Optometrist referrals in Greater Manchester: glaucoma first, at 12.2%

What its authors call the first large-scale analysis of electronic optometry referrals in the UK was published in Ophthalmic and Physiological Optics on 26 September. Researchers in Manchester looked at 104,190 referrals from Greater Manchester optometrists between June 2022 and May 2024. Glaucoma was the commonest reason for an optometrist referral, and 10.2% of all the referrals were sent to hospital as "Not Otherwise Specified", with no subspecialty named.

Most earlier studies, the authors note, looked at one condition at a time. Two such studies show what the hospital finds in glaucoma and wet AMD referrals, and the numbers cut both ways.

What the study did

It is a retrospective service evaluation of routinely collected data from the NHS England North West Electronic Eyecare Referral System, limited to referrals from Greater Manchester. The authors described where referrals went and why, and tested how deprivation, age, sex and ethnicity related to each type, with deprivation and ethnicity measured by area rather than per patient.

What 104,190 optometrist referrals showed

81.8% went to hospital ophthalmology: 71.6% to a named clinic type and 10.2% as "Not Otherwise Specified", an option on the form for when the referrer cannot settle on a diagnosis or no clinic type fits. 15.0% went to GPs, and 3.0% to glaucoma enhanced services in the community.

Glaucoma led, at 12.2% (12,777 referrals), then other medical retina at 11.6%, YAG laser capsulotomy at 11.1% and cataract at 10.8%. Cataract and paediatric binocular vision referrals came more often from more deprived areas, and vitreoretinal, adult binocular vision and other medical retina from less deprived ones.

The authors say the figures suggest, rather than confirm, that community schemes were underused. They also set out why glaucoma is hard to refer well: a GOS sight test is time-limited and does not routinely include visual fields, OCT or gonioscopy, so a referral made outside an enhanced scheme often rests on a single clinical impression, and referring when uncertain may be the safest choice for the patient.

What the hospital finds missing

A Dalhousie University team scored 522 referrals to two glaucoma specialists in 2024. Optometrists' referrals were the more complete, with a median score of 9 against 5 for ophthalmologists', but visual fields and OCT were among the elements most often missing from both, and optometrists more often left out ocular history and medications. 33.9% of patients referred by optometrists had an intervention at the first visit, against 59.7% of those referred by ophthalmologists. The abstract does not define an intervention, and the comparison is unadjusted, so the gap may reflect who is referred as much as how.

In Bradford, a review of 394 referrals to a specialist macular treatment centre found the letters themselves were good: legibility was high, and distance acuity was recorded in 99.0% before the pandemic. But 39.8% of referrals for suspected wet AMD were confirmed, the commonest misdiagnosis being dry AMD. Even so, 76.8% of the suspected wet AMD referrals made before the pandemic were judged necessary, because the patient was treated or observed over several visits.

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Why it matters in practice

• Name the clinic when you can, and keep "Not Otherwise Specified" for when no diagnosis or clinic type fits.
• Send what the College asks for: the relevant findings, the reason for referral with images where appropriate, what you discussed with the patient, and the urgency (Guidance for Professional Practice, C206). For signs of possible glaucoma at a routine sight test, the College notes that NICE recommends additional tests before referral (C195).
• For suspected wet AMD, the acuity carries weight: in Bradford, reduced visual acuity was the sign most strongly linked to a confirmed diagnosis, followed by haemorrhage.
• Use the glaucoma scheme where one is commissioned. Only 3.0% of the Manchester referrals went to one, a figure the authors say understates use.
• Ask for the reply. The Bradford authors cite a study in which the reply rate to optometrists' referrals was 2.6%, and the Manchester team suggest delayed or absent replies may prompt glaucoma re-referrals. Without a reply, the optometrist never learns whether the diagnosis was right.
• The government's £20 million plan aims to give every optical practice with an NHS contract in England access to the NHS e-Referral Service by April 2028.

The caveats

• The Manchester data count referral events, not patients or outcomes, and nothing in them says whether a referral was right.
• Repeat referrals could not be linked, and the authors say re-referral may inflate glaucoma's count. Referrals made inside enhanced schemes use a separate form and were not captured, so glaucoma, cataract and scheme use are likely to be undercounted. Glaucoma's lead over other medical retina is narrow, and the authors read the ranking as a pattern of recorded referral activity.
• The Canadian figures come from the abstract, as the full paper could not be opened, and its clinics and funding differ from the UK's.
• The Bradford study is one centre, from March 2019 to February 2021, half of it during the pandemic.

Sources

1. 1.Who Gets Referred for What? Large Scale Analysis of Clinical, Socioeconomic and Demographic Drivers Within Electronic Optometry Referrals · Ophthalmic and Physiological Optics, 26 September 2026
2. 2.Assessing referral quality in glaucoma care: a retrospective analysis of clinical data in optometrist and ophthalmologist referrals · Canadian Journal of Ophthalmology, 17 July 2026
3. 3.The quality, accuracy and appropriateness of UK optometric age-related macular degeneration referrals · Ophthalmic and Physiological Optics, 7 February 2025
4. 4.Referrals (Guidance for Professional Practice, C206) · College of Optometrists
5. 5.Millions to get faster eye care on the high street · GOV.UK, 8 June 2026