Assessment of referrals to the hospital eye service by optometrists and GPs in Bradford and Airedale

Investigating the impact of OCT imaging of the crystalline lens on the accuracy and precision of cataract assessment

PURPOSE

To determine if supplementing standard clinical assessments with Optical Coherence Tomography (OCT) imaging of the crystalline lens improves the accuracy and precision of lens opacity assessment and associated clinical management decisions by optometrists.

METHODS

Fifty optometrists registered in the UK or Éire undertook a clinical vignette study where participants graded lens opacities and made associated clinical management decisions based on the image(s)/information displayed. Three forms of vignettes were presented: (1) Slit-lamp (SL) images of the lens, (2) SL and OCT images and (3) SL, OCT and visual function measures. Vignettes were constructed using anonymised data from 50 patients with varying cataract severity, each vignette being presented twice in a randomised order (total vignette presentations = 300). The accuracy of opacity and management decisions were evaluated using descriptive statistics and non-parametric Bland-Altman analysis where assessments from experienced clinicians were the reference. The precision of assessments was examined for each vignette form using non-parametric Bland-Altman analysis.

RESULTS

All (n = 50) participants completed the study, with 36 working in primary eyecare (primary eyecare) settings and 14 in hospital eyecare services (HES). Agreement was highest where vignettes contained all clinical data (i.e., SL, OCT and visual function data-grading: 51.0%, management: 50.5%), and systematically reduced with decreasing vignette content (p < 0.001). A larger number of vignettes containing imaging and visual function measures exhibited below reference (i.e., less conservative) grading compared with vignettes containing imaging data alone (all p < 0.05). HES-based optometrists were more likely to grade lens opacities lower than clinicians working in primary eyecare (p < 0.001). Good measurement precision was evident for all vignettes, with a mean bias close to zero and limits of agreement below one grading step for all conditions.

CONCLUSIONS

The addition of anterior segment OCT to SL images improved the accuracy of lens opacity grading. Structural assessment alone yielded more conservative decision making, which reversed once visual functional data was available.

Evaluating referrals of flashing lights and floaters coming into secondary care from primary care

CLINICAL RELEVANCE

Optometrists should look to take every opportunity to expand their knowledge, understanding and skills pertaining to vitreoretinal conditions.

BACKGROUND

Despite the existence of acute eye care schemes and the up-skilling of optometrists, many units are still noticing large numbers of poor-quality referrals with high false positive rates. The authors pondered whether these schemes are effective.

METHODS

At two different time points, a prospective analysis of patients took place, of all the flashing lights and floaters referrals coming into secondary care at the Royal Glamorgan Hospital, Wales, UK. The following data was captured: the exact source of the primary care referral, the diagnosis being queried, the secondary care diagnoses made and the secondary care management decisions. The accuracy of retinal break and Shafer's sign detection were also directly compared between primary care and secondary care using Cohen's Kappa Coefficient.

RESULTS

For the 2018 period, n = 51 patients were included. For the 2022-23 period n = 100 patients were included. The majority of referrals during both periods were from optometrists (>80%) via the WECS pathway. The most common diagnoses being queried were retinal breaks (~50%), followed by retinal detachments (~20%). Interestingly up to 20% of patients seen in secondary care were diagnosed as normal examinations and ~ 20%. Over 1/3 of patients were discharged after their first visit to the EEC. Statistically significant differences were found between the accuracy of retinal tear and Shafer's identification between the primary and secondary care settings.

CONCLUSION

A high number of false positive referrals are coming into secondary care from the WECS pathway and clear training and education needs have been identified.

Measures of multiple deprivation and visual field loss in glaucoma clinics in England: lessons from big data

BACKGROUND/OBJECTIVES

To examine the association between multiple deprivation with late diagnosis and rapid worsening of glaucoma in patients in English hospital eye services (HES).

METHODS

602,439 visual fields (VFs) were extracted from five regionally different glaucoma clinics in England. Mean Deviation (MD) worse than -12 dB was used as a surrogate definition for advanced VF loss at diagnosis in patients with ≥2 reliable VF records. MD loss worse than -1 dB per year was used to define rapid VF progression in patients with ≥6 VFs. Patient data were stratified into deciles of the Index of Multiple Deprivation (IMD) from residential postcodes.

RESULTS

There was an association between IMD and advanced VF loss at diagnosis in 44,956 patients with 18% (293/1608) and 11% (771/6929) in the most and least deprived IMD decile, respectively. Age-corrected odds ratio (OR) for having advanced VF loss at entry into HES was 1.42 (95% confidence interval [CI] 1.21-1.67) and 0.75 (95% CI: 0.66-0.85) in the most and least deprived IMD decile respectively (reference = fifth decile). In 15,094 patients with follow up data (median [interquartile range] of 6.9 [4.5, 10.0] years), the proportion having rapid VF progression did not differ across the IMD spectrum.

CONCLUSION

Large-scale VF data from clinics indicates that glaucoma severity at presentation to English HES is associated with levels of multiple deprivation. We found no evidence to suggest likelihood of having rapid VF progression during follow-up is associated with IMD; this hints at equity of glaucoma care and outcomes once patients are in English HES.

A Quality Improvement Project of Acute Red Eye Consultations in Primary Care: Improving the Identification of Red Flags

Aim The acute red eye or conjunctival injection is the most common ophthalmic presentation in primary care. The aim of this audit was to improve red eye consultations by increasing the number of red flag features documented in the history of patients. Method The National Institute of Clinical Excellence (NICE) Clinical Knowledge Summary (CKS) outlines red flag features, which should be documented for an acute red eye consultation. Two interventions were implemented to attempt to improve consultations. The first involved creating a template in the Egton Medical Information Systems. The second involved training doctors in the recognition of red flag features and identifying sight-threatening conditions. Red eye consultations and red flag features documented were recorded in the two months before and after the interventions. Results All documentation of red flag features assessed in this project increased post intervention. However, lateralisation, visual changes, and eye pain were commonly asked prior to the intervention and did not show a statistically significant difference. They showed an increase from 90% (19/21) to 100% (19/19), 71% (15/21) to 84% (16/19), and 67% (14/21) to 79% (15/19), respectively. After the interventions, significant increases in asking about headaches (14% (3/21) to 74% (14/19), pupil changes (5% (1/19) to 58% (11/19)), and method of injury (high velocity 10% (2/21) to 84% (16/19), foreign body 14% (3/21) to 84% (16/19), chemical 10% (2/21) to 84% (16/19) were observed (p<0.05). Photophobia inquiries also significantly increased (14% (3/19) to 79% (15/19), P<0.05). Conclusion  The number of red flag features identified and documented for acute red eye consultations increased with the introduction of an online template and a teaching session.

