthalmic opticians referred 118 (81%)of the patients with suspected glaucoma. Half of thecases of suspected squint were referred by generalpractitioners as compared with roughly a third byophthalmic opticians and a fifth by hospital doctorsand community medical officers.The type of information in the referral letter also

varied with the referring agent. Ophthalmic opticianswere more likely than general practitioners to providedetails of an ophthalmic examination and indicatethe anatomical location of the problem. Failure byophthalmic opticians to specify an anatomical locationoccurred in two out of 17 referrals for red eye and 17out of 168 referrals for visual loss. Failure by generalpractitioners to specify an anatomical location occurredin 26 out of 66 referrals for red eye (39%) and 41 out of133 referrals for visual loss (31%). As expected, areport of visual acuity was provided in all referralsinitiated by ophthalmic opticians, whereas the generalpractitioners provided this information for only 28patients (21%) referred for visual disturbance or visualloss.Of the 324 patients who were unable to obtain

appointments during the study period, only 32 hadsuspected glaucoma, squint, or red eye, priorityappointments having been given to patients with theseconditions. Visual loss, mostly due to cataract orretinal disease, accounted for 202 of the 324 referrals(62%), followed by disorders of the eyelids or ocularadnexa (39; 12%).

Accuracy ofreferralThe accuracy of referral was assessed by comparing

the primary and secondary (if any) reasons for referralwith the final diagnosis (table III). The reason forreferral was considered appropriate if the diagnosissuggested by the referring agent was confirmed by theophthalmologist or if both the symptoms reportedand the designated anatomical location of the problemcorresponded to the final diagnosis. Ophthalmic opti-cians were far more likely to refer patients withglaucoma correctly (96 cases; 80%) than were general

TABLE II-Referring agents and primary reasons for referral

Referring agent

OphthalmicGeneral Ophthalmic medical Hospital Community

Reason for referral practitioner optician practitioner doctor medical officer Other Unknown Total

Suspected glaucoma 25 118 2 145Red eye:

Conjunctiva 29 6 1 36Cornea 4 7 11Uvea 5 1 6 86Sclera 2 1 3Unknown 26 2 1 1 30

Lids/adnexa 107 9 9 2 127Binocular vision abnormality 70 44 13 13 140Visual disturbance/visual loss:

Cornea 4 8 12Lens 39 55 1 8 103Vitreous 8 8 345Retina 11 46 1 12 71Optic nerve 6 1 7Visual pathway 2 1 3Other 24 30 2 56Unspecified 41 17 9 5 1 73Refraction 4 5 1 3 13

Asymptomatic fundal abnormality 2 47 9 58Headache 6 4 1 11Other 29 12 10 1 2 54Rereferral 92 14 7 2 2 117Unknown 16 6 4 2 2 30

Total 546 439 4 88 23 1 1 2 1113

BMJ VOLUME 297 5 NOVEMBER 1988 1163

practitioners (10 cases; 37%). Ophthalmic opticiansreferred patients for assessment of glaucoma if theyfound physical signs of the disease (optic disc cupping,raised intraocular pressure, loss of visual field),whereas general practitioners mostly referred on thebasis of pain, visual loss or haloes, or a positive familyhistory.The accuracy of referrals for abnormalities of bino-

cular vision, mostly squint, was 61% (28 cases) forophthalmic opticians and 52% (40 cases) for generalpractitioners. General practitioners tended to referyounger children, whereas the ophthalmic opticianswere more likely to refer older children who had faileda school sight test.The accuracy of referrals in cases of red eye by both

ophthalmic opticians and general practitioners waslow. In 11 cases (a quarter of referrals in which an

TABLE III-Accuracy of referral by general practitioners andophthalmic opticians expressed as proportion ofprimary and secondarydiagnoses confirmed at ophthalmological outpatient consultation*

