A light in the dark

This is not a rugby match or pop concert, but a representation of the number of people in Wales who are at risk of permanent sight loss while waiting for ophthalmology care.

Data published by NHS Wales shows that 80,191 people at risk of irreversible sight loss waited beyond their recommended treatment date in April 2025.

The challenges regarding waiting times in Wales have provided an impetus for optometrists to transform the way they are working – offering more eye care on the High Street through enhanced General Ophthalmic Services (GOS) contracts that enable optometrists to provide increased treatment and monitoring in the community.  

Talking to OT, optometrist and chief optometric adviser, David O’Sullivan, OBE, explained that addressing long waiting times for treatment has prompted innovation within optometry in Wales. This is an opportunity that many optometrists have embraced, he highlighted.   

In February 2025, more than 3000 patients were seen in the community through the new Independent Prescribing Service (WGOS5) which enables optometrists to provide urgent eye care services in primary care. Across Wales, there are 90 practices currently providing this service.  

In the same month, 800 patients were seen at 73 practices across Wales through glaucoma, medical retina and hydroxychloroquine services (WGOS4).  

“The changes that we have made in optometry are ahead of the curve – we are talking once in a generation change,” optometrist and chief optometric adviser, David O’Sullivan OBE, told OT.  

A helping hand 

The reformed national eye care contract, which was introduced in October 2023, has helped to provide the infrastructure required to enable optometry to begin to help ease the burden on secondary care.   

“We’ve been able to look at things in a transformational manner,” O’Sullivan emphasised.    

“We want everybody to be working at the top of their licence. We are seeing an increase in complex cases that would previously have been seen in secondary care,” he added.  

Almost two years on from the new eye care contract being signed, O’Sullivan recently travelled to different areas across Wales to speak with practitioners about the widespread reforms to optometry.   

He shared that generally the feedback from optometrists has been positive about the changes to the ways they are working.  

“They are enthusiastic about our new pathways, and they want to get involved,” he said.

However, he emphasised that some changes will take time to embed, with the ultimate goal of improving patient care.   

Acknowledging the long waiting times, O’Sullivan said: “We all have a responsibility to address those long waiting lists, and work to eliminate avoidable sight loss.”

Offering care in the community 

Optometrist and Cardiff University lecturer, Dr Grant Robinson, is one of three optometrists who provides WGOS4 glaucoma care to patients at the NHS Wales University Eye Care Centre.  

Robinson receives referrals from optometrists who suspect glaucoma or ocular hypertension during the course of a routine eye examination.   

“To date, I most commonly see chronic open-angle glaucoma and ocular hypertension cases. Less frequently I encounter patients with primary angle closure or secondary glaucoma,” he said.  

“Anecdotally I often hear that the experience is less stressful than visiting the hospital. For most, our clinic is more local than the hospital, which has reduced the burden of travel,” he shared with OT.   

He highlighted that the WGOS4 has also begun to have an effect on waiting times for treatments.   

“In my area the time taken from initial referral to review has reduced a lot now that community optometrists with higher qualifications are being better utilised. This means the risk of avoidable sight loss caused by lengthy hospital waiting lists is lower,” Robinson shared.  

As an independent prescribing (IP) optometrist, Robinson also provides urgent eye care services that would traditionally have been provided in a hospital setting through WGOS5.  

“Most patients are very thankful to receive treatment closer to home and not to have to contend with a trip to eye casualty. Inter-professional relationships with pharmacists and GPs continue to grow, enabling patients to gain access to the treatment they need much more efficiently,” Robinson said.   

He told OT that he feels proud to be involved in services that represent the evolution of the profession in Wales.  

“When I speak to my peers who also provide WGOS4 and WGOS5 in the community I am enthused to be part of a network of forward-thinking optometrists who have also been willing to invest in upskilling,” Robinson emphasised.  

Reducing pressure on secondary care 

IP optometrist, Owain Mealing, offers both new suspected glaucoma and ocular hypertensive filtering, and urgent eye care services at Davies and Jones Optometrists.  

Mealing highlighted that WGOS4 and WGOS5 help to ease the pressure on the hospital eye service.  

“Around 75% of glaucoma referrals received can be discharged or managed within primary care,” he said.   

He added that ocular hypertension patients who opt for selective laser trabeculoplasty are directly listed within the hospital eye service and often seen within 12 weeks from the initial referral by a primary care optometrist.   

