P ERSPECTIVE
Electronic Referrals and Digital Imaging Systems in
Ophthalmology: A Global Perspective
V. Swetha E. Jeganathan, MBBS, MPhil (Ophth), MAppMgt (Health),*†
H. Nikki Hall, MBChB, FRCOphth,†‡§
and Roshini Sanders, MBChB, DO, FRCS†§
Abstract: Ophthalmology departments face intensifying pressure to
expedite sight-saving treatments and reduce the global burden of disease.
The use of electronic communication systems, digital imaging, and rede-
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signed service care models is imperative for addressing such demands.
The recently developed Scottish Eyecare Integration Project involves an
electronic referral system from community optometry to the hospital oph-
thalmology department using National Health Service (NHS) email with
digital ophthalmic images attached, via a virtual private network con-
nection. The benefits over the previous system include reduced waiting
times, improved triage, e-diagnosis in 20% without the need for hospital
attendance, and rapid electronic feedback to referrers. We draw on the
experience of the Scottish Eyecare Integration Project and discuss the
global applications of this and other advances in teleophthalmology. We
focus particularly on the implications for management and screening of
chronic disease, such as glaucoma and diabetic eye disease, and oph-
thalmic disease, such as retinopathy of prematurity where diagnosis is
almost entirely and critically dependent on fundus appearance. Currently
in Scotland, approximately 75% of all referrals are electronic from com-
munity to hospital. The Scottish Eyecare Integration Project is globally
the first of its kind and unique in a national health service. Such speedy,
safe, and efficient models of communication are geographically sensitive
to service provision, especially in remote and rural regions. Along with
advances in teleophthalmology, such systems promote the earlier detec-
tion of sight-threatening disease and safe follow-up of non‒sight-threat-
ening disease in the community.
Key Words: electronic referrals, digital imaging, teleophthalmology,
screening, telemedicine, Scottish Eyecare Integration Project
(Asia-Pac J Ophthalmol 2017;1:3–7)
O phthalmology in the 21st century faces many challenges.
The burden of chronic disease management is augmented
by factors including an aging population, financial constraints,
earlier detection of disease and, in many countries, increasing
rates of diabetic retinopathy (DR). Developing community-based
services to maximize access and streamline the use of the hospital
eye service is key to coping with this rising demand. This strategy
is absolutely dependent on high-quality communication between
From the *Kellogg Eye Center, University of Michigan, Ann Arbor, USA; and
†Queen Margaret Hospital, NHS Fife; ‡University of Edinburgh, Edinburgh;
and §Princess Alexander Eye Pavillion, Edinburgh, Scotland, UK.
Received for publication May 17, 2016; accepted September 5, 2016.
The authors have no funding or conflicts of interest to declare.
Reprints: V. Swetha E. Jeganathan, MBBS, MPhil (Ophth), MAppMgt (Health),
Kellogg Eye Center, University of Michigan, Ann Arbor, MI 48105 USA.
Email: vswetha@ausdoctors.net.
Copyright © 2017 by Asia Pacific Academy of Ophthalmology
ISSN: 2162-0989
DOI: 10.22608/APO.2016110
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
hospital and community-based ophthalmic services such as lo-
cal optometrists. Electronic referral systems allow for the safe
and effective sharing of clinical information between the two,
enabling better triage, diagnosis, and management. Furthermore,
the enhancement of referral quality with digital imaging is well
documented.1 Our experience, recent evidence in this area, and
the global applications are the focus of this article.
Advances in Referral and Communication
Systems: The Scottish Experience
The paper-based referral system (as shown in Fig. 1) is still
the principal pathway in the majority of United Kingdom (UK)
ophthalmology departments and in many parts of the world. In
this setting, an optometrist sends a letter to a general practitioner
(GP), who then has to make a decision whether to refer the patient
to the hospital eye service (HES). A consultant of the HES then
reviews the combined referral and decides whether an appoint-
ment is required.
The current technological possibilities make this indirect re-
ferral approach via the GPs and handwritten report by an optom-
etrist very limited. Many clinicians and scientists have noticed
that electronic referrals would be more efficient, more accurate,
faster, and more resource sparing.2 Electronic optometric referrals
(Fig. 2) can include images (Fig. 3), are legible, and encourage the
inclusion of a minimum dataset of clinical information. Further,
they facilitate direct referral to the hospital but can concomitantly
request that the GP send a summary of the patient’s community
medical record. According to recent evidence, there is a need to
make an effective triage among conditions that could safely be
managed in the community with the aid of electronic referral/
digital images to HES.3 Some of these include DR, retinopathy
of prematurity (ROP), and glaucoma. This model of electronic
referral retains the crucial involvement of the GP but does not
require him/her to triage and forward the referral onto the HES,
and is thus beneficial in terms of time and resources.
In 2005, the Scottish government funded a pilot study in Fife
to assess the feasibility of a new electronic-based referral system
with attached digital images, directly from optometrists to HES.