The effectiveness of interventions for optometric referrals into the hospital eye service: A review

PURPOSE

Ophthalmic services are currently under considerable stress; in the UK, ophthalmology departments have the highest number of outpatient appointments of any department within the National Health Service. Recognising the need for intervention, several approaches have been trialled to tackle the high numbers of false-positive referrals initiated in primary care and seen face to face within the hospital eye service (HES). In this mixed-methods narrative synthesis, we explored interventions based on their clinical impact, cost and acceptability to determine whether they are clinically effective, safe and sustainable. A systematic literature search of PubMed, MEDLINE and CINAHL, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), was used to identify appropriate studies published between December 2001 and December 2022.

RECENT FINDINGS

A total of 55 studies were reviewed. Four main interventions were assessed, where two studies covered more than one type: training and guidelines (n = 8), referral filtering schemes (n = 32), asynchronous teleophthalmology (n = 13) and synchronous teleophthalmology (n = 5). All four approaches demonstrated effectiveness for reducing false-positive referrals to the HES. There was sufficient evidence for stakeholder acceptance and cost-effectiveness of referral filtering schemes; however, cost comparisons involved assumptions. Referral filtering and asynchronous teleophthalmology reported moderate levels of false-negative cases (2%-20%), defined as discharged patients requiring HES monitoring.

SUMMARY

The effectiveness of interventions varied depending on which outcome and stakeholder was considered. More studies are required to explore stakeholder opinions around all interventions. In order to maximise clinical safety, it may be appropriate to combine more than one approach, such as referral filtering schemes with virtual review of discharged patients to assess the rate of false-negative cases. The implementation of a successful intervention is more complex than a 'one-size-fits-all' approach and there is potential space for newer types of interventions, such as artificial intelligence clinical support systems within the referral pathway.

Assessment of optometrists' referral accuracy and contributing factors: A review

PURPOSE

In the UK, ophthalmology has the highest number of outpatient appointments within the National Health Service. False-positive referrals from primary care are one of the main factors contributing to the oversubscription of hospital eye services (HESs). We reviewed the accuracy of referrals originating from primary care optometrists and contributing factors, such as condition type and years since registration.

RECENT FINDINGS

Of the 31 studies included in the review, 22 were retrospective analyses of referrals and appointments at the HES. Eight were prospective studies, and one used online clinical vignettes. Seven assessed the accuracy of referrals for all ocular conditions. The remaining studies focused on glaucoma (n = 11), cataracts (n = 7), emergency conditions (n = 4), neovascular age-related macular degeneration (n = 1) and paediatric binocular vision (n = 1). The diagnostic agreement for suspected emergency ocular conditions was the lowest, with only 21.1% of referrals considered to require urgent attention in one study. For glaucoma, the first-visit discharge rate was high (16.7%-48%). Optometrist referral accuracy was overall 18.6% higher than General Medical Practitioners'; however, the two mainly referred different ocular conditions. Female optometrists made more false-positive referrals than males (p = 0.008). The proportion of false positives decreased by 6.2% per year since registration (p < 0.001).

SUMMARY

There was significant variation in referral accuracy across different ocular conditions, partly due to differences when defining accurate referrals. Optometrists working in primary care are generally more limited in their resources than the HES. Thus, choosing the cautious option of referral when they are unsure could be in the patients' best interests. The possible effect of increased use of advanced imaging on referrals requires evaluation. Although interventions such as refinement schemes have been put in place, these vary across regions, and their approaches such as virtual referral triaging may reduce unnecessary HES face-to-face appointments and promote communication between primary and secondary care.

Optometry independent prescribing during COVID lockdown in Wales

INTRODUCTION

During the COVID-19 lockdown, primary care optometry services in Wales moved to a hub model of provision. Three independent prescribing models were available in different areas: a commissioned Independent Prescribing Optometry Service (IPOS), independent prescribers that were not commissioned and no independent prescribers available. This allowed a unique opportunity for comparison.

METHOD

Optometry practices completed an online survey for each patient episode. Analysis of the data gave insight into patient presentation to urgent eye services and the drugs prescribed by optometrists. Medicines prescribed, sold or given and onward referral were compared between areas with an IPOS service (n = 2), those with prescribers but no commissioned service (n = 2) and those with no prescribers (n = 2).

RESULTS

Data from 22,434 reported patient episodes from 81 optometry practices in six health boards between 14 April 2020 and 30 June 2020 were analysed. Urgent care accounted for 10,997 (49.02%) first appointments and 1777 (7.92%) follow-ups. Most (18,006, 80.26%) patients self-referred. The most common presenting symptom was 'Eye pain/discomfort' (4818, 43.81% of urgent attendances). Anterior segment pathology was the most reported finding at first (6078, 55.27%) and follow-up (1316, 74.06%) urgent care appointments. Topical steroids (373, 25.99% of prescriptions) were the most prescribed medications. More medications were prescribed in areas with an IPOS service (1136, 79.16% of prescriptions) than areas with prescribers but no commissioned service. There were more follow-up appointments in optometric practice and fewer urgent referrals to ophthalmology in IPOS areas.

CONCLUSION

Urgent care services were most utilised by patients with discomfort caused by anterior eye conditions. IPOS services enabled optometrists to manage conditions to resolution without referral and without reduction in medications sold or given. Commissioners should recognise the value in reducing burden in urgent ophthalmology and the need for follow-up as part of a commissioned independent prescribing service.

Referrals from community optometrists in England and their replies: A mixed methods study

PURPOSE

Community optometrists, through routine eye examinations, identify patients with disease or ocular abnormalities requiring referral to the Hospital Eye Service. In many cases no reply to the referral letter is received, resulting in some patients being re-referred unnecessarily, potentially increasing the number of other patients who lose sight whilst on hospital waiting lists. This study investigated, qualitatively and quantitatively, factors influencing optometric referrals and replies.

METHODS

The three-phase, sequential mixed methods study started with a literature review and qualitative phase, interviewing stakeholders to identify issues for exploration in subsequent phases. The second, quantitative phase, undertook documentary analysis of 349 patient referral records from three optometric practice modalities (domiciliary, independently owned, and corporate chain) in England. A final qualitative phase obtained views from stakeholders to explore unexplained findings from the first two phases.

