What is the proper way to write a referral letter for a patient with cataract and blurry vision, who has underlying hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD), to an ophthalmology clinic?

How to Write a Referral Letter for Cataract with Blurry Vision

Your referral letter should clearly communicate the patient's visual complaint, relevant ocular findings, pertinent medical comorbidities (especially hypertension and COPD), and the specific reason for referral to facilitate appropriate ophthalmologic evaluation and surgical planning.

Essential Components of the Referral Letter

Patient Demographics and Chief Complaint

• State the patient is an elderly female presenting with cataract and blurry vision 1
• Specify which eye(s) are affected and duration of symptoms 1
• Note any functional impact on daily activities or quality of life, as this guides surgical timing 1

Relevant Medical History

Hypertension:

• Document blood pressure control status, as uncontrolled hypertension can cause hypertensive chorioretinopathy presenting as blurry vision 2
• Note current antihypertensive medications 1
• Poorly controlled arterial blood pressure may warrant preoperative medical optimization before cataract surgery 1

Chronic Obstructive Pulmonary Disease:

• Specify COPD severity and current treatment 1
• Document any recent exacerbations or hospitalizations 1
• Note if the patient requires supplemental oxygen, as this affects anesthesia planning 1
• Poorly controlled COPD may necessitate preoperative medical evaluation by the primary care physician before proceeding with cataract surgery 1

Ocular Information to Include

Visual Function:

• Current best-corrected visual acuity in each eye 1
• Specific visual complaints beyond blurriness (glare, difficulty with near tasks, night vision problems) 1
• Impact on activities of daily living 1

Examination Findings (if available):

• Intraocular pressure measurements 1
• Pupillary examination results 1
• Type of cataract if identified (nuclear, cortical, posterior subcapsular) 1
• Any other ocular comorbidities such as glaucoma, macular degeneration, or diabetic retinopathy 1

Specific Considerations for This Patient

Anesthesia Planning:

• The ophthalmologist needs to know about COPD for appropriate anesthesia selection (topical vs. local vs. general) 1
• Patients with severe systemic diseases like poorly controlled COPD may require coordination with primary care or anesthesia services 1

Surgical Risk Assessment:

• Both hypertension and COPD are relevant systemic conditions that could impact surgical outcomes 1
• The ophthalmologist will assess the patient's ability to cooperate and position for surgery 1

Sample Referral Structure

Opening paragraph: State patient age, gender, chief complaint of cataract with blurry vision, and which eye(s) are affected 1

Medical history paragraph: List hypertension with control status and current medications, COPD with severity and current treatment 1

Visual symptoms paragraph: Describe functional impact on daily activities, duration of symptoms, and any specific visual complaints 1

Examination findings paragraph: Include visual acuity, any ocular findings you've documented, and intraocular pressure if measured 1

Reason for referral: Explicitly state you are referring for cataract evaluation and management, and note that the patient's systemic conditions may require special consideration for surgical planning 1

Closing: Request timely evaluation and indicate your availability for further information or coordination of care 1

Critical Pitfalls to Avoid

• Do not delay referral if the patient has significant functional impairment from cataract, as surgery timing should be based on patient need and mutual agreement with the surgeon 1
• Do not omit medication lists, particularly antihypertensives and bronchodilators, as these affect perioperative management 1
• Do not fail to mention COPD severity, as poorly controlled disease may require preoperative medical clearance 1
• Do not forget to document blood pressure control, as hypertensive emergencies can present with visual symptoms that may be confused with cataract 2
• Ensure clear communication channels for postoperative coordination, especially given the patient's comorbidities requiring ongoing medical management 1