Guidance on diabetic eye screening, conversion rates for cataract surgery and glaucoma referral criteria published by AoMRC and NHS England

  • 20 Jul 2023
  • RCOphth

The Academy of Medical Royal Colleges (AoMRC), in partnership with NHS England, has published a new set of ‘evidence based interventions (EBI)’ including measures for ophthalmology. The guidance aims to increase ophthalmic capacity in England by improving efficiency in the referral pathways for diabetic retinopathy, glaucoma and cataracts into hospital eye services. Implementing these changes will require clinicians and commissioners to work closely together, ensuring effective pathways are developed that are properly resourced. 


What is the Evidence-based interventions programme?

The evidence-based interventions (EBI) programme is an initiative led by the AoMRC to improve the quality of patient care by reducing the number of medical or surgical interventions and other tests and treatments, which evidence shows are inappropriate for some patients in some circumstances.  

This is the third list of guidance produced by the EBI programme and contains three ophthalmology-related measures, alongside guidance for other specialties including cardiology and urology.  


OCT integrated with diabetic retinopathy may improve secondary care capacity but referral requirements should not be prescriptive 

Diabetic macular oedema is the leading cause of sight loss for young adults in developed countries but can be mitigated through effective early detection and intervention. The guidance highlights recent data which suggests UK diabetic eye screening programmes (DESP) which use photographic data are highly successful at detecting diabetic retinopathy. 

The guidance therefore proposes that Optical Coherence Tomography (OCT) be implemented in the diabetic eye screening pathways of patients with diabetic retinopathy grading M1 and above, or as part of a referral refinement protocol prior to referral to hospital eye services. Providing OCT scans alongside fundal photography increases the ability of DESP to detect diabetic retinopathy, improving sensitivity and specificity at the pre-hospital assessment stage, reducing unnecessary referrals of patients into ophthalmology units. 

By improving referral efficiencies, pressures in ophthalmology units are reduced and face-to-face capacity is protected. To fully realise the opportunities presented by the integration of OCT into DESP, standardisation of imaging between eye care centres and primary and secondary services is required, as called for by RCOphth and the College of Optometrists. 

Given many virtual imaging hubs have already been set up by hospital eye services, this guidance should be implemented rationally, avoiding the unnecessary reorganisation of these hubs. 


Cataract surgery shared decision aims to improve conversion rates 

Conversion rates of patients referred for cataract surgery varies significantly across England, between 40% to 92%, while RCOphth guidance outlines that effective referral processes can lead to conversation rates of more than 80%. NHS England guidance outlines how shared decision making (SDM) gives patients control over the way their care is delivered and can improve conversion rates.  

By recommending that cataract referrals not be accepted unless a formally documented SDM process has been performed by the referring optometrist, the guidance aims to ensure only those patients who wish to undertake surgery are referred, thereby freeing up consultant time. The guidance notes that it should be a threshold for access and that access to surgery should not be restricted based on visual acuity. 

Patients on outpatient waiting lists are often at highest risk of avoidable sight loss, so efforts to reduce outpatient backlogs – including through improved cataract surgery referral conversion rates – are welcome. As highlighted through RCOphth’s guidance on reducing outpatient appointments, many ophthalmology units are already undertaking efforts to improve capacity through the use of other measures such as remote consultations and risk stratification. 


Two-factor authentication for glaucoma referrals 

Monitoring and treatment of glaucoma accounts for 20% of ophthalmology outpatient activity, with referrals through routine optometric sight tests. However, due to a lack of sensitivity in these referrals there are many instances of false positive referrals – often up to 40% – to ophthalmology units. 

To help reduce instances of false positive referrals, this new guidance recommends additional testing for glaucoma and related conditions prior to secondary care referral. Specifically, it calls for: Central visual field assessment, optic nerve assessment and fundus examination using stereoscopic slit lamp, intraocular pressure measurement, peripheral anterior chamber configuration and depths assessment and OCT. Before deciding to refer, the guidance suggests consideration of repeated visual field assessment and intraocular pressure (IOP) measurement – a so-called ‘two-factor authentication’. 

Ensuring improved quality referrals from primary care for both cataract and glaucoma will need local integrated care systems (ICSs) to establish mechanisms for sense checking referrals. Additional support and resourcing may therefore be needed to develop local eye care referral pathways which account for the additional repeated visual field assessments and IOP measurements outlined in the guidance. Without this additional support, this well-evidenced guidance may prove difficult for local eye care services to implement. 

Alongside the College of Optometrists, the RCOphth continues to call for better utilisation of the skills of primary care optometrists, allowing them to work at the top of their license and facilitating greater integration of optometry and ophthalmology to improve capacity and patient care. These developments – particularly the integration of OCT scans in diabetic retinopathy – can only be achieved if underpinned by investment in digital technologies.  

While this guidance can help improve ophthalmic capacity, the ophthalmology workforce remains key to meeting current and future patient need. RCOphth’s recent workforce census 2022 found that three-quarters of eye units do not have enough consultants to meet patient need and 25% of ophthalmologists are set to leave the workforce over the next five years.  

We continue to engage all stakeholders to call for an eye care workforce plan in each UK nation, encompassing the entire eye care workforce, to meet future patient need.