RESULTS

Phase 1 identified communication, financial, professional and technological issues for further exploration. In Phase 2, the referral rate was 22.2% for domiciliary provider, 2.1% for independent practice and 2.5% for the corporate chain, with the variation most likely explained by patient age and associated ophthalmic disease, illness and disability. The referral reply rate was 5.7% for domiciliary provider, 25.0% for independent practice and 4.9% for the corporate chain. The community optometrist remained unaware of the outcome of their referral in 72.8% of cases. Qualitative analyses indicate the main factors influencing referral reply rates are technology, the General Medical Practitioner, community optometrists' utility to and utility of the National Health Service and patient mobilisation.

CONCLUSIONS

The low referral reply rate creates a break in the feedback loop required to raise the standard of referrals and avoid unnecessary re-referral. Of the factors identified that influence referral reply rates, technology is key in view of the increasing use of online referral platforms. Feedback to the referring optometrist should be embedded in such systems.

Design and use of vignettes to investigate referral decision-making by optometrists

PURPOSE

This study describes the design and application of a range of online clinical vignettes for measuring the impact of Continuing Education and Training (CET) and identifying unwarranted variation in optometric decision-making concerning referrals to secondary care.

METHODS

Twenty computerised vignettes were developed to assess clinical and referral management decisions taken in primary care optometry. The online system was specifically designed to present vignettes (ten pre-CET and ten post-CET) that avoided prompting correct answers. The main study group was qualified optometrists (N = 31) who chose any CET options available to United Kingdom optometrists over six months. Participants submitted a record of the CET undertaken, which was compared with an anonymised General Optical Council (GOC) reference sample. The vignettes were also completed by newly-qualified (N = 18) and pre-registration (N = 11) groups.

RESULTS

CET had no significant correlation (p = 0.37) with improvement in optometric clinical decision-making and referral practice (qualified group). Selection bias affected this group who had more CET points (p = 0.008) and peer discussion points (p = 0.003) than the GOC reference sample. Results were indicative due to small sample sizes. Newly-qualified practitioners were significantly more likely to refer than the qualified group (p = 0.004). Number of referrals decreased with time since qualification (p = 0.006).

CONCLUSION

Computerised vignettes are a useful tool for comparing referral decisions between groups. Recruiting clinicians for time-consuming vignette studies is challenging. Strategies to reduce unwarranted variation in optometry, including support for newly-qualified optometrists, require further investigation.

Review of referrals reveal the impact of referral content on the triage and management of ophthalmology wait lists

OBJECTIVES

Many chronic eye conditions are managed within public hospital ophthalmology clinics resulting in encumbered wait lists. Integrated care schemes can increase system capacity. In order to direct implementation of a public hospital-based integrated eye care model, this study aims to evaluate the quality of referrals for new patients through information content, assess triage decisions of newly referred patients and evaluate the consistency of referral content for new patients referred multiple times.

DESIGN

A retrospective and prospective review of all referral forms for new patients referred to a public hospital ophthalmology clinic between January 2016 and September 2017, and September 2017 and August 2018, respectively.

SETTING

A referral-only public hospital ophthalmology clinic in metropolitan Sydney, Australia.

PARTICIPANTS

418 new patients on existing non-urgent wait lists waiting to be allocated an initial appointment, and 528 patients who were newly referred.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the information content of referrals for new patients. The secondary outcomes were triage outcomes for new incoming referrals, and the number of new patients with multiple referrals.

RESULTS

Of the wait-listed referrals, 0.2% were complete in referral content compared with 9.8% of new incoming referrals (p<0.001). Of new incoming referrals, 56.7% were triaged to a non-urgent clinic. Multiple referrals were received for 49 patients, with no change in the amount of referral content.

CONCLUSIONS

Most referrals were incomplete in content, leading to triage based on limited clinical information. Some new patients were referred multiple times with their second referral containing a similar amount of content as their first. Lengthy wait lists could be prevented by improving administrative processes and communication between the referral centre and referrers. The future implementation of an integrated eye care model at the study setting could sustainably cut wait lists for patients with chronic eye conditions.

Referrals from community optometrists to the hospital eye service in Scotland and England

Objectives

This audit assesses communication between community optometrists (COs) and hospital eye service (HES) in Scotland and England.

Methods

Optometric referrals and replies were extracted from six practices in Scotland and England. If no reply was found, replies/records were copied from HES records. De-identified referrals, replies and records were audited against established standards, evaluating whether referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated.

Results

From 905 de-identified referrals, RR ranged from 2.6 to 8.7%. From COs’ perspective, the proportion of referrals for which they received replies ranged from 37 to 84% (Scotland) and 26 to 49% (England). A total of 88–96% of referrals (Scotland) and 63–76% (England) were seen in the HES. Adjusting for cases when it is reasonable to expect replies, RRR becomes 45–92% (Scotland) and 38–62% (England) with RRR significantly greater in Scotland (P = 0.015). Replies were copied to patients in 0–21% of cases. Referrals were to the appropriate service and judged necessary in ≥90% of cases in both jurisdictions. Accuracy of referral ranged from 89 to 97% (Scotland) and 81 to 98% (England). The reply addressed the reason for referral in 94–100% of cases (Scotland) and 93–97% (England) and was meaningful in 95–100% (Scotland) and 94–99% (England).

Conclusions

Despite the interdisciplinary joint statement on sharing patient information, this audit highlights variable standard of referrals and deficits in replies to the referring COs, with one exception in Scotland. Replies from HES to COs are important for patient care, benefitting patients and clinicians and minimising unnecessary HES appointments.

Utilization trends of an ophthalmology-specific emergency department: the Massachusetts Eye and Ear experience

Purpose

To describe the utilization trends of a dedicated ophthalmology emergency department (ED) in Boston, Massachusetts.

Methods

The medical records of 500 randomly selected patients who presented at the Massachusetts Eye and Ear (MEE) Emergency Department (ED) from January 2015 to March 2016 were reviewed retrospectively. Data were analyzed using the Pearson χ2 test and multiple logistic regression. The primary study outcome measure was whether a patient's visit was emergent or nonemergent. Emergent or nonemergent conditions were classified based on the diagnosis and treatment required at follow-up appointments. Nonemergent diagnoses were classified as conditions that could have been seen as an outpatient without negative consequences for vision.

