Collaborative care of non-urgent macular disease: a study of inter-optometric referrals

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.

Topical Review: Optometry in Nepal-Clinical Practice, Research Advances, and Challenges

SIGNIFICANCE

This article reviews educational standard, clinical practice, research advances, and challenges associated with optometry in Nepal and provides critical considerations for contemporary and new optometry programs in countries with similar socioeconomic status and health care systems.Optometry education started in Nepal in 1998 with the primary objective of addressing the unmet needs of eye health and vision care in the country. Over the last two decades, this program has made significant contributions to facilitating and improving the delivery of quality eye care and establishing the nation's eye health system as an exemplary model in South Asia. Despite the positive impact in a short time, optometry education and the profession continue to face several challenges, including a shortage of training resources and facilities, poor quality control and regulation of practice standards, lack of professional recognition, limited pathways for entry to governmental jobs via the national public service commission, and limited clinical and academic opportunities in existing eye care programs. This article reviews current education and clinical practice standards, highlights research advances, and discusses present and future challenges in sustaining and improving the quality of education and advancing the scope of practice of optometry in Nepal. Given the limited access to primary eye care services in Nepal, appropriate professional recognition and integration into the national health system, and initiatives targeted at improving the delivery of optometry education in alignment with successful international models may provide a long-sought solution to making eye care services accessible to all and lowering the burden of visual impairment in the country.

Multispectral pattern recognition measures change in drusen area in age-related macular degeneration with high congruency to expert graders

Drusen are a hallmark lesion of age-related macular degeneration (AMD) and changes in their area and/or volume are strongly associated with disease progression. Assessment of longitudinal change in drusen size in clinical practice however is limited to a single commercial tool or manual inspection by clinicians. In this study we analysed change in drusen area in 33 eyes with intermediate AMD across two separate visits using a novel technique known as multispectral pattern recognition for en face retinal images from various imaging modalities (infrared (815 nm), fundus autofluorescence (488 nm) and green (532 nm) scanning laser ophthalmoscopy). We found 91% (30/33 eyes) agreement in the direction of drusen change for multispectral pattern recognition relative to expert graders who graded eyes as having drusen progression, regression or being stable. Multispectral pattern recognition showed 100% sensitivity (22/22 eyes) and 73% specificity (8/11 eyes). In comparison, we found only 70% (23/33 eyes) agreement in the direction of drusen change with a commercially available change analysis software, the Cirrus Advanced RPE Analysis relative to expert graders, with a sensitivity 64% (14/22 eyes) and specificity of 82% (9/11 eyes). Total drusen area or amount of change between visits had no significant effect on agreement. This suggests multispectral pattern recognition can quantify longitudinal change in drusen area from multimodal imaging with greater congruency to expert graders than a commercially available platform based on a single imaging modality. Considering the association of drusen area and disease progression, this method could aid clinical assessment and monitoring of AMD.

Introduction of structured record keeping in age-related macular degeneration: a before and after study

CLINICAL RELEVANCE

Structured record keeping improves documentation in age-related macular degeneration; however, it may have a more limited effect on the management decisions of a group of already highly trained clinicians, especially in the context of other well-embedded clinical decision support tools.

BACKGROUND

Structured record keeping has been associated with a range of advantages including improved history taking and communication, reduced number of unnecessary referrals, and enhanced diagnostic accuracy. The aim of this study was to examine the impact of a structured record keeping, quality improvement tool on recording, reporting and management congruency.

METHODS

A before and after retrospective record review study was performed in a single academic, intermediate-tier care institute in New South Wales, Australia. The structured record keeping tool intervention captured 31 items in addition to the prior pre-existing medical record: six items relating to historical risk factors, two items relating to patient activation, 13 items signifying core clinical signs, five items for change analysis and five items regarding the ongoing patient management plan.

RESULTS

Two hundred medical records from 151 patients with age-related macular degeneration were analysed. There was a statistically significant improvement in the number of reports that explicitly specified the number of clinical structural risk factors (from 24 to 75%; Fisher's exact p < 0.001) and risk of progression to advanced disease (from 71 to 84%; p = 0.041); however, this documentation had no statistically significant effect on the report-recommended management plan and/or the final report-recommended review period.

CONCLUSION

Disease-specific, structured record keeping improves the outgoing documentation of key clinical signs and is effective in prompting the transposition of these signs into a quantified risk progression score. It has limited value in improving management consistency among a group of highly trained eye care staff.