Following treatment and attaining target pressures, the patient can be discharged back into primary care optometry for ongoing monitoring, Mealing shared.  

“IP has resulted in a greater than 90% retention of patients within primary care, allowing the redeployment of a doctor from eye casualty to a clinic where more specialist medical or surgical backlogs can be dealt with,” he said.  

“Patients are delighted to have shorter waiting times to get an opinion on whether they need intervention for glaucoma or can continue to be monitored by their optometrist. This really makes for better peace of mind,” he observed.   

He emphasised that being able to put his skills and knowledge into practice has been very rewarding.   

“Undertaking the training at cost for professional curiosity without the means to actually use the skills was very disheartening. Being able to completely resolve a sight-threatening eye condition in primary care does provide that satisfaction hit at the end of the day compared with the days of ‘detect and refer’,” Mealing said.  

Patients are delighted to have shorter waiting times to get an opinion on whether they need intervention

A postcode lottery

Williams and Parry Ltd optometrist, Karen Schneider, recently moved from working within Powys Teaching Health Board to Aneurin Bevan University Health Board.  

Across the seven health boards in Wales, Powys Teaching Health Board has the second lowest proportion of patients at highest risk of irreversible sight loss waiting beyond their target treatment date – 30% compared to 55% at Aneurin Bevan University Health Board. 

“When I first heard about the waiting times, I was shocked,” she told OT.   

In January 2024, a memo shared with primary care optometrists by Aneurin Bevan University Health Board listed the waiting time for cataracts in December as 135 weeks, while the waiting time for a hospital glaucoma appointment was 91 weeks.   

When contacted by OT, Aneurin Bevan University Health Board clarified that the waiting times in the memo were the longest waiting times for each specialty rather than an average waiting time. 

“I think the new contract in Wales is excellent and will have a big impact on the workload at the hospital, as well as paying us fairly for our time,” she said.   

“Our practice sees a high volume of IP referrals which would otherwise need to be seen at the hospital, plus our medical retina practitioners are reducing the number of incorrect referrals reaching the hospital,” Schneider explained.   

While Schneider is positive about the effects of contact reforms, she outlined the uncertainty that long waiting times place on optometrists working in the community.   

“We are all trying to do our best, but our hands are tied,” she said.   

“It is stressful when you are making a clinical decision about whether to refer, and in the back of your mind you have to pre-empt the next 12 months,” she said. 

I think the new contract in Wales is excellent and will have a big impact on the workload at the hospital

The patient perspective

More than half of patients categorised as being at the highest risk of irreversible sight loss are waiting beyond their target treatment date within Betsi Cadwaladr University Health Board.  

Anglesey resident and age-related macular degeneration (AMD) patient, Edward Kenna, 81, who is receiving AMD treatment through Betsi Cadwaladr University Health Board, waited 23 weeks for his last Eylea injection – seven weeks over the recommended treatment interval.   

“Eyesight is one of the things we all take for granted, but when it’s taken away, you’re in a very dark world indeed,” he told OT.

During the period of limbo between when Kenna was meant to receive his injection and treatment, a conversation he had with a fellow patient over a year ago repeatedly returned to his mind.   

“While we were waiting for our injections, I was talking with this lady and eventually she said to me, ‘I can’t see your face’,” Kenna said.   

“It was like a hammer blow. That thought sticks with you all the time. You go to bed with it every night,” he said.   

Kenna also has glaucoma and cataracts. However, he cannot afford to self-fund treatment and faces a long waiting time to be seen through the NHS.  

“I don’t want to be carried by anybody. I was brought up to be independent, but I need help now,” he said.   

Within Hywel Dda University Health Board, 66% of patients at the highest risk of irreversible sight loss are waiting beyond their target treatment date.   

Pembrokeshire resident, Stuart Walder, 78, has been waiting up eight weeks over the recommended treatment interval for his wet AMD injections.   

Walder decided to self-fund his treatment for cataracts after being informed of the waiting time.  

“I was told that I was likely to wait two years for treatment, at which point I raided the piggy bank,” he said.   

Walder told OT that while he chose to prioritise quality of life by paying close to £6000 for treatment, he is aware that not everyone will have this level of savings.  

The retired engineer is concerned that further deterioration in his vision would compromise his ability to drive – making it more challenging to visit his grandchildren in England and volunteer at the Gwili Steam Railway.  

