What lies ahead: The promise of technology

Technology is an enabler of some of the changes we will see in the future (updated July 2021)

Optometrist looking at optical coherence tomography (OCT) machine

In the last decade, optometry has already embraced technological developments such as fundus photography, leading to greater sophistication in assessment and diagnosis. Advances in imaging technology, such as optical coherence tomography (OCT) which takes high-resolution, cross-sectional images of the back of the eye, have enabled optometrists to spot changes in eye health at an earlier stage. OCT is becoming more and more commonplace in primary care optical practices, with many practice owners choosing to invest their own resources in this valuable equipment that would previously have only been used in hospitals.

We expect further significant technological changes in the next decades, which could transform the role of the optometrist. The most significant one of these will be the use of artificial intelligence (AI) to diagnose eye disease. A partnership between Moorfields Eye Hospital and DeepMind Health has already shown that AI can help people to diagnose eye disease as accurately as world-leading experts.

To make a real difference, AI will need to be deployed in a way that makes efficient use of the whole eye healthcare workforce. Putting new AI tools in the hands of overstretched hospital consultants will bring some benefits – but there is a much bigger prize to be had.

We have already argued that primary eye healthcare providers in the UK – the optical practices familiar on every High Street which offer NHS and private sight tests – can play a major role in taking pressure off secondary eye care. Optometrists working in community practice are a skilled workforce, trained to detect eye diseases, and increasingly treating those diseases under NHS extended services contracts. And there are around ten registered optometrists for every ophthalmologist in the UK: they are a much more available workforce. But we recognise a limitation because most patients seen in High Street optical practices have healthy eyes. Primary care optometrists will, by definition, see rare conditions only rarely.

This is where AI could be a game-changer. A 2018 study¹ demonstrated that the DeepMind model enables ophthalmology consultants to diagnose patients more accurately than when relying only on traditional tools, such as OCT, fundus exams and notes. It also indicated that if optometrists equipped with AI would obtain the same increase in diagnostic efficacy, they could routinely deliver specialist-level diagnoses in a primary care environment.

We have already seen a shift in the optometrists’ role: away from being refractionists who prescribe optical appliances to fully-fledged clinicians who interpret the findings of increasingly complex equipment, allowing them fully to utilise the clinical skills they gain in their education. This requires the ability to explain technical information in lay terms, including sometimes the need to convey disappointing news to patients.

The large, widely distributed optometric workforce will then be able to play a much greater role in delivering eye care, reducing pressure on hospital eye services. To achieve that goal, policymakers will need to lay the foundations by:

Building the use of AI into optometrists’ training and professional development
Enhancing the role of the optometrist as “expert explainer”: interpreting and conveying the results of tests to patients, including imparting worrying news
Driving the design and commissioning of eye healthcare services in which primary optometrists routinely use AI to make quick and accurate diagnoses and referrals

AI will always be a tool for the optometrist rather than a replacement of their knowledge and interpretive skills. This is why optometric education needs to continue to provide a thorough grounding in theory alongside the practical skills they need.

Another key tool is the ability to refer patients to hospital electronically, including to transfer images and, crucially, to receive information about the outcome of the referral.

Although GPs routinely receive feedback on the referrals they make to hospital, this is not the case for optometrists, even though they are now responsible for the vast majority of referrals to hospital eye departments. The main reason for this is that most hospital IT systems do not make it easy to generate a letter to the referring optometrist. But some hospitals have put significant effort into solving this problem, helping their patients and fellow clinicians in doing so^2,3.

Referral feedback is important because:

It is a vital check that the referral has been acted on
It informs the optometrist if the patient needs follow-up in primary care
It helps optometrists improve their referrals in the future

Progress on e-referrals in the UK nations (as at July 2021)

England

The implementation of eye care electronic referral systems (EeRS) is in progress across all seven NHS England and Improvement regions. Four regions have already signed contracts with five suppliers to deliver EeRS across at least part of their Integrated Care System (ICS). The other three regions are expected to procure solutions imminently. In each region there will be a number of early adopter sites, to test and improve the EeRS system and the ability to share images between optometry and ophthalmology. The aim is to enable electronic referrals, allow the sharing of images including OCT and to develop and strengthen shared care. Optometrists should more easily receive feedback and be able to obtain advice from specialist secondary care ophthalmology teams, This in turn will improve access for patients and allow more care to be delivered closer to home.

However, some of the areas have not included the requirement for referral feedback functionality in their specifications. This represents a significant missed opportunity. Unless EeRS includes two way communication it will fail fully to deliver the improvements that are needed. AOP and other optical bodies are lobbying for all the systems to include the ability to feed back to referring optometrists as standard.

Northern Ireland

In Northern Ireland 258/271 practices are able to use the e-portal which allows them to process all NHS claims, have access to their HSCB email and create e-referrals. Optometrists also have access to patients’ electronic care records which include Ophthalmology letters and patient medications. This is a great resource to reduce duplicated referrals and improve patient management.

Scotland

All Health Boards in Scotland have provided access to SCI-Gateway – the same referral platform used by GPs – which allows electronic referrals to the Hospital Eye Service. This helps the HES in triaging the appointments as the different pathways are sent to the appropriate team and allows the attachment of retinal photos and visual fields etc. Provision of access to this system to locums varies – some Boards have given everyone access and others have only given access to those permanently in a practice.

Wales

In Wales, following a successful pilot in the South East, £3.5m has been provided to allow implementation of an Electronic Patient Record (EPR) system using OpenEyes so that community optometry can refer into the hospital eye services across Wales. This comes with access to the patient record which will help make the patient journey more accessible and make it easier to track a patient’s care.