Internal Use Only

Ophthalmology Referral - Prince of Wales Outback Eye Service
Bourke Health Service fax: 6870 2680, Brewarrina Health Service fax: 6839 2822, Cobar Health Service fax: 6879 9580,
Lightning Ridge Health Service fax: 6820 5780, Walgett Health Service fax: 6817 9480
Phone: 0418 322 705 (Joanna) 0419 111 687 (Ben) for all general enquiries
We accept referrals by fax to your preferred clinic location or email: WNSWLHD-OESReferrals@health.nsw.gov.au If the appointment is urgent please phone Joanna/Ben for next clinic availability.	
Referral to: Outback Eye Service - Ophthalmologist	Referral Date:	<TodaysDate>			
Patient Details: <PtTitle>	
Surname:	 <PtSurname>	Given
Name/s:	 <PtFirstName>	
Date of Birth:	<PtDoB>	<PtSex>	Medicare
number:	 <PtMCNo>			
Email:	 <PtEmail>			Ref: <PtMCLine>	Exp:	<PtMCExpiry>	
Contact Number/s:	 <PtPhoneMob>	Interpreter
Required?	Yes/ No
Language:	
Indigenous Status:	<Indigenous Status>	
Postal Address:	<PtAddress>						
Next Of Kin:	 <NOKName>	Contact Number/s of
N.O.K:	 <NOKContact>
 <NOKContact2>	
Relationship:	 <NOKRelation>			

Please note: Incomplete referrals will not be triaged. We strongly encourage a full optometry review prior to referral.	
Clinical Reason for Referral: <Clinical Reason for Referral>	
Relevant Ocular/Medical History:

Previous Ophthalmic: <Previous Ophthalmic>	Relevant Eye Drops and Medications:	
Driving:
Yes/No	Visual Acuity		IOP
(mm Hg)	Refraction							
	Unaided	BC (glasses/ PH)		Sphere		Cyl	Axis	Prism	Base	Add	
Right Eye:	6/	6/								
Left Eye:	6/	6/								
Investigations: (OCT/ VF/ Biometry/ FFA/ ERG/ Radiology/ Pathology/ Tomography/ Other)

Referring Practitioner: <Referring Practitioner>	
Name:	 <DrName>	Provider No:	 <DrProviderNo>	
Practice Address:	<LocationAddress>	

Western NSW Local Health District is committed to integrated care. Please provide the details below of other health professionals involved in their care (for future clinical correspondence).	
General Practitioner: Address:
Phone:	Optometrist: Address: Phone:	Ophthalmologist: Address:
Phone:	

Ophthalmology Referral Options

Refer to Emergency Department	Refer to Outback Eye Service – Eye Clinic	
Emergency
Urgent cases need to be seen immediately	Category 1
Urgent next clinic	Category 2
< 3 months	Category 3
< 6 months	
-	Acute angle closure glaucoma
-	Acute vision loss or signs of stroke
-	Central retinal artery occlusion
-	Chemical injury
-	Giant Cell Arteritis
-	Infectious keratitis (Hypopyon, fungal, Gonococcal/Chlamydia
-	Intraocular foreign bodies
-	Malignant hypertension
-	Orbital cellulitis/acute dacryocystitis
-	Orbital fractures
-	Retinal detachment (macula on, if macula off can wait up to a week)
-	Superior retinal tear
-	Suspecting penetrating eye injury
-	Transient Ischemic Attack/Amaurosis fugax	-	Acquired nystagmus
-	Acute visual field loss
-	Choroidal Melanoma or suspected retinal tumours
-	Corneal decompensation (Bullous Keratopathy, Endothelial Keratopathy)
-	Cranial nerve palsies
-	Diabetes with sudden vision loss
-	Ischemic ocular conditions
-	Macula hole
-	Macula oedema
-	Non-resolving Central Serous Chorioretinopathy
-	Optic neuritis
-	Papilledema
-	Post-op injection inflammation
-	Proliferative diabetic retinopathy
-	Proptosis with visual changes
-	Ptosis if pupil occluded
-	Recent onset pupil changes
-	Retinal tear (not superior)
-	Retinopathy of prematurity
-	Vitreous haemorrhage with retinal pathology (excluding Posterior Vitriol Detachment)
-	Wet Age Related Macular Degeneration
-	White pupil reflex in children	-	Cataract with Best Corrected Visual Acuity (BCVA) > 6/21
-	Epiretinal membrane with vitreoretinal traction VA >6/12
-	Eyelid tumours
-	Glaucoma un-responsive to topical therapy
-	Recent onset retinal hole
-	Severe non-proliferative diabetic retinopathy without macula oedema	-	Cataract with Best Corrected Visual Acuity (BCVA) >6/12 <6/21
-	Epiretinal membrane symptomatic
-	Eyelid problems: ectropion/entropion/ptosis
-	Proptosis without visual issues (Thyroid eye disease)
-	Pterygium encroaching pupil margin
-	Retinoschisis
-	Retinoschisis requiring treatment
-	Unresolving large chalazion	
Refer to local Optometrist	
Category 4	
-	Cataract with Best Corrected Visual Acuity BCVA <6/12
-	Chemical injury follow up
-	Choroidal naevus
-	Congenital nystagmus
-	Conjunctivitis
-	Contact lens complications
-	Corneal and sub-tarsal foreign bodies
-	Corneal ulceration
-	Diabetes review, non-proliferative diabetic
retinopathy (mild-mod)	-	Drug toxicity screening ie. Plaquenil/tamoxifen
-	Dry Age Related Macular Degeneration
-	Elevated intraocular pressure >30mmHg
-	Epiretinal membrane asymptomatic and no significant distortion
-	Eye discharge
-	Eye health screening
-	Eye pain
-	Eyelid lumps (stye, chalazion)	-	Flashes, floaters
-	Fuchs dystrophy
-	Glaucoma suspect
-	Herpes simplex/ zoster infection
-	Hyphema
-	Keratoconus
-	Monitoring of long-standing retinal hole and retinoschisis
-	Non-infectious Keratitis
-	Post-op cataract inflammation	-	Pterygium visually insignificant
-	Pupil changes with change in vision
-	Refractive error, presbyopia
-	Severe dry eyes, watery eyes, blepharitis
-	Strabismus, amblyopia
-	Sudden onset of blurred vision/ headaches/diplopia
-	Swollen eye
-	Trauma to eye/orbit, chemical burns
-	Uveitis