Results

Of the 500 cases, 252 were males and 248 were females. The median age was 45 years (range, 2-101 years). The most common diagnoses were posterior vitreous detachment (8.6%), corneal abrasion (8.4%), dry eye syndrome (7%), and viral conjunctivitis (5.4%). Of the total, 92.6% of patients originated from within Massachusetts. The majority of patients were self-referred (78.6%) or referred from another hospital (12.8%). Nonemergent visits accounted for 49.4% of patients seen. Compared to patients who presented with duration of symptoms for ≥1 week, patients who presented with symptoms of <1 week were more likely to present with an emergent condition (8.8% vs 41.8%). Referrals from an outside ophthalmologist or hospital were predictive of emergent patient visits (OR, resp., 1.971 [95% CI, 0.478-3.462; P = 0.01]; 1.040 [95% CI, 0.462-1.616; P < 0.001]).

Conclusions

In our study, nonemergent patient visits comprised nearly half of all ophthalmology ED visits. Emergent visits were associated with acute symptoms and referrals from outside healthcare providers.

New digital models of care in ophthalmology, during and beyond the COVID-19 pandemic

COVID-19 has led to massive disruptions in societal, economic and healthcare systems globally. While COVID-19 has sparked a surge and expansion of new digital business models in different industries, healthcare has been slower to adapt to digital solutions. The majority of ophthalmology clinical practices are still operating through a traditional model of ‘brick-and-mortar’ facilities and ‘face-to-face’ patient–physician interaction. In the current climate of COVID-19, there is a need to fuel implementation of digital health models for ophthalmology. In this article, we highlight the current limitations in traditional clinical models as we confront COVID-19, review the current lack of digital initiatives in ophthalmology sphere despite the presence of COVID-19, propose new digital models of care for ophthalmology and discuss potential barriers that need to be considered for sustainable transformation to take place.

Danish teleophthalmology platform reduces optometry referrals into the national eye care system

Objective

The purpose of this study was to evaluate the stratification of follow-up and referral pathways after implementation of a systematic cloud-based electronic-referral teleophthalmological service for optometry-initiated ocular posterior segment disease referrals to the Danish national eye care system.

Methods and Analysis

A retrospective cohort study was conducted in the period from 1 August 2018 to 31 July 2019. Patients with suspected ocular posterior segment disease reviewed by the telemedical ophthalmology service were included. The service stratified patients into the categories: no need for follow-up, follow-up by optometrist, follow-up by the telemedical service and referral to the national Danish eye care service.

Results

From a pool of 386 361 customers, 9938 patients were enrolled into this study. 19.5% of all patients were referred to the Danish national eye care system, while 80.5% of the patients in the telemedical service were not, in the period from 1 August 2018 to 31 July 2019. 14.4% of the optometrist referrals did not need any follow-up, while a majority of 66.1% needed some follow-up either by the optometrist themselves or within the telemedical service.

Conclusion

Optometrist posterior segment disease referrals can be considerably reduced with a risk stratified approach and optimal use of technology. New models can improve and streamline the healthcare system.

Referrals from community optometrists to the hospital eye service in England

PURPOSE

In the UK, most referrals to the hospital eye service (HES) originate from community optometrists (CO). This audit investigates the quality of referrals, replies, and communication between CO and the HES.

METHODS

Optometric referrals and replies were extracted from three practices in England. If no reply letter was found, the records were searched at each local HES unit, and additional replies or records copied. De-identified referrals, replies and records were audited by a panel against established standards to evaluate whether the referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated.

RESULTS

A total of 459 de-identified referrals were extracted. The RR ranged from 3.6%-8.7%. The proportion of referred patients who were seen in the HES unit was 63%-76%. From the CO perspective, the proportion of referrals for which they received replies ranged from 26%-49%. Adjusting the number of referrals for cases when it would be reasonable to expect an HES reply, RRR becomes 38%-62%. Patients received a copy of the reply in 3%-21% of cases. Referrals were made to the appropriate service in over 95% of cases, were judged necessary in 93%-97% and were accurate in 81%-98% of cases. The referral reply addressed the reason for the referral in 93%-97% and was meaningful in 94%-99% of cases. The most common conditions referred were glaucoma, cataract, anterior segment lesions, and neurological/ocular motor anomalies. The CO/HES dyad (pairing) in the area with the lowest average household income had the highest RR.

CONCLUSIONS

In contrast with the Royal College of Ophthalmologists/College of Optometrists joint statement on sharing patient information, CO referrals often do not elicit a reply to the referring CO. Replies from the HES to COs are important for patient care, benefitting patients and clinicians, and minimising unnecessary HES appointments.

Quality and targeting of new referrals for ocular complications of diabetes from primary care to a public hospital ophthalmology service in Western Sydney, Australia

Patients with diabetes require regular examination for eye disease, usually in primary care settings. Guidelines recommend patients with at least moderate non-proliferative diabetic retinopathy (NPDR) be referred to an ophthalmologist for treatment; however, poorly targeted referrals lead to access blocks. The quality of new referrals associated with diabetes to a public ophthalmology service in Sydney, New South Wales, Australia, were assessed for referral completeness and targeting. A cross-sectional audit of medical records for new patients referred to Westmead Hospital Eye Clinic in 2016 was completed. Completeness of medical and ophthalmic information in referrals and subsequent patient diagnosis and management in 2016-17 was recorded. Sub-analyses were conducted by primary care referrer type (GP or optometrist). In total, 151 new retinopathy referrals were received; 12% were sent directly to a treatment clinic. Information was incomplete for diabetes status (>60%), medical (>50%) and ophthalmic indicators (>70%), including visual acuity (>60%). GP referrals better recorded medical, and optometrists (37%) ophthalmic information, but information was still largely incomplete. Imaging was rarely included (retinal photos <1%; optical coherence tomography <3%). Median appointment wait-time was 124 days; 21% of patients received treatment (laser or anti-vascular endothelial growth factor) at this or the following encounter. Targeting referrals for ocular complication of diabetes to public hospitals needs improvement. Education, feedback and collaborative care mechanisms should be considered to improve screening and referral in primary care.

Delayed attendance at routine eye examinations is associated with increased probability of general practitioner referral: a record linkage study in Northern Ireland

PURPOSE

To investigate relationships between health and socio-economic status with delayed attendance at routine eye examinations and risk of subsequent general practitioner (GP) referral in Northern Ireland.