Referring agent

General OphthalmicReason for referral practitioner optician Total

Suspected glaucoma 10/27 96/120 106/147Red eye 8/40 5/15 9/55

Conjunctiva 7/29 2/6 9/35Cornea 0/4 3/7 3/11Uvea 0/5 0/1 0/6Sclera 1/2 0/1 1/3

Lids/adnexa 78/109 5/9 83/118Binocular vision

abnormality 40/77 28/46 68/123Visual loss 59/74 138/174 197/248Visual disturbance/loss:Cornea 3/4 3/8 6/12Lens 42/43 52/59 94/102Vitreous 4/8 4/8Retina 7/11 36/48 43/59Optic nerve 2/6 2/6Visual pathway 0/2 0/1 0/3Refraction 2/4 2/5 4/9

Asymptomatic fundalabnormality 1/2 43/47 44/49

*Table includes primary and secondary reasons for referral. Hence figuresdo not correspond to those in table II.

TABLE Iv-Diagnoses of 58 patients with unspecified visual lossreferred by general practitioners and ophthalmic opticians

Referring agent

General OphthalmicDiagnosis practitioner optician Total

No abnormality 6 7 13Refractive error 2 2Binocular vision abnormality including

amblyopia 2 3 5Cataract 8 8Macular degeneration 3 1 4Retinal vascular occlusion 6 2 8Optic nerve abnormality 3 3Other retinal abnormality 1 1Other 10 4 14

Total 41 17 58

TABLE v-Reasonsfor referral and referring agents in 122 patientsfound to have no appreciable abnormalityat ophthalmological outpatient consultation

Referring agent

Hospitaldoctor and

General Ophthalmic communityReason for referral practitioner optician medical officer Unknown Total

Squint 2 1 4 9 34Lids/adnexa 11 11Red eye 8 2 1 11Suspected glaucoma 3 14 17Visual loss, unspecified 6 7 2 1 16Visual loss, vitreous, retina, optic nerve 1 7 8Other 12 8 5 25

Total 62 42 16 2 122

anatomical lesion was specified) no abnormality couldbe found, presumably because the condition hadresolved by the time that the patient was seen in theclinic. Most of the remaining false positive referralsfor red eye were because of incorrect location of theprimary disorder.

Ophthalmic opticians and general practitionersreferred broadly comparable numbers of patients withvisual loss due to cataract. The accuracy of referral forcataract was lower for ophthalmic opticians (52 of 59cases; 88%) than for general practitioners (42/43; 98%)because the opticians tended to refer patients withcataract that was not considered clinically significant.Many more patients with diseases of the posterior

segment of the eye were referred by ophthalmicopticians than by general practitioners, and in nearlyhalf of the referrals by ophthalmic opticians thepresenting condition was asymptomatic. Though accu-racy of referral was comparable in cases in which ananatomical location was specified, general practitionerswere far more likely to refer patients with visual loss forunspecified reasons (41 patients; 13 found to haveabnormality of posterior segment) (table IV) than wereopticians (17 patients).The most common reason for referral in the 122

patients (11%) subsequently found to have no appre-ciable disease (table V) were abnormalities of binocularvision (mostly squint), suspected glaucoma, and visualdisturbances or visual loss.

SCREENING FOR OCULAR DISEASE

One hundred and eighty (16%) of the 1113 patientsin the series were classified as not having symptomsand so may be assumed to have been referred as a resultofscreening. Most ofthem were referred by ophthalmicopticians (149 cases) and the remainder by generalpractitioners (10), other hospital consultants (13),community medical officers (five), or other agents(three). Table VI lists the referring agents and primarydiagnoses in these cases. Interestingly, all referrals forasymptomatic glaucoma were initiated by ophthalmicopticians. The remaining patients presented withvarious conditions, but to examine the roles ofophthalmic opticians and general practitioners inscreening for eye disease we analysed patients withglaucoma and diabetic retinopathy.