The results of our pilot study at NHS Fife showed superiority of
the electronic referral system over the old paper-based approach.
We compared the number of necessary appointments determined
by using the new electronic-based system with 2 control groups
dealing with the old paper-based system.3 The results were as-
tonishing, with the electronic system marking 37% of cases
as not requiring a hospital eye appointment, as opposed to the
control groups in which an appointment was not needed in 15%
and 8.4% of cases (Fig. 4). This large reduction in the number
of clinic appointments required stems from better efficacy of the
direct approach, and although some limitations were granted, the
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Jeganathan et al
Figure 1. The old paper referral form, in existence throughout Scotland
for decades, possibly since the inception of the NHS.
electronic-based referrals were recognized as safe and clinically
accurate. Limitations were shown in 4 cases that were deemed
not requiring a HES appointment and were subsequently found to
have pathology, such as a peripheral retinal tear.3
In 2011, the Scottish government committed £6.6 million to
electronic connections between community and HES. The Scot-
tish Eyecare Integration Project was launched in 2013, with plans
for Scottish-wide connection of 14 healthcare boards and 900
optometry practices using a bespoke virtual private network con-
nection.4 Over 50 local referral forms were amalgamated into 5
standardized electronic forms, tailored to the type of referral. The
implementation of teleophthalmology in Scotland has become
an important goal, with a target of 90% electronic referrals by
the end of 2016. One of the most important conclusions of the
Scottish Eyecare Integration Project was that the extension of this
practice to the rest of the UK would reduce the burden on the
NHS, whose resources are stretched at a time of an increasing
aging population.5
Technological Advances
Owing to recent technological advances, rural areas with
limited access to healthcare can now promote better screening and
ophthalmic care by using smartphone technology. A broad range
of iPhone app-based testing tools is available, including near vi-
sion cards, accommodation targets, a fluorescein light, color vi-
sion plates, Amsler grids, and optokinetic nystagmus drum simu-
lation.6 These can be particularly useful in emergency settings,
complementing and facilitating traditional clinical examination.
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Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017
Figure 2. The new referral form.
Furthermore, specially designed camera attachments and
software systems are being developed, such as the PEEK (Por-
table Eye Examination Kit) vision system.7 The main specialized
function of these small kits attached to smartphones is taking fun-
dus photographs, so called smartphone fundoscopy.8 This makes
the technology required for diagnostically useful fundus imaging
far more compact and affordable and has implications globally
for triaging in the community many ophthalmic conditions (in-
cluding DR) and those that require hospital consultation.9
Significance of Electronic Referrals for
Glaucoma
A recent meta-analysis addressing the global burden of glau-
coma found a global prevalence of 3.54% (95% credible interval,
2.09–5.82) in 40–80 year olds.10 With 64.3 million people world-
wide affected in 2013, they project an increase to 111.8 million
in 2040, with a disproportionate effect on Asia and Africa. Much
of the clinical information required for decision making in glau-
coma referral and management is captured electronically: optic
disc photography, optical coherence tomography (OCT) of nerve
fiber layer, visual fields. Stereoscopic images are increasingly
used. Thus, the availability of electronic referral systems (Fig. 5)
and advances in digital imaging are reshaping glaucoma services
worldwide.
Imaging or grading of the iridocorneal angle is not yet wide-
ly incorporated into teleglaucoma or electronic referral systems.
This is particularly an issue in Asia, where 80% of the world’s pri-
mary angle-closure glaucoma (PACG) cases are found. We now
© 2017 Asia-Pacific Academy of Ophthalmology
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017
know that PACG affects over 1% of the adult population in China
and Japan.11 There are further controversies regarding glaucoma’s
suitability for remote diagnosis. Some studies point out that the
problem lies in the inability to make the diagnosis of glaucoma
with 1 single portable device and in the suspicion that some of
the devices claiming their accuracy are still not ready to be used
widely.12 On the other hand, some systematic studies have come
to the conclusion that teleophthalmology produced even better re-
sults in diagnosing glaucoma than in-person contact, not to men-
tion its benefit for persons from rural areas and significant cost
reduction.13
Significance of Electronic Referrals for
Diabetes
A recent systematic review and meta-analysis confirmed
the high diagnostic accuracy of telemedicine in DR.14 Subgroup
analysis examined the effect of different digital imaging tech-
niques, with mydriatic wide-field (100–200 degree angle) imag-
ing giving the best results. In addition to ultra-widefield imaging,
OCT can be used to greatly enhance DR screening.15 The poten-
tial incorporation of OCT into DR referrals is arguably the most
useful in reducing the burden on the hospital eye service. Along
with reducing unnecessary appointments, the earlier detection of
center-involving macular edema facilitates prompt intravitreal
treatment.
To our knowledge, the only universal DR screening program
(DRS) at this moment exists in the UK. This is despite clear evi-
dence of its benefit: the prevalence of sight-threatening diabetic
eye diseases and of all grades of retinopathy is significantly lower
in diabetic patients who undergo screening with the DRS.16 How-
ever, DRS in the UK is not flawless, sometimes involving com-
promise between the existing infrastructure, the educated profes-
sionals conducting it, and the efficacy of the method.17 On rare
occasions DRS can miss changes that could be sight threatening,
although every effort is made to reduce the risk of this happening.