METHODS

We constructed a cohort of 132 046 community dwelling individuals aged ≥60 years, drawing contextual information from the 2011 Northern Ireland Census. Using linked administrative records of routine eye examinations between 2009 and 2014, we calculated 311 999 examination intervals. Multinomial models were used to estimate associations between contextual factors and examination interval (classified into three groups: early recall, on-time, delayed attendance). Associations between examination interval and referral risk were estimated using logistic regression.

RESULTS

Delayed attendance was recorded for 129 857 (41.6%) examination intervals, 53 759 (17.2%) delayed by ≥6 months. Female sex, poor general or mental health were each associated with delay, as were longer distances to optometry services among those aged ≥70 years (longest vs shortest: Relative Risk Ratio = 1.21 [1.14, 1.28]). Low income and residence in social housing were associated with reduced delay risk. There were 3347 (3.5%) and 11 401 (5.3%) GP referrals in the 60-69 and ≥70 years age groups respectively. Delayed attendance was associated with increased referral risk in both groups (Odds Ratios: 60-69 years = 1.30 [1.04, 1.61]; ≥70 years = 1.07 [1.01, 1.13]).

CONCLUSIONS

Poor health and longer distances to optometry services were associated with delayed attendance at routine eye examinations but low income was not. Delayed attendance was associated with increased GP referral risk, indicative of missed opportunities to detect potentially serious eye conditions.

Impact of optical coherence tomography on diagnostic decision-making by UK community optometrists: a clinical vignette study

Purpose

In recent years, there has been widespread investment in imaging technologies by community optometrists in the UK, most notably optical coherence tomography (OCT). The aim of the current study was to determine the value of OCT in the diagnosis of posterior segment diseases in a representative sample of community optometrists using a clinical vignette methodology.

Methods

A group of community optometrists (n = 50) initially completed a standardised training package on OCT interpretation followed by a computer‐based assessment featuring 52 clinical vignettes, containing images of healthy (n = 8) or glaucomatous (n = 18) discs or healthy (n = 8) or diseased (n = 18) fundi. Each vignette featured either a single fundus/disc photographic image, or a combination of a fundus/disc image with the corresponding OCT scan. An expert panel confirmed that the fundus images presented alone and those in combination with OCT data were of a similar level of difficulty and that the cases were typical of those seen in primary care. For each case, the optometrist selected their diagnosis from a pull‐down list and reported their confidence in their decision using a 10‐point Likert scale. Pairwise comparisons of the fundus image alone and fundus image/OCT combination were made for both diagnostic performance and confidence.

Results

The mean percentage of correct diagnoses using fundus imaging alone was 62% (95% CI 59–64%) and for the combination of fundus image/OCT was 80% (95% CI 77–82%). The mean false negative rate with fundus alone was 27% reducing to 13% with the OCT combination. Median confidence scores for fundus imaging alone was 8.0 (IQR 7.0–8.0) and 8.3 (IQR 8.0–9.0) for the combination. Improvements in performance and confidence were statistically significant (p < 0.001).

Conclusion

The results from this vignette study suggests that OCT improves optometrists’ diagnostic performance compared to fundus observation alone. These initial results suggest that OCT provides valuable additional data that could augment case‐finding for glaucoma and retinal disease; however, further research is needed to assess its diagnostic performance in a routine clinical practice setting.

Care pathways for glaucoma detection and monitoring in the UK

Glaucoma presents considerable challenges in providing clinically and cost-effective care pathways. While UK population screening is not seen as justifiable, arrangements for case finding have historically been considered relatively ineffective. Detection challenges include an undetected disease burden, whether from populations failing to access services or difficulties in delivering effective case-finding strategies, and a high false positive rate from referrals via traditional case finding pathways. The enhanced General Ophthalmic Service (GOS) in Scotland and locally commissioned glaucoma referral filtering services (GRFS) elsewhere have undoubtedly reduced false positive referrals, and there is emerging evidence of effectiveness of these pathways. At the same time, it is recognised that implementing GRFS does not intrinsically reduce the burden of undetected glaucoma and late presentation, and obvious challenges remain. In terms of diagnosis and monitoring, considerable growth in capacity remains essential, and non-medical health care professional (HCP) co-management and virtual clinics continue to be important solutions in offering requisite capacity. National guidelines, commissioning recommendations, and the Common Clinical Competency Framework have clarified requirements for such services, including recommendations on training and accreditation of HCPs. At the same time, the nature of consultant-delivered care and expectations on the glaucoma specialist's role has evolved alongside these developments. Despite progress in recent decades, given projected capacity requirements, further care pathways innovations appear mandated. While the timeline for implementing potential artificial intelligence innovations in streamlining care pathways is far from established, the glaucoma burden presents an expectation that such developments will need to be at the vanguard of future developments.

Impact of the Manchester Glaucoma Enhanced Referral Scheme on NHS costs

Objectives

Glaucoma filtering schemes such as the Manchester Glaucoma Enhanced Referral Scheme (GERS) aim to reduce the number of false positive cases referred to Hospital Eye Services. Such schemes can also have wider system benefits, as they may reduce waiting times for other patients. However, previous studies of the cost consequences and wider system benefits of glaucoma filtering schemes are inconclusive. We investigate the cost consequences of the Manchester GERS.

Design

Observational study.

Methods

A cost analysis from the perspective of the National Health Service (NHS) was conducted using audit data from the Manchester GERS.

Results

2405 patients passed through the Manchester GERS from April 2013 to November 2016. 53.3% were not referred on to Manchester Royal Eye Hospital (MREH). Assuming an average of 2.3 outpatient visits to MREH were avoided for each filtered patient, the scheme saved the NHS approximately £2.76 per patient passing through the scheme.

Conclusion

Our results indicate that glaucoma filtering schemes have the potential to reduce false positive referrals and costs to the NHS.