Clinical outcomes of the Centre for Eye Health: an intra-professional optometry-led collaborative eye care clinic in Australia

Clinical relevance: This novel clinical model is the first of its kind in Australia and was designed to help reduce unnecessary referrals into overburdened public systems by utilising pre-existing community-based resources.Background: The Centre for Eye Health (CFEH) is an intra-professional optometry-led care clinic offering an alternative pathway to traditional ophthalmology-based pathways (public hospital clinics or private practices) for 'at-risk' patients requiring ocular imaging, diagnostic and management services. This study evaluates the CFEH integrated eye-care model in the identification of chronic eye diseases within the community.Methods: A retrospective random clinical audit of over 750 medical records of patients referred to the CFEH between July 2016 and June 2019 was conducted. Demographics of patients, referral type, final diagnosis and recommended management plans were extracted from this subset. Clinic key performance indicators (referral turnaround time, and net cost per patient appointment) were also extracted.Results: Of the 755 referrals associated with the audited records, 77.4% resulted in the identification of patients with or at-risk of developing eye diseases with 73.5% of this cohort requiring ongoing monitoring at CFEH or referral to ophthalmology. Although the CFEH model is not designed to diagnose or manage acute conditions, 1.5% of patients in this pathway required same day ophthalmological or medical intervention. The cost per patient was equivalent to hospital eye departments costs.Conclusion: This integrated care pathway has the potential to reduce unnecessary referrals from optometrists to hospital ophthalmological service by offering a safe and effective alternate pathway. The majority of patients seen within this pathway were able to be monitored within optometry-led services. This is a unique clinical model utilising inter-professional referrals within optometry which has the potential to reduce preventable blindness within the community through the early detection of eye diseases.

Glaucoma Community Care: Does Ongoing Shared Care Work?

Purpose:

We assessed a novel, public, vertical integrated care model for glaucoma management in the community.

Methods:

This study was a retrospective, longitudinal study of 266 patients diagnosed or suspected of glaucoma. Patients were stratified to either ongoing ophthalmology-led (n = 81) or optometry-led shared care (n = 185). Demographics and clinical characteristics, including the re-referral rate and timeliness of follow up were analysed.

Results:

Just under half (565/1224, 46%) of all follow up consultations over the total study period of 45 months were seen in optometry-led care, with a re-referral rate to ophthalmology of 21%. Treated patients showed a median intraocular pressure reduction of 20% and a median time delay of just two days between the actual and recommended review period.

Conclusions:

Shared care provides an effective option for managing the ongoing care burden in chronic stable glaucoma cases at low risk of vision loss.

A qualitative exploration of Australian eyecare professional perspectives on Age-Related Macular Degeneration (AMD) care

Despite the existence of evidence-based recommendations to decrease risk and progression of Age-Related Macular Degeneration (AMD) for some time, self-reported practices suggest that eyecare professionals' advice and people with AMD's adherence to these recommendations can be very poor. This study uses qualitative methods to explore Australian eyecare professionals' perspective on barriers to effective AMD care. Seven focus groups involving 65 optometrists were conducted by an experienced facilitator. A nominal group technique was used to identify, prioritize and semi-quantify barriers and enablers to AMD care. Participants individually ranked their perceived top five barriers and enablers with the most important granted a score of 5 and the least important a score of 1. For each barrier or enabler, the number of votes it received and its total score were recorded. Barriers and enablers selected by at least one participant in their top 5 were then qualitatively analysed, grouped using thematic analysis and total score calculated for each consolidated barrier or enabler. In-depth individual interviews were conducted with 10 ophthalmologists and 2 optometrists. Contributions were audio-recorded, transcribed verbatim and analysed with NVivo software. One hundred and sixty-nine barriers and 51 enablers to AMD care were identified in the focus groups. Of these, 102 barriers and 42 enablers were selected as one of their top 5 by at least one participant and further consolidated into 16 barriers and 10 enablers after thematic analysis. Factors impacting AMD care identified through analysis of the transcripts were coded to three categories of influence: patient-centered, practitioner-centered, and structural factors. Eyecare professionals considered poor care pathways, people with AMD's poor disease understanding / denial, and cost of care / lack of funding, as the most significant barriers to AMD care; they considered shared care model, access, and communication as the most significant enablers to good AMD care. These findings suggest that Australian eyecare professionals perceive that there is a need for improved patient support systems and appropriately funded, clearer care pathway to benefit people with AMD.

Impact of referral refinement on management of glaucoma suspects in Australia

BACKGROUND

In ageing populations, the prevalence of chronic diseases such as glaucoma is projected to increase, placing additional demands on limited health-care resources. In the UK, the demand for secondary care in hospital eye clinics was inflated by high rates of false positive glaucoma referrals. Collaborative care models incorporating referral refinement, whereby glaucoma suspect referrals are triaged by suitably trained optometrists through further testing, can potentially reduce false positive referrals. This study examined the impact of a referral refinement model on the accuracy of glaucoma referrals in Australia.