Furthermore, screening does not replace regular eye examina-
tions and patients should attend both.
Teleophthalmology could help to solve another issue of DRS,
which stems from social deprivation and insufficient attendance
of the screening events.18 This could be particularly important
for low-income countries with high incidence of diabetes mel-
litus and subsequent DR. Sub-Saharan countries, such as Malawi,
currently do not have any systematic screening program for DR,
even though a real epidemic of diabetes is evident in that country.
A total of 5.6% of adults aged from 25 to 64 in Malawi suffer
from diabetes, 90% of whom have type 2.19
Figure 3. An example of images attached to the electronic
optometrist’s referral system that aids in diagnostic triage in a case of
suspected papilledema.
© 2017 Asia-Pacific Academy of Ophthalmology
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Electronic Referrals and Digital Imaging Systems
Significance of Electronic Referrals for
ROP
As with DR, the accurate grading of ROP is possible on the
basis of fundus imaging. With technological progress, high-reso-
lution imaging, and increasing use of mobile imaging devices,
ROP diagnostics is becoming more and more advanced. In 2015,
the American Academies of Pediatrics and of Ophthalmology is-
sued guidelines entitled “Telemedicine for Evaluation of Retinop-
athy of Prematurity,” which systematically reviewed the literature
on the topic and detailed important practical considerations.20
Beyond ROP, the concept has been extended to universal
neonatal eye screening with fundus imaging, proposed by scien-
tists in India.21 By conducting the screening at this neonatal level,
they have reached the conclusion that 48 (4.7%) of the 1021 ex-
amined infants had abnormal findings, and all of them required
medical attention, whereas 1% of them required some sort of
intervention. They propose serious consideration of the idea of
screening all newborns with fundus photography, not just those
at risk of ROP.
Cautions and Limitations
Telemedicine has already changed the world of medicine in
many positive ways. Long distance testing, self-testing meters,
use of smartphones, and communication possibilities between
medical institutions and professionals on different levels have
made medical administration much easier and created the neces-
sary environment to meet the challenge of an increasing number
of patient visits. However, we note several cautions. Despite all
the advancements, telemedicine also carries risks, such as com-
munication between the doctor and the patient potentially being
jeopardized.22 Not all aspects of remote ophthalmic care are well
suited to remote diagnosis. In the field of glaucoma, for example,
gonioscopic assessment is a procedure for which technicians are
usually not trained, limiting the remote diagnostic accuracy. Ad-
ditionally, a degree of caution is always necessary when interpret-
ing 2-dimensional ophthalmic images and there is an acceptance
that a full clinical examination is the gold standard for many
conditions.
With regards to electronic referrals, bypassing the GP in the
referral route may result in patients being pigeon-holed into 1 sys-
tem or 1 management pathway. For example, they may be directed
Figure 4. Comparison of the old paper-based and new electronic
referral pathways.
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Jeganathan et al
Figure 5. Electronic glaucoma referral.
to a virtual glaucoma clinic that might not be set up to detect other
pathology, deal with systemic medical issues, detect incidental
findings, and discuss psychosocial effects of the condition.23
Global Applications for Chronic Eye
Disease
The application of teleophthalmology in the management and
tracking of chronic eye diseases has developed to a great extent,
especially in developed countries. With the use of teleophthal-
mology, it is now much easier to track relapses, exacerbations,
and the response to treatment. For health institutions, teleoph-
thalmology potentially provides a significant reduction in costs
and use of resources, as hospital stay in patients with chronic eye
diseases is now significantly reduced, with a reduction in the bur-
den of disease.24 However, controversies still exist, which in some
areas may be a result of not yet well established methodology
of teleophthalmology research. Nevertheless, where ophthalmic
units care for geographically spread-out patients, this innovative
initiative is beneficial as unnecessary patient transport to hospital
can often be avoided. Teleophthalmology is probably most ben-
eficial in this context by providing improved access and feasible
screening/monitoring.
Conclusions
The experience of the unique Scottish Eyecare Integration
Project is an example of the benefits to service delivery result-
ing from electronic communication and digital imaging systems.
Such speedy, safe, and efficient models of referral are geographi-
cally sensitive to service provision, especially in remote and rural
regions. Along with advances in teleophthalmology and imaging,
such systems promote the earlier detection of sight-threatening
6 | www.apjo.org
Copyright © 2017 Asia-Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Asia-Pacific Journal of Ophthalmology • Volume 6, Number 1, January/February 2017
disease and safe follow-up of non‒sight-threatening disease in the
community. With increasing global ophthalmic disease and new
sight-saving treatments with narrow windows of treatment appli-
cation, teleophthalmology stands to help prioritize the expanding
demand for ophthalmic services around the world.
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