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

INTRODUCTION: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.