METHODS

Optometrist-initiated glaucoma suspect referrals to the Glaucoma Management Clinic (Sydney, Australia) were prospectively recruited. Glaucoma suspect referrals arising from two pathways were eligible for inclusion, either directly from a community optometrist (standard care) or following comprehensive assessment at the Centre for Eye Health (referral refinement). Main outcome measures were the positive predictive value and false positive rate of referrals. The impact of referral letter content on management outcomes was also investigated.

RESULTS

Of 464 referrals received between March 2015 and June 2018, 252 were for treatment of naïve glaucoma suspects and eligible for inclusion. Following ophthalmological assessment, 45.6 per cent (n = 115/252) were prescribed treatment for open angle glaucoma or ocular hypertension. Positive predictive value of community optometry referrals was 33.8 per cent (n = 25/74) and 50.6 per cent (n = 90/178) following referral refinement. The first visit discharge (false positive) rate was 26 per cent (n = 19/74) for community referrals compared to four per cent (n = 8/178) with referral refinement. Positive predictive value increased with the number of abnormal clinical examination findings associated with referral (χ² test, p < 0.0001). The number of abnormal findings reported in referrals was significantly higher with referral refinement compared to without (n = 1.9 versus 1.5, t-test, p < 0.0001).

CONCLUSION

Referral refinement can improve the diagnostic accuracy of optometry-initiated referrals for glaucoma suspects in Australia, thereby decreasing unnecessary referrals to hospital and other secondary clinics.

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.

Vascular Changes in Intermediate Age-Related Macular Degeneration Quantified Using Optical Coherence Tomography Angiography

Purpose

To examine changes in retinal vasculature and ganglion cell layer (GCL) thickness in intermediate age-related macular degeneration (AMD) using optical coherence tomography angiography (OCTA).

Methods

Zeiss Cirrus Angioplex OCTA 6 × 6 mm scans and a macula 512 × 128 cube scans of the central retina were taken of 63 eyes with intermediate AMD and 51 control eyes. For OCTA scans, the superficial and deep capillary plexus were automatically segmented and vascular density quantified as total number of pixels contributing to the blood flow signal detectable by OCTA. Images were then skeletonized and vessel length, diameter index, morphology, and branching complexity determined. Foveal avascular zone (FAZ) characteristics and GCL thickness were extracted from in-built Angioplex software.

Results

Vascular density was significantly reduced in the superficial capillary plexus of AMD eyes compared with normal eyes, particularly in the superior quadrant (42.4% ± 1.6% vs. 43.2% ± 1.4%; P < 0.05). A nonsignificant reduction was also seen in the deep capillary plexus (P = 0.06). Total vessel length and average vessel diameter were all significantly decreased in AMD eyes suggesting density changes were related to decreased vessel number and caliber. Vascular complexity and number of branch points was significantly decreased in the deep capillary plexus (P < 0.05) suggesting loss or significantly reduced flow of vessels. Average GCL thickness was also significantly reduced in the AMD eyes (P < 0.05). No significant changes in FAZ parameters were observed in AMD eyes.

Conclusions

This study suggests intermediate AMD affects both the quantity and morphology of inner retinal vasculature and may be associated with changes in inner retinal structure. This work builds upon the notion that AMD pathogenesis may extends beyond the outer retina.

Translational Relevance

Better understanding of retinal vascular changes in AMD can provide insights in the development of treatment and prevention protocols for these diseases.

A collaborative care pathway for patients with suspected angle closure glaucoma spectrum disease

BACKGROUND

Currently, no specific collaborative care pathway exists that distinguishes open angle glaucoma from narrow angle or angle closure disease. This study evaluates a newly developed referral and collaborative care pathway specifically for patients with angle closure spectrum disease.

METHODS

The medical records of consecutive patients referred to the Centre for Eye Health for glaucoma assessment were examined, six months before (Pre Suite) and after (Post Suite) the introduction of a novel referral pathway for anterior chamber angle assessment (Angle Suite). Patient demographic and clinical data, the referral letter and practitioner characteristics were extracted.