Walder worries that one day he will no longer be able to admire the puffins, gannets and razor bills of the Pembrokeshire Coast, or safely carve wooden bowls, goblets and the occasional wooden handle for the railway.   

“I am left to wonder if there is hope of keeping vision in my left eye in the longer term,” he said.  

Your eyesight is one of the things we all take for granted, but when it’s taken away, you’re in a very dark world indeed

A closer look at the numbers

While the number of patients waiting for ophthalmology care in Wales may seem extensive, this can be partly attributed to the unique, pioneering approach that the nation takes to monitoring patients who are at risk of sight loss.   

NHS Wales keeps track of all patients at risk of avoidable sight loss, including those who are waiting for follow up care.  

Director of RNIB Cymru, Ansley Workman, highlighted that Eye Care Measures – a new metric for reporting waiting times – were introduced in 2019 with the aim of prioritising patients by clinical need.   

“While it is shocking to see the number of patients waiting too long for eye care, at least here in Wales we know the scale of the problem,” she said.   

“This gives Wales’ eye care services a fighting chance of tackling the current failings in the system, to help prevent patients with greatest risk from losing their sight permanently,” Workman emphasised.  

Talking to OT, O’Sullivan highlighted that a focus on referral to treatment times is more common in other nations of the UK.   

“The crux of referral to treatment times is that it concentrates heavily on new patients,” O’Sullivan said.   

“Referral to treatment times are important, but equally important are the patients who are waiting for follow up care,” he said. 

“We know that with an older population, there is an increased prevalence of eye disease,” he said.  

He noted that as in other nations of the UK, the COVID-19 pandemic created a significant backlog within ophthalmology.  

“We had a perfect storm of capacity and demand mismatch,” O’Sullivan shared. 

Challenges that Wales has faced in addressing ophthalmology waiting times were identified through a recent Senedd inquiry. These included providing connectivity between primary and secondary care, workforce challenges within ophthalmology and a lack of investment in the NHS estate.  

O’Sullivan shared with OT that while optometrists working in Wales have managed to secure NHS emails, there is still work to be done on implementing an electronic patient record and electronic referrals across the nation.    

“We need to move services from ophthalmology into optometry. The way to do that safely and with the appropriate clinical governance is to have that shared electronic record,” he highlighted.   

In a submission to the same Senedd inquiry, the Royal College of Ophthalmologists noted that Wales has a lower number of ophthalmologists per head of population than every UK nation except Northern Ireland – at 1.97 ophthalmologists per 100,000 people. In England, there are 2.56 ophthalmologists per 100,000 people.  

The National Clinical Strategy for Ophthalmology, published in September 2024, stated Aneurin Bevan University Health Board had to stop all activity in 2023 after a roof collapse due to a faulty overflow pipe, while the Betsi Cadwaladr University Health Board ophthalmology department has “ivy growing through walls and a roof that requires buckets when it rains.” 

The changes that we have made in optometry are ahead of the curve – we are talking once in a generation change

Although director Workman welcomes optometry’s support in delivering eye care in the community, she told OT that more action is required.   

“The new, groundbreaking, Wales General Ophthalmic Services has led to radical change in Wales, securing delivery of more clinical work in primary care optometry services, allowing optometrists to work to the top of their skillset,” she said.  

“This is a great step in the right direction, but we still need to see the promised wider reform of the eye care services across the board and this can’t afford to be compromised by limitations of time or funding,” Workman emphasised.   

Ophthalmologists and experts have produced a National Clinical Strategy that identifies some of the key challenges facing eye care in Wales and how they can be addressed.   

“We’re calling on Welsh Government to take the right path to transform our eye care services, giving it the vital investment it needs, before our eye care services are too damaged to repair,” Workman said.   

“It is heartbreaking to hear from people who are languishing on waiting lists, when timely treatment could have saved their sight,” she added.   

Lead of the Royal College of Ophthalmologists in Wales, Dr Rhianon Reynolds, acknowledged that ophthalmology services in Wales are under “immense pressure.”   

“We’re short of consultants, our clinical spaces are crumbling, and we desperately need more training places,” she said.  

She highlighted that the National Clinical Strategy for Ophthalmology, which calls for organisational reform and pathway transformation, provides a blueprint for an effective and sustainable service to meet growing demand.  

“Our clinicians deserve to be able to go into work and do what they do without feeling the overwhelming pressure of thousands of patients on the waiting list weighing down on their shoulders,” she said.