Severity of Visual Field Loss at First Presentation to Glaucoma Clinics in England and Tanzania

Purpose: To compare severity of visual field (VF) loss at first presentation in glaucoma clinics in England and Tanzania.Methods: Large archives of VF records from automated perimetry were used to retrospectively examine vision loss at first presentation in glaucoma clinics in Tanzania (N = 1,502) and England (N = 9,264). Mean deviation (MD) of the worse eye at the first hospital visit was used as an estimate of detectable VF loss severity.Results: In Tanzania, 44.7% {CI_95%: 42.2, 47.2} of patients presented with severe VF loss (< -20 dB), versus 4.6% {4.1, 5.0} in England. If we consider late presentation to also include cases of advanced loss (-12.01 dB to -20 dB), then the proportion of patients presenting late was 58.1% {55.6, 60.6} and 14.0% {13.3, 14.7}, respectively. The proportion of late presentations was greater in Tanzania at all ages, but the difference was particularly pronounced among working-age adults, with 50.3% {46.9, 53.7} of 18-65-year-olds presenting with advanced or severe VF loss, versus 10.2% {9.3, 11.3} in England. In both countries, men were more likely to present late than women.Conclusions: Late presentation of glaucoma is a problem in England, and an even greater challenge in Tanzania. Possible solutions are discussed, including increased community eye-care, and a more proactive approach to case finding through the use of disruptive new technologies, such as low-cost, portable diagnostic aids.

Standardising the cataract referral process for public hospitals: perspectives of optometrists in New South Wales, Australia

BACKGROUND

Previous research has shown that cataract surgery referral letters to major metropolitan public hospitals in New South Wales have insufficient detail to inform patient triage or apply prioritisation tools. This study aimed to canvass the views of optometrists working in New South Wales and the Australian Capital Territory (NSW/ACT) on standardising the referral process for public hospital cataract surgery.

METHODS

An online survey was sent to all NSW/ACT members of Optometry Australia in October 2017. Respondents were asked to select clinical and personal information to be included on a referral template using a list of 25 items. Data were also gathered on preferences for the cataract referral process and sources of cataract referral guidelines.

RESULTS

Two hundred and thirteen (response rate 13 per cent) optometrists completed the survey. There was close to universal support for inclusion of items like visual acuity (99 per cent), whereas other items had low support, including the date and details of previous refraction (26 per cent), history of falls (29 per cent) and health insurance status (29 per cent). Three-quarters of optometrists stated they would be willing to administer and report data from a patient survey about the functional impact of their cataract and level of visual disability. The preferred format of a standardised cataract referral template varied, although time efficiency and ease of completion were commonly cited reasons for preferences. Confirmation of receipt of referral from the public hospital, and a copy of the referral letter for the optometrist's records were also desirable. For the 61 per cent of respondents who reported accessing guidelines for cataract referral, 69 per cent stated the main source was Optometry NSW/ACT with fewer accessing guidelines directly from a public hospital or the NSW Health website.

CONCLUSION

Optometrists' preferences will be useful to inform the design and implementation of a standardised cataract referral template.

The relationship between unwarranted variation in optometric referrals and time since qualification

PURPOSE

To investigate variation in optometric referral decision-making and the influence of experience and continuing education and training (CET).

METHODS

To gain insight into unwarranted variation in referral activity in the United Kingdom (UK): (1) triage data were audited to investigate source of referral, provisional diagnosis, and outcome; (2) an online system was developed to present two sets of 10 vignettes, designed to avoid prompting answers. Participating optometrists completed 10 pre-CET vignettes, recording their tests and management decisions. The main group of participants chose whatever CET they wished over a 6-month period and then completed another 10 post-CET vignettes. A second group of newly-qualified optometrists completed the vignettes before and after a CET course intervention, followed by a third group of pre-registered optometrists with an intervention of 6-months experience of their pre-registration year.

RESULTS

The audit identified 1951 optometric referrals and 158 optometrists (211 referrals were from general medical practitioners), with 122 of the 158 optometrists making fewer than ten referrals. Two newly-qualified optometrists generated 12.5% of the total referrals in the audit (N = 2162). Many suspect glaucoma referrals were based on a single suspect measurement resulting in a high discharge rate after community review, as did referrals for certain fundus-related appearances for which no treatment was indicated. The intervention of gaining CET points appeared to have no significant impact (p = 0.37) on referral decision-making, although this part of the study was underpowered. Self-selection bias was confirmed in the main group. When the main group and newly-qualified practitioners were compared, the number of referrals was negatively associated with time since qualification (p = 0.005). When all 20 referral decisions were compared, all optometrists referring more than 10 vignette patients came from a group of newly-qualified practitioners up to 2 years post-qualification. Pre-registered optometrists generally referred more appropriately than newly-qualified. Upon qualification, there was a significant increase in the number of sight tests undertaken per day (p = <0.0005).

CONCLUSIONS

Gaining CET points alone is unlikely to significantly improve referral decision-making. Mentoring and targeted CET for the newly-qualified up to 2 years post-qualification should be considered. Ophthalmology replies to the referring newly-qualified optometrist are vital for moderating future referrals and developing clinical confidence.

Clinical safety of a minor eye conditions scheme in England delivered by community optometrists

OBJECTIVE

The aim of this study was to monitor the activity and evaluate the clinical safety of a minor eye conditions scheme (MECS) conducted by accredited community optometrists in Lambeth and Lewisham, London.

METHODS AND ANALYSIS

Optometrists underwent an accredited training programme, including attendance at hospital eye services (HES) clinics. Patients who satisfied certain inclusion criteria were referred to accredited MECS optometrists by their general practitioners (GPs) or could self-refer. Data were extracted from clinical records. A sample of MECS clinical records was graded to assess the quality of the MECS optometrists' clinical management decisions. Referrals to the HES were assessed by the collaborating ophthalmologists and feedback was provided.

RESULTS

A total of 2123 patients (mean age 47 years) were seen over 12 months. Two-thirds of the patients (67.3%) were referred by their GP. The most common reasons for patients needing a MECS assessment were 'red eye' (36.7% of patients), 'painful white eye' (11.1%), 'flashes and floaters' (10.2%); 8.7% of patients had a follow-up appointment. Of the patients seen, 75.1% were retained in the community, 5.7% were referred to their GP and 18.9% were referred to the HES. Of the HES referrals, 49.1% were routine, 22.6% urgent and 28.3% emergency. Of the records reviewed, 94.5% were rated as appropriately managed; 89.2% of the HES referrals were considered appropriate.

CONCLUSION

The findings of this study indicate that optometrists are in a good position to work very safely within the remits of the scheme and to assess risk.

Are cataract surgery referrals to public hospitals in Australia poorly targeted?

IMPORTANCE

Referral letters constitute the first step on the pathway to cataract surgery; however, little is known on how effective referral letters are in providing adequate information to triage patients and inform surgical prioritization.