GlaucomaThere were 70 referrals for suspected asymptomatic

glaucoma and a further 77 for symptomatic disease. Ofthese, 120 were initiated by ophthalmic opticians and27 by general practitioners. Glaucoma was confirmedin 33 cases (20 asymptomatic) and borderline glaucomaor ocular hypertension in a further 73 (48 asympto-matic). The diagnosis was confirmed in 96 (80%) of thereferrals from ophthalmic opticians but in only 10(37%) cases referred by general practitioners. Allpatients referred by general practitioners hadsymptoms. From information in the referral letterswe attempted to assess the diagnostic proceduresundertaken by the opticians and general practitioners(table VII). Ophthalmic opticians reported intraocularpressure measurements in 52 of the 96 referrals (54%)in which glaucoma or features of borderline glaucomawere confirmed. The remaining patients were referredfor suspicious optic disc cups, loss of visual field, orother clinical features. General practitioners referredpatients with suspected glaucoma primarily on thebasis of symptoms. Overall an ocular examination wasreported in less than one third of the patients referred.

Suspected glaucoma was not confirmed by theophthalmologist in 24 patients referred by ophthalmicopticians and 17 referred by general practitioners(table VII). Among the unconfirmed cases referred bythe opticians raised intraocular pressure was the

BMJ VOLUME 297 5 NOVEMBER 19881164

TABLE VI-Prima?, diagnosis of' 117* patients without symptoms referred by various agents

Referring agent

Ophthalmic General Hospital CommunityPrimary diagnosis optician practitioner doctor medical officer Total

Suspected glaucoma/glaucoma 70 70Diabetic retinopathy 3 7 10Squintdamblyopia 6 2 1 2 11Refractive error 6 1 1 8Corneal abnormality 4 4Congenital abnormalities of anterior

segment 2 2Choroidal naevus 8 8Macular degeneration 7 7Other abnormalities of retina 13 13Optic disc abnormalities 3 1 4Congenital abnormalities of posterior

segment 4 4Others 5 1 2 8No abnormality found 18 5 3 2 28

Total 149 10 13 5 177*

*Three patients referred by other agents omitted from table.

TABLE VII-Diagnostic proceduresforglaucoma employed by ophthalmic opticians and generalpractitioners*

Ophthalmic opticians General practitioners

Normal or Normal orDiagnosis other Diagnosis otherconfirmed diagnosis confirmed diagnosis

Ophthalmoscopy 20 4 3 3Visual fields IOphthalmoscopy and visual fields 8 3 1Ophthalmoscopy, visual fields, and intraocular pressures 14 3Ophthalmoscopy and intraocular pressures 17 1Visual fields and intraocular pressures 10 IIntraocular pressures 11 3Unknown 16 9 6 13

Total 96 24 10 17

*Table includes primary and secondary reasons for referral. Hence figures do not correspond to those in table II.

principal factor in only nine, the others being referredbecause of suspicious ophthalmoscopic appearances orreduced visual fields. Among the unconfirmed casesreferred by general practitioners ophthalmoscopy orvisual field examination was the basis for referral infour, the remainder being referred for suspicioussymptoms.

Diabetic retinopathyThere were only 36 patients in whom the primary

diagnosis was diabetic retinopathy, and 20 of themwere referred from diabetic clinics by consultantphysicians as a presumed result of screening. Six,however, were referred by general practitioners, and ineight others the referral was initiated by ophthalmicopticians. Three of the patients referred by ophthalmicopticians did not have symptoms, and in two casesdiabetes was diagnosed only after these ocular compli-cations had been discovered. All six patients referredby general practitioners had symptoms, but one ofthem was not a known diabetic and was diagnosed as aresult of the referral. All referral letters from opticiansgave funduscopic findings but funduscopy wasreported in only two cases referred by general practi-tioners. Patients referred by ophthalmic opticians andconsultant physicians were much more likely to needlaser treatment than those referred by general practi-tioners.