RESULTS

Angle Suite (n = 77) patients had an appointment much sooner compared to Pre (n = 383) and Post Suite (n = 425) patients (p < 0.0001). Following the introduction of Angle Suites, there was a reduction of incidental angle closure disease found in routine, non-angle closure glaucoma assessment. Onward referral was required by 36.4 per cent of patients referred for suspected angle closure disease, while the rest could be discharged back into the community (13.0 per cent) or reviewed at the Centre for Eye Health (50.6 per cent). Multinomial logistic regression found that the presence of an angle description in the referral letter improved the true positive rate for angle closure disease (p < 0.0001).

CONCLUSIONS

The clinical pathway may reduce the number of incidental angle closure patients and improved the timeliness of appropriate clinical care delivered to a subset of patients who may benefit from prompt medical attention. This pathway provides an opportunity for appropriately staffed and equipped collaborative care clinics to reduce the burden on tertiary level ophthalmic facilities.

Peripheral retinal findings in populations with macular disease are similar to healthy eyes

PURPOSE

Recent evidence suggests several macular diseases are associated with peripheral retinal changes. This study investigated the number, type and management consequences of peripheral retinal findings detected in patients attending a referral only, eye-care clinic, the Centre for Eye Health(CFEH) with macular disease.

METHODS

Records of 537 patients attending CFEH for a macular assessment were included in the study. Subjects were classified as having age-related macular degeneration (AMD), epiretinal membrane (ERM), central serous chorioretinopathy (CSCR), inherited macular dystrophy or no macular disease. Data extracted included reason for referral, macular findings, peripheral findings (based on examination by ultra-widefield scanning laser ophthalmoscopy), diagnosis and management.

RESULTS

After age-matching, the number of peripheral findings in subjects with AMD, ERM or CSCR was not significant different to normal subjects. The most common finding for all cohorts were non-specific, degenerative changes such as drusen or pigmentation (61-72%) except inherited macular dystrophy subjects who had mostly vascular findings (30%; p < 0.05). Subjects with AMD and ERM with peripheral findings were significantly more likely to be reviewed or referred to an ophthalmologist than discharged back to their community eye care provider compared to subjects without findings. However only 8% of subjects had altered management based specifically on peripheral findings suggesting the macular findings in most subjects dictated their management. For those with a change, it was significant (upgrade to referral to an ophthalmologist). Peripheral findings also flagged 5% of subjects with vascular findings for referral to their general practitioner (GP).

CONCLUSIONS

Overall, the percentage and distribution of peripheral retinal findings in some macular diseases was similar to normal subjects. However, subjects with peripheral findings appeared to have significant differences in management. Considering some common findings, such as peripheral drusen may be relevant to AMD pathogenesis and therefore affect management of this disease, assessment of the peripheral retina should not be overlooked when the clinical focus is on the posterior pole.

An evidence-based approach to the routine use of optical coherence tomography

Optical coherence tomography is an imaging technology that has revolutionised the detection, assessment and management of ocular disease. It is now a mainstream technology in clinical practice and is performed by non-specialised personnel in some settings. This article provides a clinical perspective on the implications of that movement and describes best practice using multimodal imaging and an evidence-based approach. Practical, illustrative guides on the interpretation of optical coherence tomography are provided for three major diseases of the ocular fundus, in which optical coherence tomography is often crucial to management: age-related macular degeneration, diabetic retinopathy and glaucoma. Topics discussed include: cross-sectional and longitudinal signs in ocular disease, so-called 'red-green' disease whereby clinicians rely on machine/statistical comparisons for diagnosis in managing treatment-naïve patients, and the utility of optical coherence tomography angiography and machine learning.

The advantages of intermediate-tier, inter-optometric referral of low risk pigmented lesions

Purpose

Pigmented ocular lesions are commonly encountered by eye‐care professionals, and range from benign to sight or life‐threatening. After identifying a lesion, the primary care professional must establish the likely diagnosis and decide either to reassure, to monitor or to refer. The increasing use of ocular imaging technologies has contributed to an increase in the detection rate of pigmented lesions and a higher number of referrals, which may challenge existing pathways of health‐care delivery. Specialist services may be over‐burdened by referring all patients with pigmented lesions for an opinion, while inter‐optometric referrals are underutilised. The aim of this study was to describe the referral patterns of pigmented lesions to an optometry led intermediate‐tier collaborative care clinic.

Methods

We performed a retrospective review of patient records using the list of patients examined at Centre for Eye Health (CFEH) for an initial or follow up pigmented lesion assessment between the 1/7/2013 and the 30/6/2016. Analysis was performed on: patient demographic characteristics, the referrer's tentative diagnosis, CFEH diagnosis and recommended management plan.