BACKGROUND

Benchmarking exercises are important to document referral processes and to identify areas where improvements can be made.

DESIGN

Cross-sectional study with longitudinal follow-up conducted at two metropolitan public hospitals in New South Wales, Australia.

PARTICIPANTS

A total of 400 sequential cataract referral letters.

METHODS

An audit of cataract referral letters was performed and content benchmarked against international prioritization tools. Medical records were reviewed 1 year following referral.

MAIN OUTCOME MEASURES

Referral quality and waiting times.

RESULTS

Two-thirds of patients referred for cataract surgery were yet to have their initial hospital appointment in the year following referral (65%, 245/376). One half of referrals seen in clinic (49%, 64/113) were not listed for cataract surgery. Multivariate analysis revealed referral letter content was not indicative of surgical booking, with the major predictors being hospital-recorded visual acuity and grading of cataract (P < 0.0001). Referral content lacked sufficient detail to apply prioritization tools developed in other settings.

CONCLUSION AND RELEVANCE

This audit highlights a disconnect between referral letter content and hospital assessment of patients. Current referrals to public hospitals are poorly targeted, with high numbers of referred patients not proceeding to surgery. Patients commonly waited over 1 year to have their ophthalmic assessment at these public hospital eye clinics, revealing lengthy 'wait-for-waits' as a barrier to care. Standardized referral templates may facilitate improvement of referral pathways and shorten waiting times.

Factors influencing accuracy of referral and the likelihood of false positive referral by optometrists in Bradford, United Kingdom

AIMS

Levels of false positive referral to ophthalmology departments can be high. This study aimed to evaluate commonality between false positive referrals in order to find the factors which may influence referral accuracy.

METHODS

In 2007/08, a sample of 431 new Ophthalmology referrals from the catchment area of Bradford Royal Infirmary were retrospectively analysed.

RESULTS

The proportion of false positive referrals generated by optometrists decreases with experience at a rate of 6.2% per year since registration (p<0.0001). Community services which involved further investigation done by the optometrist before directly referring to the hospital were 2.7 times less likely to refer false positively than other referral formats (p=0.007). Male optometrists were about half as likely to generate a false positive referral than females (OR=0.51, p=0.008) and as multiple/corporate practices in the Bradford area employ less experienced and more female staff, independent practices generate about half the number of false positive referrals (OR=0.52, p=0.005).

CONCLUSIONS

Clinician experience has the greatest effect on referral accuracy although there is also a significant effect of gender with women tending to refer more false positives. This may be due to a different approach to patient care and possibly a greater sensitivity to litigation. The improved accuracy of community services (which often refer directly after further investigation) supports further growth of these schemes.

A review of 1000 referrals to Walsall's hospital eye service

BACKGROUND

Referrals to ophthalmology are predominantly made from general practitioners (GPs) and optometrists. These two groups of referrers receive differing types and levels of training and are equipped with different instrumentation. The purpose of this study was to determine whether the quality of referrals to the hospital eye service (HES) differs between GPs and optometrists in Walsall.

METHODS

Referrals into the HES were identified from Q1 2014 retrospectively until 1000 notes had been reached. Each record was scrutinized using a standard template. Data were analysed and summary statistics produced including positive predictive values and interobserver agreement.

RESULTS

We achieved our target of auditing 1000 records. The false-positive rate (patients being discharged from HES with a 'normal vision' diagnosis) was 7.7% of referrals from GPs and 6.2% of referrals from optometrists. Concordance between referred condition and diagnosed condition at HES between optometrists and ophthalmologists was 76.1%, and between GPs and ophthalmologists was 67.2%.

CONCLUSIONS

In view of findings from this study, it is important for commissioners in the new reconfigured National Health Service to ensure that enhanced ophthalmic services are commissioned only on the basis of hard evidence sourced from local data rather than opinion or on data from another geographical area.

A survey of current and anticipated use of standard and specialist equipment by UK optometrists

PURPOSE

To investigate current and anticipated use of equipment and information technology (IT) in community optometric practice in the UK, and to elicit optometrists' views on adoption of specialist equipment and IT.

METHODS

An anonymous online questionnaire was developed, covering use of standard and specialist diagnostic equipment, and IT. The survey was distributed to a random sample of 1300 UK College of Optometrists members.

RESULTS

Four hundred and thirty-two responses were received (response rate = 35%). Enhanced (locally commissioned) or additional/separately contracted services were provided by 73% of respondents. Services included glaucoma repeat measures (30% of respondents), glaucoma referral refinement (22%), fast-track referral for wet age-related macular degeneration (48%), and direct cataract referral (40%). Most respondents (88%) reported using non-contact/pneumo tonometry for intra-ocular pressure measurement, with 81% using Goldmann or Perkins tonometry. The most widely used item of specialist equipment was the fundus camera (74% of respondents). Optical Coherence Tomography (OCT) was used by 15% of respondents, up from 2% in 2007. Notably, 43% of those anticipating purchasing specialist equipment in the next 12 months planned to buy an OCT. 'Paperless' records were used by 39% of respondents, and almost 80% of practices used an electronic patient record/practice management system. Variations in responses between parts of the UK reflect differences in the provision of the General Ophthalmic Services contract or community enhanced services. There was general agreement that specialised equipment enhances clinical care, permits increased involvement in enhanced services, promotes the practice and can be used as a defence in clinico-legal cases, but initial costs and ongoing maintenance can be a financial burden. Respondents generally agreed that IT facilitates administrative flow and secure exchange of health information, and promotes a state-of-the-art practice image. However, use of IT may not save examination time; its dynamic nature necessitates frequent updates and technical support; the need for adequate training is an issue; and security of data is also a concern.

CONCLUSION

UK optometrists increasingly employ modern equipment and IT services to enhance patient care and for practice management. While the clinical benefits of specialist equipment and IT are appreciated, questions remain as to whether the investment is cost-effective, and how specialist equipment and IT may be used to best advantage in community optometric practice.

Addressing inequalities in eye health with subsidies and increased fees for General Ophthalmic Services in socio-economically deprived communities: a sensitivity analysis

OBJECTIVES

Poor knowledge of eye health, concerns about the cost of spectacles, mistrust of optometrists and limited geographical access in socio-economically deprived areas are barriers to accessing regular eye examinations and result in low uptake and subsequent late presentation to ophthalmology clinics. Personal Medical Services (PMS) were introduced in the late 1990 s to provide locally negotiated solutions to problems associated with inequalities in access to primary care. An equivalent approach to delivery of optometric services could address inequalities in the uptake of eye examinations.