DiscussionWhen we compared the referral patterns of general

practitioners and ophthalmic opticians some cleartrends emerged. Nearly one third ofreferrals by generalpractitioners alone were for disorders of the externaleye or ocular adnexa compared with only 6% (26/439)for referrals initiated by the opticians. Generalpractitioners were also more likely to refer cases ofsuspected squint. By contrast, referrals of patientswith suspected glaucoma and to a less extent visual loss

were far more likely to be initiated by the opticians.Ophthalmic opticians were also far more likely to referdisorders of the retina or optic disc and generalpractitioners to refer patients with visual loss forunspecified reasons. There was little evidence thatgeneral practitioners screened for glaucoma or diabeticretinopathy, whereas ophthalmic opticians screenedfor glaucoma with considerable skill and also initiatedreferrals of several patients with previously unrecog-nised diabetic retinopathy.These differences in referral patterns are due to

several factors. Patients with symptoms due to externalocular disease generally visit their general practitioner,but when suffering from visual loss they frequentlyvisit an optician in the belief that they need newglasses. General practitioners do not usually undertakefunduscopy, or at least do not report their findings inthe referral letters, whereas funduscopy is a routinepart of the NHS sight test. As a consequence ophthal-mic opticians are more likely to detect abnormalities ofthe posterior segment of the eye. Ophthalmic opticiansconduct ocular examinations, maintaining a highdegree of vigilance for asymptomatic conditions suchas glaucoma. They are obliged to refer a patient inwhom they find an abnormality without makinga diagnosis. General practitioners rarely screen forocular disease but usually refer patients with ocularsymptoms and often suggest a diagnosis withoutproviding details of an ocular examination. In generalthe accuracy of the opticians' examinations was higherthan the analysis-of diagnostic accuracy suggested, thediscrepancy largely being due to a difference in theclinical importance attributed to the findings of theophthalmologist.The quality of referrals to a consultant is important

for the service provided. Where the service is over-stretched, as in the outpatient department in this studyand in many throughout Britain, any reduction in theaccuracy of referrals will have serious consequences.Time spent on patients referred inappropriately willfurther delay the treatment of those who genuinelyneed specialist attention, some of whom have condi-tions which without treatment may lead to irreversibleloss of vision. Priorities can be decided only if thereferral letters contain reasonably detailed and accu-rate information, which was by no means always thecase. Improvements in the accuracy of referrals needto be directed towards reducing the number of falsepositive referrals and improving the quality oftrue positive referrals. The most important reasons forfalse positive referrals in this study were suspectedsquint and glaucoma; greater utilisation or develop-ment of community based screening programmescould reduce the false positive referral rate.At present the nearest approach to a screening

service for ocular disease is provided by ophthalmicopticians. Under the terms and conditions of serviceophthalmic opticians providing NHS sight testing areobliged to inform the general practitioner of anyabnormality in the eyes. Thus in addition to refraction,the optician routinely performs an ophthalmic exami-nation that includes funduscopy. In recent years manyophthalmic opticians have also acquired equipment formeasuring intraocular pressures5 and, less commonly,for the accurate assessment of visual fields. Muchscreening is therefore undertaken in the context of theNHS sight test, though this screening, particularly forglaucoma, has undergone spontaneous growth withoutplanning or policy agreement between the GeneralOphthalmic Service and the hospital eye services. Inthe white paper Promoting Better Health, outlining thegovernment's proposals in the Health and MedicinesBill, the government contends that "without theconstraints imposed by the NHS contract, ophthalmicopticians will be free to offer either a standard sight test

BMJ VOLUME 297 5 NOVEMBER 1988 1165

or a fuller eye examination to meet their patients'needs and preferences."6 This seems to imply thatophthalmic opticians would no longer be under anobligation to provide anything more than a routinerefraction test and that any form of ocular screeningwould be confined to those willing and able to pay anadditional fee.

In our study two thirds of all correct referrals forglaucoma occurred as a result of current screeningpractices by ophthalmic opticians. Other studies havealso shown that opticians are a main source of referralsfor glaucoma24 and that general practitioners refer onlypatients with symptoms. Though the consequences ofthe proposed loss of the NHS funded sight test aredifficult to predict, it is reasonable to assume that thenumber of patients seen by ophthalmic opticians willfall. This will probably have little impact on referralsfor squint or red eye, but referrals for asymptomaticconditions that are detected during the routine sighttest are likely to decline. This may reduce the numberof referrals for trivial conditions such as minor abnor-malities of the fundus or mild ocular hypertension,but there will also be a reduction in referrals ofpatients with early asymptomatic glaucoma and as aconsequence an increase in patients presenting withadvanced, symptomatic disease.

