ABSTRACT

Purpose: To determine the type and frequency of consul-tations with the eye department of a major tertiary careteaching hospital.

Methods: A retrospective review was undertaken of themedical records of inpatient consultations within theOphthalmology Department of Royal Prince Alfred Hospitalover the period from 1 July 1995 to 30 June 1997. The consults were divided into six types of consultation. Adetermination was made of the outcome and effect onpatient management of each consultation.

Results: There were 506 consultations over the 2-yearperiod. For 389 patients a full ophthalmic assessment wasrequested and 175 of them (45%) had an ophthalmologicaldiagnosis made or had change in management as a result ofthe consultation.

Conclusion: Ophthalmological consultation is a valuableinpatient consultation service that makes a significant differ-ence in the management of patients from other medicaland surgical units within the hospital.

Key words: consultations, inpatients, ophthalmology, outcomes.

INTRODUCTION

Consultations with ophthalmologists are among the com-monest referrals within the medical system. The value ofthese ophthalmological services within the broad medicalcommunity is well understood, given the high prevalence ofpotentially blinding diseases such as glaucoma, cataract, dia-betic eye disease and age-related macular degeneration inthe community and their increasing prevalence with age.1,2

There have been major changes in the way patients witheye disease are managed in hospitals over the last decade.The most significant change may have been the move today-only admissions for most elective eye surgery as a resultof advances in ocular microsurgery and anaesthesia. This

changing pattern of ophthalmic practice has led some non-ophthalmologists to question the need for an ophthal-mology unit within a general hospital.

A small number of studies have looked at utilization ofeye-care services in major teaching hospitals by inpatientsand outpatients.3,4 Other studies have looked at oculartrauma and single diseases such as ocular manifestations ofHIV infection.5,6 A computerized search of the medical literature was unable to locate any broad-based study thatlooked at eye-care services provided by ophthalmologists toinpatients of other medical units in the Australian hospitalsystem. This audit was performed to identify the pattern andfrequency of inpatient ophthalmology consults within alarge tertiary care hospital.

METHODS

This audit was performed at the Royal Prince AlfredHospital in Sydney, Australia. Royal Prince Alfred Hospitalis a principal teaching hospital of the University of Sydneyand is a 660-bed multidisciplinary tertiary care hospital thatserves a population of 340 000 people in inner Sydney andreceives tertiary referrals from far western New SouthWales. There are about 54 000 elective admissions per yearand about 13 500 emergency admissions per year to thevarious departments of the hospital. The ophthalmologydepartment admits approximately 950 elective admissionsper year and 35 emergency admissions per year. There areabout 3500 outpatient visits per year to the ophthalmologydepartment.

The services provided by the ophthalmology departmentat Royal Prince Alfred Hospital can be divided into the following types of health-care services:

1. Assessment and management of outpatients referredto the outpatient clinics.

2. Management of elective surgical patients, includingsurgery and postoperative care.

3. Emergency admission and management of patientswith acute ophthalmological conditions and trauma.

4. Provision of a consultation service for inpatients ofother units within the hospital.

Clinical and Experimental Ophthalmology (2001) 29, 59–63

Original Article

Ophthalmologists in teaching hospitals: do we make a difference to patient outcome?Chandra Bala MB BS, Alexander C Poon FRACO, Paul Joblin MB ChB and Peter J McCluskey MD FRACODepartment of Ophthalmology, Royal Prince Alfred Hospital, Sydney, Australia

� Correspondence: Dr Peter J McCluskey, 357 Beamish Street, Campsie, NSW 2194, Australia.