STUDY DESIGN

One-way and multiway sensitivity analyses.

METHODS

Variations in assumptions were included in the models for equipment and accommodation costs, uptake and length of appointments. The sensitivity analyses thresholds were cost-per-person tested below the GOS1 fee paid by the NHS and achieving break-even between income and expenditure, assuming no cross-subsidy from profits from sales of optical appliances.

RESULTS

Cost per test ranged from £ 24.01 to £ 64.80 and subsidy required varied from £ 14,490 to £ 108,046. Unused capacity utilised for local enhanced service schemes such as glaucoma referral refinement reduced the subsidy needed.

CONCLUSIONS

In order to support the financial viability of primary eye care in socio-economically deprived communities, income is required from additional subsidies or from sources other than eye examinations, such as ophthalmic or other optometric community services. This would require a significant shift of activity from secondary to primary care locations. The subsidy required could also be justified by the utility gain from earlier detection of preventable sight loss.

Improving access to optometry services for people at risk of preventable sight loss: a qualitative study in five UK locations

Background

Reducing preventable sight loss is an increasing priority for public health and health care providers. We examined the factors affecting people's use of optometry services in population groups at increased risk of sight loss.

Methods

This is a qualitative study in five UK locations. In England, participants were from the Pakistani and Black Caribbean communities; in Scotland from the Pakistani community; and in Northern Ireland and Wales from white socio-economically deprived communities. Thirty-four focus groups were conducted (n = 289). The study included people who attend optometry services and people not engaged with services.

Results

Barriers to access included limited awareness of eye health and eye disease, concern about the cost of spectacles and the appropriateness of optometry in a commercial setting. Attendance at the optometrist was primarily symptom led. A positive previous experience or continuing relationship with the optometrist helped to alleviate the barriers and promote attendance.

Conclusion

Addressing the disparity between the broader messages about eye health and the current perception of the function of optometry could help improve access to services. Uptake may be improved through the co-production of interventions that better resonate with local communities. Non-retail service delivery options should be explored.

The effectiveness of schemes that refine referrals between primary and secondary care--the UK experience with glaucoma referrals: the Health Innovation & Education Cluster (HIEC) Glaucoma Pathways Project

OBJECTIVES

A comparison of glaucoma referral refinement schemes (GRRS) in the UK during a time period of considerable change in national policy and guidance.

DESIGN

Retrospective multisite review.

SETTING

The outcomes of clinical examinations by optometrists with a specialist interest in glaucoma (OSIs) were compared with optometrists with no specialist interest in glaucoma (non-OSIs). Data from Huntingdon and Nottingham assessed non-OSI findings, while Manchester and Gloucestershire reviewed OSI findings.

PARTICIPANTS

1086 patients. 434 patients were from Huntingdon, 179 from Manchester, 204 from Gloucestershire and 269 from Nottingham.

RESULTS

The first-visit discharge rate (FVDR) for all time periods for OSIs was 14.1% compared with 36.1% from non-OSIs (difference 22%, CI 16.9% to 26.7%; p<0.001). The FVDR increased after the April 2009 National Institute for Health and Clinical Excellence (NICE) glaucoma guidelines compared with pre-NICE, which was particularly evident when pre-NICE was compared with the current practice time period (OSIs 6.2-17.2%, difference 11%, CI -24.7% to 4.3%; p=0.18, non-OSIs 29.2-43.9%, difference 14.7%, CI -27.8% to -0.30%; p=0.03). Elevated intraocular pressure (IOP) was the commonest reason for referral for OSIs and non-OSIs, 28.7% and 36.1%, respectively, of total referrals. The proportion of referrals for elevated IOP increased from 10.9% pre-NICE to 28.0% post-NICE for OSIs, and from 19% to 45.1% for non-OSIs.

CONCLUSIONS

In terms of 'demand management', OSIs can reduce FVDR of patients reviewed in secondary care; however, in terms of 'patient safety' this study also shows that overemphasis on IOP as a criterion for referral is having an adverse effect on both the non-OSIs and indeed the OSIs ability to detect glaucomatous optic nerve features. It is recommended that referral letters from non-OSIs be stratified for risk, directing high-risk patients straight to secondary care, and low-risk patients to OSIs.

Teleophthalmology with optical coherence tomography imaging in community optometry. Evaluation of a quality improvement for macular patients

Purpose

To describe a quality improvement for referral of National Health Service patients with macular disorders from a community optometry setting in an urban area.

Methods

Service evaluation of teleophthalmology consultation based on spectral domain optical coherence tomography images acquired by the community optometrist and transmitted to hospital eye services.

Results

Fifty patients with suspected macular conditions were managed via telemedicine consultation over 1 year. Responses were provided by hospital eye service-based ophthalmologists to the community optometrist or patient within the next day in 48 cases (96%) and in 34 (68%) patients on the same day. In the consensus opinion of the optometrist and ophthalmologist, 33 (66%) patients required further “face-to-face” medical examination and were triaged on clinical urgency. Seventeen cases (34%) were managed in the community and are a potential cost improvement. Specialty trainees were supervised in telemedicine consultations.

Conclusion

Innovation and quality improvement were demonstrated in both optometry to ophthalmology referrals and in primary optometric care by use of telemedicine with spectral domain optical coherence tomography images. E-referral of spectral domain optical coherence tomography images assists triage of macular patients and swifter care of urgent cases. Teleophthalmology is also, in the authors’ opinion, a tool to improve interdisciplinary professional working with community optometrists. Implications for progress are discussed.

Challenges to establishing nationwide diabetic retinopathy screening programs

PURPOSE OF REVIEW

To review the results of recently published studies on diabetic retinopathy screening.

RECENT FINDINGS

Despite numerous public health campaigns and the existence of guidelines designed to promote annual retinal exams for diabetes patients, an unacceptably high number of patients are not screened for diabetic retinopathy. Current findings suggest the need for novel methods to improve compliance with retinal screening exams among diabetes patients to preserve vision functionality in this population.

SUMMARY

Diabetic retinopathy represents a major cause of acquired vision loss. The following review addresses the factors that contribute to inadequate retinopathy screenings among diabetes patients and proposes solutions that have the potential to increase the quality and accessibility of screening programs for diabetes patients.