Chronic simple glaucoma is a common disorder,insidious, progressive, and irreversible, affecting be-tween 0 5% and 1-0% of the population over 40,7 'andis asymptomatic until visual loss is far advanced. Itaffects 150 000-300 000 people and is responsible forabout 12% of the registered blind in England andWales.9 Medical and surgical treatment have a provedeffect in slowing its progression."0' A reduction in thecurrent amount of screening for glaucoma as a result ofthe proposed legislation may well result in delayeddiagnosis with serious results for the patient. Establish-ment of a planned glaucoma screening service, withagreement between ophthalmologists and ophthalmicopticians on the screening tests and criteria for referral,could both reduce the incidence of blindness fromthe disease and relieve demand on the hospital eyeservices.

Using data from our study we can attempt to assessthe impact of such a glaucoma screening service.Referral would have been avoided for most of the 41false positive referrals for glaucoma and for most of the73 patients with ocular hypertension or borderlinefindings. Thus a community based screening servicemight have saved nearly 100 new outpatient appoint-ments a year and would have had an even greaterimpact on follow up appointments. Based on theaverage age of our patients with ocular hypertension orborderline findings the life expectancy of these patientsfrom life tables is about 16 years. Given a constant rateof referral, we could expect 1550 follow up outpatientappointments a year. Only a minority of these patientswill develop glaucoma, and thus a glaucoma screeningservice could save over 1000 follow up appointments ayear. The cost of the NHS sight test is £9.75, whereasthe cost of a hospital outpatient appointment is about£30. If the money which the government proposesto withdraw from the NHS sight test was divertedto a comprehensive glaucoma screening service thestandard ofglaucoma screening would improve and thewaiting times for outpatient appointments would fallwithout additional cost. The unknown quantity is thenumber of patients currently undiagnosed, but even ifthis was twice the number found in this study-that is,66 rather than 33-there would still be a reduction inthe number of referrals for glaucoma.Though screening for glaucoma may detect early

cases, it presents a serious problem. Three diagnosticprocedures are required to diagnose glaucoma reliably:funduscopy to assess the optic disc, tonometry to

measure intraocular pressures, and instrumentationto assess visual fields. Without all three, screeningprocesses generate appreciable numbers of false posi-tive and false negative cases. The most problematicaspect has until recently been the assessment of visualfields. Screening without visual field assessment willnot only detect patients with glaucoma but also identifya much larger population with incomplete features ofthe disease. As studies have shown that patients withocular hypertension or suspicious disc cupping are atdefinite risk of glaucoma'2 this population cannot beignored. Any widespread glaucoma screening withreferral criteria that excluded assessment of visualfields would generate large numbers of cases of in-complete glaucoma and place enormous extra pressureson hospital eye services. The development of com-puterised central field analysers in which the test fieldis compared automatically with parameters from aseries of normal fields, however, has made visual fieldscreening a realistic objective, and agreed criteria forreferral could be established while other patients withlesser abnormalities could be kept under review in thescreening clinic.

Diabetic retinopathy remains the commonest causeof blindness in the young and middle aged in theUnited Kingdom, but effective treatment is availableand early detection offers the best hope of a successfuloutcome. Though funduscopy is performed routinelyon many patients attending diabetic clinics, fewer thanhalf of all known diabetics attend these clinics.'3 Mostremain under the sole care of their general practitionersand are much less likely to have regular funduscopy.We believe that the pattern of diabetic care in theBurton area is representative of the pattern nationally.Thirty six patients with diabetic retinopathy werereferred during the 14 months of the study. Almost aquarter of these referrals were initiated by ophthalmicopticians performing routine eye tests. All the patientsreferred by general practitioners alone had symptoms,and there was no indication that these referrals resultedfrom routine screening.The issue of who should screen for diabetic retino-

pathy has inevitably arisen. Studies show that ophthal-mic opticians have the necessary skills to detectdiabetic retinopathy at a treatable stage,'4 but thoughthey are participating in screening programmes inseveral centres in the United Kingdom,'5 their roleremains controversial. Scott and Flanagan stated thatmost referrals from opticians were for lesions that wereof no clinical importance-a view not substantiated byour study-and considered it exceptionally rare fordiabetes to be detected by finding retinopathy in aperson not known to be suffering from the disease.'6 Inour study, though numbers were small, a quarterof patients referred by ophthalmic opticians for retino-pathy were undiagnosed diabetics, and more than halfthe patients referred required laser treatment.