The fourth type of service was the subject of this study.The names, hospital numbers and diagnoses of inpatientsseen as consults were recorded by the nurse in charge of theophthalmology clinic. The patients consisted of all adult (18years or older) inpatient consultations admitted under non-ophthalmological medical or surgical units. Patients assessedin the Accident and Emergency (A&E) Department wereexcluded whether the assessment was requested by A&E staffor other medical staff. However, if these patients wereadmitted by a medical or surgical unit who later requestedanother ophthalmological assessment, these patients wouldbe included in the audit. Patients seen in A&E were deliber-ately not included because the occurrence of ophthalmicassessment in A&E by the ophthalmology department wasnot recorded. All attempts were made to see the patients onthe same day or the next day of the request for consultation.If patients were discharged before assessment, they wereasked to contact their local ophthalmologist or to return forfollow up as an outpatient. These patients were not includedin this audit. Paediatric inpatient services were only availableat Prince Alfred Hospital for part of the period of the studyand were not included in the study because this was a newand fledgling service over the time period of the study.

A retrospective review of the medical records of inpatientconsultations seen by the ophthalmology department overthe period from 1 July 1995 to 30 June 1997 was performed.Information regarding the demographics, the referring unitand the medical condition requiring hospitalization was collected. The nature of the request, the duration of symp-toms, the ophthalmological diagnoses, any investigationssuggested and the interventions recommended wererecorded. The information obtained from the medical recordsof patients was assimilated into a computerized database.Each requested consultation was considered a distinct eventand therefore several patients had multiple consultations.

Patient numbers for the period of the audit were com-pared to the numbers of patients seen in the 5 years beforethe study. The number of consultations requested during the

years of the audit was within 10% of the number seen ineach of the preceding 5 years.

The consultations were arbitrarily classified into sixgroups.

1. Service: services such as computerized visual fieldtesting or refraction for replacement spectacles wererequested without review by an ophthalmologist. A relevantexample would be performing postoperative visual fields ona patient who had undergone surgery for pituitary tumour.

2. Trauma: assessment of inpatients from other unitsadmitted following trauma.

3. New ocular symptoms: inpatients who developed newocular symptoms during the course of their hospitalization.This category excludes the above trauma group. Relevantexamples would be patients developing symptoms such asblurred vision or ocular pain while in hospital.

4. Review of known eye disease: inpatients with previ-ously diagnosed ocular disease, requiring review of theirocular condition. A patient with known glaucoma usingtopical beta-blocker admitted to hospital with respiratorydisease is a typical example of such a consultation. Patientswho were regularly seen in the clinic and had a regular out-patient eye clinic appointment at a time when they were inhospital, were not included in this study.

5. Ocular screening: inpatients without any ocular symp-toms with systemic disease known to potentially involve theeye such as recently diagnosed diabetes.

6. Diagnosis of systemic disease: inpatients withoutocular symptoms, referred for assessment to help with thediagnosis of an undetermined systemic disease process. Thedevelopment of skin rash, arthralgias and renal failure in ayoung woman possibly due to systemic vasculitis or collagendisease is one example.

RESULTS

Over the 2-year period of the audit, Royal Prince AlfredHospital had 26 985 acute and 108 112 elective admissions.

60 Bala et al.

Table 1. Number of eye consults from referring units

Unit No. consultations (%) Total no. of admissions No. eye consults out of n = 506 for unit total no. of admissions (%)

Neurosurgery 175 (34) 2551 6.9%Neurology 41 (8) 1969 2.1%Endocrine 39 (8) 1824 2.1%Respiratory medicine 27 (5) 4011 0.7%Immunology 27 (5) 2513 0.7%Cardiology 24 (5) 7055 0.3%Haematology 20 (4) 3407 0.6%Geriatrics 15 (3) 2259 0.7%Ear, nose and throat 14 (3) 2133 0.7%Renal medicine & transplantation 13 (3) 276 4.7%Head and neck surgery 12 (2.5) 1161 1.0%Dermatology 12 (2.5) 1021 1.2%Cardiothoracic 11 (2) 2868 0.4%Other units 76 (15)

A total of 506 inpatient consultations were performed and438 patients were seen over the same period. The inpatientconsultations amount to 7% of all the consultations seen inthe ophthalmology department during this period. The maleto female ratio was 1.2 : 1.