Results

Across 182 patient records, the primary lesion prompting referral was usually located in the posterior segment: choroidal naevus (105/182, 58%), congenital hypertrophy of the retinal pigment epithelium (CHRPE; 11/182, 6%), chorioretinal scarring (10/182, 5%) or not specified (52/182, 29%). Referrals described a specific request for ocular imaging in 25 instances (14%). The number of cases with a non‐specific diagnosis was reduced after intermediate‐tier care assessment (from 29% to 10%), while the number of diagnoses with less common conditions rose (from 2% to 21%). There was a 2% false positive referral rate to intermediate‐tier care and a first visit discharge rate of 35%. A minority required on‐referral to an ophthalmologist (22/182, 12%), either for unrelated incidental ocular findings, or suspicious choroidal naevi. Conditions most amenable to optometric follow up included: 1) chorioretinal scarring, 2) choroidal naevus, and 3) CHRPE.

Conclusions

Intermediate‐tier optometric eye‐care in pigmented lesions (following opportunistic primary care screening) has the potential to reduce the number of cases with non‐specific diagnoses and to increase those with less common diagnoses. The majority of cases seen under this intermediate‐tier model required only ongoing optometric surveillance.

Advanced imaging for the diagnosis of age-related macular degeneration: a case vignettes study

Background

The aim of this study is to evaluate the diagnosis, staging, imaging and management preferences, and the effect of advanced imaging among practising optometrists in age‐related macular degeneration (AMD).

Methods

Up to 20 case vignettes (computer‐based case simulations) were completed online in a computer laboratory in random order by 81 practising optometrists of Australia. Each case presented findings from a randomly selected patient seen previously at the Centre for Eye Health for a macular assessment in the following order: case history, preliminary tests and colour fundus photography. Participants were prompted to provide their diagnosis, management and imaging preference. One additional imaging result (either modified fundus photographs and infrared images, fundus autofluorescence, or optical coherence tomography [OCT]) was then provided and the questions repeated. Finally, all imaging results were provided and the questions repeated a third time.

Results

A total of 1,436 responses were analysed. The presence of macular pathology in AMD was accurately detected in 94 per cent of instances. The overall diagnostic accuracy of AMD was 61 per cent using colour fundus photography. This improved by one per cent using one additional imaging modality and a further four per cent using all imaging. Across all responses, a greater improvement in the diagnostic accuracy of AMD occurred following the presentation of OCT findings (versus other modalities). OCT was the most preferred imaging modality for AMD, while multimodal imaging was of greatest benefit in cases more often misdiagnosed using colour fundus photography alone. Overall, the cohort also displayed a tendency to underestimate disease severity.

Conclusion

Despite reports that imaging technologies improve the stratification of AMD, our findings suggest that this effect may be small when applied among practising optometrists without additional or specific training.

Collaborative care of non-urgent macular disease: a study of inter-optometric referrals

Purpose

Diseases involving the macula and posterior pole are leading causes of visual impairment and blindness worldwide and may require prompt ophthalmological care. However, access to eye‐care and timely patient management may be limited due to inefficient and inappropriate referrals between primary eye‐care providers and ophthalmology. Optometrists with a special interest in macular disease may be useful as a community aid to better stratify and recommend best‐practice management plans for suitable patients. This study assesses such a notion by appraising the optometric referral patterns of patients with suspected macular disease to an intermediate‐tier optometric imaging clinic.

Methods

We performed a retrospective review of patient records and referrals using patients examined at Centre for Eye Health (CFEH) for an initial or follow up macular assessment between the 1/7/2013 and 30/6/2014 (n = 291). The following data were analysed: patient demographic characteristics, primary reason for referral, diagnosed/suspected condition, CFEH diagnosis and recommended management plan.

Results

The number of referrals stipulating a diagnosis, confirmed after evaluation at CFEH was 121 of 291 (42%). After evaluation at CFEH, the number of cases without a specific diagnosis was approximately halved (reduced from 47% to 23%), while the number of cases with no apparent defect or normal aging changes rose from 1% to 15%. Overall diagnostic congruency for specified macular conditions was high (58–94%); cases were seldom (30/291, 10%) found to have a completely different macular condition. 244 of 291 (84%) patients seen at CFEH were recommended ongoing optometric care: either with the referring optometrist or through recall to CFEH. Referral to an ophthalmologist was recommended in 47 instances (16%).

Conclusions

More widespread adoption of intermediate‐tier optometric eye‐care referral pathways in macular disease (following opportunistic primary care screening) has the potential to reduce the number of cases with non‐specific diagnoses and to increase those with a diagnosis of normal aging changes or no apparent disease. The majority of cases seen under this intermediate‐tier model required ongoing optometric care only and did not require face‐to‐face consultation with an ophthalmologist.