Arguably general practitioners should take moreresponsibility for screening for diabetic retinopathy,'7but general practitioners with an average of only about20 diabetics on their lists are unlikely to gain theexperience necessary to provide an effective screeningservice.'7 Unless studies showed that a substantialnumber of general practitioners could be (or werewilling to be) trained in diagnosing early diabeticretinopathy the employment of community basedspecialists-either ophthalmic opticians or ophthalmicmedical practitioners-would remain a more accept-able alternative.

Objections have been raised to mixing the commer-cial aspects of selling glasses with the primary care ofpatients, with the concern that screening for glaucomaor diabetic retinopathy may expand into the market-place.'6 If the screening aspects of the NHS sight testwere separated from refraction tests there would be

BMJ VOLUME 297 5 NOVEMBER 19881166

greater flexibility in the delivery of screening services,allowing, for example, the employment of ophthalmicmedical practitioners in health centres or generalpractices. Undoubtedly there are also some ophthalmicopticians who find the clinical aspects of their workmore interesting than the commercial and who wouldbe willing to devote some of their time to ophthalmicscreening within a general medical practice. Given thelimited amount of undergraduate and postgraduatetraining in ophthalmology that most doctors receive,the complexity of the specialty and its dependenceon expensive diagnostic equipment, and the generalpractitioner's commitments to many other aspectsof medicine, it seems unlikely that most generalpractitioners would be able to take on this role.

1 French CN. Ideal average times for sight test. Optometry Today 1987;27:741-3.2 Steinman WC. The "who" and "how" of detecting glaucoma. Br Med J

1982;285: 1091-3.3 MacKean M, Elkington AR. Referral routes to hospital with chronic open

angle glaucoma. BrMedJ 1982;285:1093-5.4 Clearkin L, Harcourt B. Referral pattern of true and suspected glaucoma to an

adult ophthalmic outpatient clinic. Trans Ophthalmol Soc UK 1983;103:284-7.

5 Tuck M. Early detection ofglaucoma-an International Glaucoma Associationsurvey. Optician 1987;195:12-8.

6 Department of Health and Social Security. Promoting better health. Thegovernment's programme for improving primary health care. London: HMSO,1987:33.

7 Hollows FC, Graham PA. Intra-ocular pressure, glaucoma and glaucomasuspects in a defined population. BrJ Ophthalmol 1966;50:570-86.

8 Bengtsson B. The prevalence of glaucoma. BrJ Ophthalmol 1981;65:46-9.9 Crick RP. Computerised clinical data base for glaucoma-ten years' experi-

ence. Research in Clinical Forums 1980;2:29-39.10 Watson PG, Grierson I. The place of trabeculectomy in the treatment of

glaucoma. Ophthalmology 1981;88:175-%.11 Sponsell WE, Dallas NL, Burbridge L. Visual field survival: the response to

timolol therapy in open-angle glaucoma. BrJ Ophthalmol 1983;67:220-7.12 Perkins ES. The Bedford glaucoma survey. 1. Long-term follow up of

borderline cases. BrJ Ophthalmol 1973;57:179-92.13 Yudkin JS, Boucher BJ, Schopflin KE, et al. The quality of diabetic care in a

London health district. J Epidemiol Community Health 1980;34:277-80.14 Bums-Cox CJ, Dean-Hart JC. Screening of diabetics for retinopathy by

ophthalmic opticians. BrMedj 1985;290:1052-4.15 Kopelman P, Keable-Elliot D. Charging patients for eye tests. Br Med J

1988;2%:719.16 Scott JD, Flanagan D. Charging patients for eye tests. Br Med J 1988;296:

290-1.17 Yudkin JS. Charging patients for eye tests. BrMedJ 1988;2%:64.