The services of the ophthalmology department were utilized by all inpatient units, with the majority of consulta-tions coming from Neurosurgery (175, 34%), Neurology(41, 8%), and Endocrinology (39, 8%). There were 58patients who had multiple consultations and 56 of themwere for repeat visual fields. This resulted in a total of 126consultations. Table 1 lists the most frequent users of oph-thalmology consultations. The total number of patientsadmitted by the other units during the audit period wererecorded and the proportion of total per unit admissionreferred to the ophthalmology department are given.

In the Service category, the majority of consultationsrequired visual field testing (117 out of 121 consultations,97%) and 50% of the fields performed were abnormal.Other services such as refraction constituted a small minor-ity of consultations.

Twenty-four patients were referred for ophthalmic reviewhaving been admitted to hospital following trauma.Following assessment, 16 out of 24 were noted to have sustained eye trauma. Eight required observation and fourpatients only required a single consultation and no review.Four patients required active management consisting ofradiological investigation in two patients, administration oftopical medications in one patient and surgery in onepatient. The surgery was performed to correct an orbitalfracture with muscle entrapment.

Thirty per cent of referrals (149 consults out of 506) pre-sented complaining of new ocular symptoms. Eyelid or con-junctival pathology such as blepharitis and conjunctivitiswas diagnosed in 19 patients. Corneal pathology was diag-nosed in 30 patients, with exposure keratopathy secondaryto either facial nerve palsy (seven cases) or intraoperativecorneal exposure (six cases) being the commonest causes.Exposure keratopathy was managed with topical medica-tions in the majority of cases, with three patients requiringtarsorraphy and one requiring gold weight insertion. Fivenew cases of uveitis, one of glaucoma, and three of cataractwere diagnosed. Retinal pathology was noted in 22 patients,with 11 consults associated with vascular events and fourwith age-related macular degeneration. Ocular disease secondary to neurological deficit was diagnosed in 41 cases.Twenty-two patients had motility disorders, while corticalpathology was noted in 19 patients. Twelve cases wereattributable to tumours and six to vascular events. Therewere no abnormalities in 14 cases.

Eighty-three referrals out of 506 (15%) were made to theophthalmology department for review of previously diag-nosed ocular disease, with 12 out of 83 cases requiring achange in treatment. Review of diabetic retinopathy was thelargest contributor to this category (30 cases), with contin-ued observation being the main outcome (26 patients). Theendocrinology unit requested the most diabetic reviews and

total number of diabetic reviews from other medical unitsnearly equalled the number from the endocrinology unit.Review of glaucoma (six patients), papilloedema (sixpatients), facial nerve palsy (five patients) and cataract (fourpatients) were the other common consultations. These con-sultations do not reflect the prevalence of these conditionsin the hospital population but the reason for referral to theophthalmology department among inpatients.

Ocular screening examinations were requested in 101 outof 506 (20%) referrals. The three commonest conditionsrequiring screening were diabetes (33 cases), cytomegalo-virus (CMV) retinitis (16 cases) and tuberculosis drug treat-ment-related screening (10 cases). Of the patients withdiabetes, 52% (17 cases) were normal, and 30% (10 patients)were diagnosed with diabetic retinopathy with two patientsrequiring laser. Six patients (18%) had visually significantcataracts, and two required cataract surgery. Among the 16immunosuppressed patients, one was diagnosed with CMVretinitis and treated. Of the 10 patients screened in hospitalfor tuberculosis drug treatment-related complications, onerequired cessation of ethambutol therapy.

Assistance with diagnosis of systemic disease was soughtfor 27 patients over the 2 years. In eight patients ocular find-ings consistent with the suspected systemic disease werenoted, although in the remaining 19 patients examinationwas normal. Papilloedema was the most commonly soughtocular manifestation and was noted to be present in four ofnine suspect patients. Other diseases where ocular signswere sought included: neurofibromatosis, infective endo-carditis, systemic vasculitis, malignant hypertension, andWilson’s disease. Ocular signs were found in two patientswith systemic vasculitis and one patient with neurofibro-matosis and infective endocarditis.

