Enhanced Macular Imaging Referral Pathway: Bridging Community Optometrists and Hospital Specialists for Smarter Eye Care

Hospital eye services in England face sustained demand, with nearly 9 million outpatient appointments in 2023–2024. Teleophthalmology pathways that combine community-acquired imaging with hospital virtual review may reduce unnecessary face-to-face visits. We evaluated an enhanced macular imaging referral pathway linking community optometry optical coherence tomography (OCT) and colour fundus imaging with hospital-led teleophthalmology review. We performed a retrospective service evaluation of 376 consecutive adult macular referrals received at University Hospitals of Bristol and Weston, between July 2024 and March 2025. Community optometrists submitted bilateral macula-centred 45° colour fundus photographs, bilateral OCT volume scans in digital imaging and communications in medicine (DICOM) format and clinical data via a secure platform. Referrals were reviewed by a consultant ophthalmologist or hospital optometrist within 1 working day. Under the previous pathway, all accepted referrals required an initial face-to-face hospital appointment. Primary outcomes were referral appropriateness, avoided hospital appointments and redirection to other sub-specialties; secondary outcomes were management decision and diagnostic category. Analyses were descriptive. Median age was 74 years (IQR 14); 54.3% were female. Overall, 327/376 referrals (87.0%, 95% CI 83.2–90.0) were appropriate for macular assessment. Of the referrals, 49 (13.0%) were inappropriate because of incomplete imaging (n = 18, 4.7%) or redirection to another sub-specialty (n = 31, 8.2%), most commonly vitreoretinal services (n = 27, 7.2%). Among appropriate referrals, 241/327 (73.7%, 95% CI 68.7–78.2) avoided the mandatory first hospital visit required under the previous pathway. Management outcomes across the cohort were: neovascular age-related macular degeneration (nAMD) pathway, 17.1%; redirection, 6.1%; discharge to community, 10.2%; virtual follow-up, 15.3%; and face-to-face appointment, 51.2%. Mean time to treatment for nAMD was 8.6 days (95% CI 6.0–11.2 days). This teleophthalmology-enabled macular referral pathway achieved high referral appropriateness and substantially reduced mandatory first-visit hospital appointments while supporting timely treatment for sight-threatening macular disease. The model appears scalable and may help National Health Service hospital eye services manage rising demand more efficiently. This study evaluated a new way of managing eye referrals from community optometrists (high-street opticians) to hospital eye specialists. Instead of sending every patient to a hospital clinic in person, optometrists sent digital photographs and detailed eye scans, known as optical coherence tomography, to hospital specialists who reviewed them remotely. The study included 376 adults referred to Bristol Eye Hospital between July 2024 and March 2025; most were aged around 74 years, and just over half were women. Nearly nine in ten referrals (87%) were appropriate for further assessment of the macula, the central part of the retina responsible for detailed vision, and almost three quarters of those patients were managed without needing to visit the hospital at all. Among patients found to need urgent treatment for wet age-related macular degeneration, a condition that can cause rapid sight loss, 91% received treatment within 14 days from their optician referral, well above the national average of 40%. These findings suggest that this type of remote review pathway can help eye specialists manage a growing number of referrals more efficiently, ensure the right patients are seen quickly and reduce unnecessary hospital visits, and that the approach could be used more widely across the National Health Service.