Why Patient-Reported Outcome Measures Have Not Reached Primary Eye Care: A Critical Narrative Review of the Targeting, Access, and Action Gaps

Eye care is shifting into community and primary care settings, yet patient-reported outcome measures (PROMs) have not followed. Non-adoption is routinely attributed to clinician time, information technology, and absent guidance, explanations that are real but have not changed practice. This critical narrative review synthesises evidence across ophthalmic PROM psychometrics, implementation science, community eye care service evaluations, and primary eye care epidemiology, with every primary source verified against its PubMed record. We propose, as hypotheses requiring validation rather than as established findings, four structural gaps: instruments calibrated in hospital and surgical cohorts may mistarget milder community populations; in the only published implementation reporting uptake, patients with lower visual acuity were less likely to attempt a self-administered vision PROM, suggesting that non-completion may be informative rather than random; we identified no primary eye care study in which scores were returned to the consultation, the step at which benefit has been demonstrated in other specialties; and the high-volume community case mix remains largely unmeasured. Beneath these, we propose a fifth, cross-cutting funding gap, since we identified no routine reimbursement route for this activity, although the service and financing evidence available to us is predominantly from the United Kingdom. We set out a staged implementation route, the observations that would confirm or refute each proposed gap, and the strongest counter-argument to our own position, namely that non-adoption may be rational where instruments carry little decision-relevant information in mild disease.