DISCUSSION

This audit identified and classified the large number of inpa-tient ophthalmic consultations that occurred within a majorteaching hospital and the frequent positive contributionsthat ophthalmologists made to patient management. Therewere approximately five consults per week over the 2-yearperiod. For 389 patients a full ophthalmic assessment wasrequested and in 175 consults (45%) a specific ophthalmo-logical diagnosis was made or there was a change in oph-thalmic management. It must be noted that this auditspecifically excludes patients with ocular trauma admittedby the ophthalmology department. There were 38 patientsadmitted by the ophthalmology department followingocular trauma in the audit period.

In the study, the four most common types of consultationwere inpatients with new ophthalmic symptoms (30%),inpatients requiring a visual field test or refraction (25%),inpatients requiring screening for ocular manifestations ofsystemic disease (20%) and inpatients with known eyedisease needing evaluation (15%). These consultationsaccount for 90% of the 506 consultations that occurredduring the study period. Table 2 outlines the distribution of

Eye consults in hospitals 61

consultations and the number in which a diagnosis was madeor if management was altered for each group except for theservice group where a full assessment was not requested.

Neurosurgery and Neurology requested the most oph-thalmic consultations. Visual field assessment in neurologi-cal and neurosurgical patients who have conditions that mayinvolve the visual pathway have always been important.Recent technological advances in visual field testingmethodology using computerized visual field testing strate-gies have revolutionized the accuracy and reproducibility ofvisual field assessment. There were 121 consultations wherethe referring unit required automated perimetry or anotherservice and did not request a comprehensive ophthalmicexamination. Fifty per cent of the visual fields were abnor-mal. However, the majority of the visual field defects werepre-existing and the test was performed to detect change inthe defect associated with surgery. Neurologists and neuro-surgeons, in particular among the various specialist groups,have rapidly appreciated the usefulness of automatedperimetry and it has become an important investigation andfollow-up parameter in the management of neurologicaldisease. This has generated a large workload for the oph-thalmology department. One hundred and seventeen of the506 consults (23.1%) were for perimetry.

The development of new ocular symptoms while in hospital was the most common cause of ophthalmologicalconsultation. Predictably, the majority of patients had non-vision-threatening disease such as blepharitis, dry eyes andconjunctivitis that was treated with local medication withoutcomplication. There were a number of potentially sight-threatening diseases such as exposure keratopathy, acuteuveitis, glaucoma, retinal vascular disease and age-relatedmacular degeneration that presented during hospitalization.Cranial nerve palsies, gaze disorders and visual field defectswere common in patients with neurological illness. Some ofthese conditions were related to the admission diagnosis (e.g.exposure keratopathy and uveitis). Others were unrelatedand may have occurred to the patient in the community.Even so, some of these diagnoses were potentially sight-threatening, and the fact that in 80% of this group patientseither had a diagnosis made or treatment initiated indicatesthe importance of an ophthalmic service in this hospital.

The endocrine and renal units referred a significant numberof their admissions to the ophthalmology department.

These were primarily patients with diabetes requiring an eyecheck-up. The patients with diabetes admitted under therenal unit had diabetic renal disease and a large number wereon dialysis. Some patients were known to have diabeticretinopathy and others were not previously recognized tohave eye disease. Arguably, this service could have been provided by a community ophthalmologist. However, halfof the 33 diabetic patients with no previously recognizedeye problems had diabetic retinopathy or cataracts and fourof these patients (4/16, 25%) required some therapy.

Patients with known eye disease such as glaucoma,cataract and papilloedema comprised the other commonreason for consultation with the ophthalmology department.It was distinctly uncommon for this group of patients torequire any change in management by the ophthalmologists.

Trauma involving the eyes, orbits and visual system iscommon in major trauma. Ocular injury is commonly asso-ciated with head and facial injuries in patients with severetrauma.6 Life-saving measures often take priority in thesepatients and they are often admitted under the Trauma orNeurosurgical units. However, it is often difficult to assessthe nature and extent of ocular injury in patients with facialand head injuries and such patients require ophthalmicreview while they are under the care of the other unit. Thisis an infrequent but important group of consultations. Therewere three patients from 24 in this category who requiredactive treatment of their ocular problem.

