Adding fundus photography to eye clinics leads to more referrals

Community eye clinics with routine fundus photography (RFP) appear to have a higher referral relative to standard care, a study has shown. The increase in referral is primarily driven by nonurgent posterior segment disease.

This stepped-wedge, cluster-randomized trial included patients with known history of hypertension or diabetes mellitus presenting to four technician-run vision centres (VCs) associated with the Aravind Eye Care System in India.

VCs were randomly assigned to standard care or RFP across five 2-week study periods (steps). Standard care was initially given to patients in each cluster. A randomly chosen cluster switched to providing RFP to eligible patients at the start of each subsequent step. All clusters took part in RFT during the last step.

Standard care included technician eye exams, optional fundus photography, and teleconsultation with an ophthalmologist, while RFP involved eye exams, dilation and 40-degree fundus photography, as well as teleconsultation with an ophthalmologist.

The authors compared standard care and RFP clusters by the proportion of patients referred for in-person assessment by an ophthalmologist because of fundus photography findings and urgency of referral. They also used generalized linear mixed models, adjusting for cluster and step, to estimate the odds of referral due to fundus photography findings vs standard care.

Of the 1,447 patients enrolled across VCs, 737 were in the standard care group and 710 in the RFP group. The latter had a higher proportion of referrals due to fundus photography findings (9.3 percent vs 3.3 percent) and urgent referrals due to fundus photography (1.8 percent vs 1.1 percent). RFP intervention, relative to standard care, resulted in a twofold increased likelihood of being referred because of photography findings (odds ratio, 2.07, 95 percent confidence interval, 0.98–4.40; p=0.058).