(Accepted 13 September 1988)

Newcastle GeneralHospital, Newcastle uponTyne NE4 6BEP J D K Dawes, FRCR,consultant radiotherapist andoncologistAlison Hart, medical studentR G Wilson, FRCS, consultantsurgeon and surgical oncologist

Correspondence to:Mr Wilson.

Mastectomy or conservation: the patient's choice

Ronald G Wilson, Alison Hart, P J D K Dawes

AbstractStudy objective-To determine whether, if given

the choice, patients with breast cancer would prefermastectomy or conservation treatment, neithertreatment having been shown to be preferable.Design-Non-randomised case series with 28

patients interviewed after two years and all foliowedup.Setting-Secondary care referral centre.Patients-153 women, aged less than 65, with T1,

T2, N1, and No tumours of the breast given thechoice of treatment (that is, ali eligible patients fromDecember 1979).

Interventions-Patients were asked, after infor-mation and counselling, which treatment they wouldprefer. The chosen treatment was given withoutfurther question. Mastectomy included node sampl-ing and local radiotherapy if indicated. Conservationtreatment comprised excision of the lump, externalradiotherapy, and irridium wire implant to tumourbed.Main results-Conservation treatment was

chosen by 54 women and mastectomy by 99.Reasons for preferring mastectomy included desirefor rapid treatment for domestic or employmentreasons and fear ofpossibility of future mastectomy.Only two of the sample interviewed regretted theirchoice. During limited foliow up no advantages toeither form of treatment were seen in terms ofrecurrence or survival.

Conclusions-Patients with breast cancer arecapable ofchoosing treatment and should play a partin deciding which treatment to have. They do notautomatically choose to retain the breast.

IntroductionMastectomy, used for many years as the primary

treatment of breast cancer, has recently come underattack in the media and from some members of themedical profession. Its critics advocate conservationtreatment, which entails minimal surgery in the formof wide local excision of the primary lesion and radicalexternal beam radiotherapy to the breast and regional

lymph nodes and, generally, a booster dose to thetumour bed.' 2 As this treatment offers a good cosmeticresult and has not been shown to be less effective thanmastectomy its proponents say that it is better than amutilating operation. Conservation is not synonymouswith conservative surgery, in which the surgery isusually a segmental or partial mastectomy with orwithout adjuvant radiotherapy and a good cosmeticresult is not usually possible.Whether conservation treatment is acceptable to

women with breast cancer or indeed is demanded bythem, as suggested by its supporters, and whether itresults in the same rate of cure as mastectomy are notknown. It is not a new concept but became morecommon after a report in 1980 ofa seven year follow upof patients who had received it in France.3 That study,which was not a controlled trial, showed that for smalltumours conservation treatment gave results almostidentical with those achieved by mastectomy. Largertumours, however, had an unacceptably high rate oflocal recurrence. A proper trial comparing mastectomywith conservation has still not been done. The trial ofFischer et al,4 which is much quoted, studied conserva-tive surgery comprising segmental mastectomy withaxillary dissection plus radiotherapy for nodal diseaseand adjuvant chemotherapy.A few patients had conservation treatment in this

hospital in the 1960s and early 1970s, and by 1979 wemade it routinely available to women attending thebreast clinic. We wanted to compare the results of thetreatments, but we were reluctant to use randomallocation to conservation or mastectomy because wethought that this might distress the patients andthereby increase the currently low psychologicalmorbidity in the unit.5 These reservations were laterjustified when an attempt by the Medical ResearchCouncil's clinical research centre to do just such a trialfailed for these reasons.6 If, as Pierguin et al said, thetwo treatments are equally effective for small tumours3we could not advise women that one was preferable.We therefore offered the two alternatives and askedwomen to select their treatment. We report the out-come of this policy over the past nine years in terms ofboth the women's preferences and the results of thetreatments. The first 17 patients offered this choice

BMJ VOLUME 297 5 NOVEMBER 1988 1167