In small numbers of patients, the ophthalmologist is ableto help greatly in the diagnosis of systemic illness. This ismost common in patients with a multisystem illness such assystemic vasculitis or occult infection, those with HIV infec-tion or following organ transplantation. Occasionally, theocular signs are pathognomonic of the disease or infectionsuch as CMV retinitis.7 In eight out of 27 patients, a positivediagnosis was made and most likely contributed to overallmanagement of the patient.

Major advances in ocular microsurgery and anaesthesiahave meant the majority of ophthalmic procedures can beperformed in a day-surgery setting. There have been similarmajor changes in ophthalmic medical practice. New diag-nostic technologies such as magnetic resonance imaginghave greatly improved the ability to non-invasively investi-gate patients with neuro-ophthalmic disease without theneed for admission to hospital. New antimicrobial and

62 Bala et al.

Table 2. Types and frequencies of consultations with the Ophthalmology Department

Type of consultation No. patients seen No. patients with ocular diagnosis after by ophthalmologist consultation or if management was changed

(% of total) (% of patients with this type of consultation)

New ocular symptoms 149 (30) 121 (80%)Service 121 (25)Screening 101 (20) 18 (18%)Known eye disease review 83 (15) 12 (15%)Diagnostic 27 (5) 8 (30%)Trauma 24 (5) 16 (67%)Total 506 ( 175 (

immunosuppressive drugs have allowed more optimumtreatment of patients as outpatients who previously wouldhave required investigation and treatment within a hospital.Thus the majority of patients with sight-threatening eyedisease are now managed outside hospital.

In the management of outpatients, hospital ophthal-mology departments provide a similar service to community-based eye clinics. However, we have identified a large groupin the inpatient population of a large tertiary hospital towhom ophthalmologists provide assessment and manage-ment of sight-threatening conditions and contribute tomedical management. Ophthalmologists are, therefore, anintegral part of a tertiary care teaching hospital and providea valuable inpatient consultation service that makes a signif-icant difference in the management of patients of othermedical and surgical units within the hospital. This is inaddition to the management of acute eye conditions, emer-gency and elective surgical patients, and outpatient carewithin the hospital community. This audit reviews the con-sultative role of ophthalmologists within the hospital andaffirms the important positive contribution made to themanagement of a diverse range of hospital inpatients.

REFERENCES

1. Mitchell P, Smith W, Attebo K, Healey PR. Prevalence ofopen-angle glaucoma in Australia: the Blue Mountains EyeStudy. Ophthalmology 1996; 103: 1661–9.

2. McCarty CA, Lloyd-Smith CW, Lee SE, Livingston PM,Stanislavsky YL, Taylor HR. Use of eye care services bypeople with diabetes: the Melbourne Visual ImpairmentProject. Br. J. Ophthalmol. 1998; 82: 410–14.

3. Harrison RJ, Wild JM, Hobley AJ. Referral patterns to an ophthalmic outpatient clinic by general practitioners and ophthalmic opticians and the role of these professionals inscreening for ocular disease. Br. Med. J. 1988; 297: 1162–7.

4. Schachat AP, McDonnell PJ, Petty BG et al. Ophthalmologyconsultations at a large teaching hospital. MPS 1989; 12:105–109.

5. McCluskey PJ, Hall AJ, Lightman S. HIV and eye disease.Med. J. Aust. 1996; 164: 484–6.

6. Poon A, McCluskey PJ, Hill DA. Eye injuries in patients withMajor Trauma. J. Trauma 1999; 46: 494–9.

7. Holland GN, Tufail A, Jordan MC. Cytomegalovirus diseases.In: Pepose JS, Holland GN, Wilhelmus KR (eds). OcularInfection and Immunity. St Louis: Mosby, 1996; 1094–6.

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