To the Editor:

We read with interest the paper by Scantling-Birch et al. [1] Core clinical skills are imparted to medical students during undergraduate training to enable them to function as a junior doctor: triaging, differential diagnoses, referral and management planning of patients. The authors argue that the gradual phasing out of ophthalmology teaching from medical schools has led to decline in the clinical confidence amongst medical students [1].

An ophthalmic consultation should be sought in all cases of visual loss or deterioration. We have conducted an audit of electronic inpatient referrals to the ophthalmology department at King’s College Hospital, London. A total of 209 inpatient referrals were received between July 1st and September 30th 2021, of which 76% (n = 159) were submitted as urgent (<1 week review). Mean time-to-review was 4.6 ± 9.1 days. Inpatient and clinic visual acuity (VA) was available for 116 (56%) patients. 67% (n = 139) referrals were made by recent graduates (Table 1). Additionally, there was a significant mean difference (logMAR −0.17, [95% CI: −0.26 to −0.08]) and low agreement between inpatient and clinic VA measurements (Fig. 1). Wilcoxon statistic indicates the examination VA significantly differed to referral VA (p = 0.02). This suggests a lack of clinical confidence in core ophthalmology skills within this group.

Table 1 Referrals categorised by referrers’ years since medical school graduation.
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Fig. 1: Bland-Altman comparison of ward and clinic VA measurements.
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This is a Bland-Altman plot of agreement between visual acuity (logMAR) on referral and examination. The dotted line represents the mean difference and dashed line represents limits of agreement (regression-based). VA visual acuity.

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Most referral requests originated from medical specialties (62%; n = 129), neurosurgery (17%; n = 35), and intensive/critical care (14%; n = 30). 55% (n = 115) offered a differential diagnosis at referral. Most frequent diagnostic categories found on clinic review were ocular findings associated with systemic disease (31%; n = 50), of which (23%; n = 38) were acute cranial neuropathy, anterior segment pathology (20%; n = 33), and 29% (n = 48) had no acute ocular pathology.

We acknowledge the constraints of conducting ophthalmological examination in a ward environment, however, reliable assessment is necessary for safe triage. Sight- or life-threatening diseases e.g., hypertension, and stroke can be diagnosed based on an appropriate clinical history and examination [2, 3]. The strategies proposed by the authors and others can be used to improve ophthalmology skills acquisition within the undergraduate medical curricula.