Clinician acceptance and workflow impact of introducing optical coherence tomography into optometrist-facilitated teleophthalmology

Introduction

Demographic ageing and the increasing prevalence of chronic retinal disease are placing substantial pressure on ophthalmology services worldwide (1,2), prompting exploration of new models for case finding and follow-up. In Denmark, high-street optician chains now offer eye health checks that include fundus photography and optical coherence tomography (OCT), with images subsequently evaluated by ophthalmologists via telemedicine (3-6). This optometrist-facilitated teleophthalmology model has the potential to expand access to retinal diagnostics while refining referrals to the public eye care system, but its success depends on both technical performance and clinician acceptance.

OCT is an integral diagnostic tool in hospital-based ophthalmology (7), particularly for macular disease and glaucoma, but its use in opportunistic, community-based screening is more recent. Introducing OCT into optometrist practices substantially increases both the volume and complexity of image data presented to telemedical screeners and may influence reading time, diagnostic confidence, and perceived screening quality. However, evidence remains limited regarding how ophthalmologists experience this transition when working within structured teleophthalmology workflows.

This study describes a single Danish teleophthalmology service in which OCT was incorporated into routine optometrist-facilitated retinal screening and reports the perceptions of ophthalmologists acting as telemedical screeners, based on a targeted questionnaire. The objective was to characterize the perceived effects of OCT on workflow, diagnostic decision-making, technical challenges, and overall satisfaction.

Organization of the teleophthalmology examination service

A retinal examination service is provided in 79 high-street optician stores (Louis Nielsen A/S, Denmark) across the country. As part of routine eye health checks, optometrists collect patient history and measure refraction, best-corrected visual acuity, and intraocular pressure using either rebound tonometry (iCare, Helsinki, Finland) or non-contact tonometry (Nidek Tonoref II/III, Aichi, Japan). Slit-lamp examination of the anterior segment is performed, and visual fields are assessed when indicated using the Octopus 900 perimeter (Haag-Streit, Bern, Switzerland), reported as a standardized four-in-one visual field output.

Optometrists initially obtained retinal imaging using 45° color fundus photography (CenterVue DRS, iCare, Helsinki, Finland). From September 2023, optician stores began implementing the Maestro2 platform (Topcon, Tokyo, Japan), enabling acquisition of combined color fundus photography and spectral-domain OCT. OCT examinations consisted of a 12 mm × 9 mm three-dimensional wide scan encompassing both the macular and peripapillary regions, with automated generation of a Hood report. Systematic implementation of Maestro2 was completed across all stores in April 2024. All images were acquired without pharmacological pupil dilation.

Optometrists reviewed the images locally, and any abnormal findings or suspicion of disease prompted submission of clinical data and imaging through the teleophthalmology system for evaluation by at least one experienced ophthalmologist. This teleophthalmology platform has been in operation since 2018 and has screened more than 20% of the Danish population (5,6). OCT was introduced as an adjunct to conventional fundus photography to improve detection and characterization of macular and optic nerve disease in an opportunistic screening context. All telemedical screeners were board-certified ophthalmologists with experience in retinal imaging and remote assessment of optometrist-sourced cases; the majority (7 out of 11) also held European Board of Ophthalmology certification. All 11 active screeners were included in the study.

The present questionnaire was conducted after OCT had been routinely available for a period of approximately 1 year, sufficient for screeners to form stable impressions of its impact on their work.

Questionnaire methods

A 13-item electronic questionnaire in English was developed to capture ophthalmologists’ experience with optometrist-facilitated retinal screening and the perceived impact of OCT on telemedical practice. Items addressed years of screening experience, changes in reading time, perceived ease of diagnosis, diagnostic support under uncertainty, interpretation without clinical context, differentiation between anterior and posterior pathology, image quality, technical challenges, perceived screening quality, satisfaction, and self-reported clinical confidence. Several items used five-point Likert scales with symmetric response options ranging from “worsened” to “improved” or from “harder” to “easier”. Language and phrasing were reviewed by a native British retinal specialist.

Questionnaire development included a two-round process of content and face validation. In the first round, six retinal specialists at a tertiary Danish hospital independently completed the questionnaire and were subsequently interviewed by the author M.L.R.R., to assess clarity, relevance, and completeness. Questions or wording repeatedly rated as unclear or non-essential were rephrased or removed. The revised questionnaire was then piloted by three senior consultants at the same institution. No substantial refinements were required following this second round. Comprehensive psychometric validation, including assessment of factor structure or test-retest reliability, was beyond the scope of the study and represents a limitation.

The questionnaire was distributed by WhatsApp with a link to an online anonymous survey on Google Analyze to all 11 ophthalmologists acting as telemedical screeners in the program, with 11 complete responses available for analysis in December 2025. Screening experience (Q1) was reported in years or categories, yielding a mean experience of approximately 4.9 years. Free-text responses were invited regarding disease entities for which OCT improved diagnostic ability (Q7) and for additional comments or suggestions (Q13). Free-text responses were counted manually. Descriptive analysis focused on the distribution of Likert responses and thematic synthesis of free-text comments to reflect the overall pattern of perceptions within this single service. The full range of questions and possible answers is available in Table 1.

The questionnaire involved only ophthalmologists and did not include patient data. According to local regulations, formal research ethics committee approval was not required, and completion of the questionnaire was considered implied consent.

Results

Experience and time consumption

Respondents reported a mean of 4.9 years of experience with optometrist-facilitated retinal screening, indicating substantial familiarity with the teleophthalmology workflow prior to OCT implementation. Two respondents had <2 years of experience, while the rest had >4 years. All respondents reported increased review time per case following the introduction of OCT, most commonly described as “slightly longer” (9 out of 11) or “longer” (2 out of 11). No respondent indicated that screening had become faster, highlighting a perceived time cost associated with OCT review.

Diagnostic process and confidence

Across respondents, OCT was consistently perceived to facilitate diagnosis rather than hinder it. Most screeners reported that OCT “moderately” (1 out of 11), “strongly” (5 out of 11) or “very strongly” (5 out of 11) assisted interpretation in situations of diagnostic uncertainty, and that it made diagnosis “slightly easier” (6 out of 11) or “easier” (4 out of 11) when limited or no additional clinical context was available. One reported “unchanged”. All respondents reported that OCT had “improved” (10 out of 11) or “slightly improved” (1 out of 11) their clinical confidence when interpreting optometrist-facilitated cases.

Disease spectrum and anatomical differentiation

In free-text responses, respondents identified neovascular and non-neovascular age-related macular degeneration (10 out of 11), central serous chorioretinopathy (7 out of 11), epiretinal membrane (6 out of 11), glaucoma (6 out of 11), vitreomacular traction (4 out of 11), optic drusen (3 out of 11) and macular hole (3 out of 11) as conditions for which OCT substantially improved their diagnostic ability. Additional conditions highlighted included retinal vein occlusion, choroidal tumors, and retinal ischemia. Regarding anatomical localization, 8 out of 11 respondents reported that OCT of the posterior segment had made it “slightly easier” or “easier” to distinguish predominantly anterior segment pathology from posterior segment disease. Three out of 11 were “unchanged”.

Image quality, technical issues, and overall satisfaction

OCT image quality relative to color fundus photography was most commonly rated as “slightly better” (7 out of 11) or “better” (1 out of 11), although a minority rated it as “slightly worse” (2 out of 11) or “no difference” (1 out of 11). Technical challenges related to access or evaluation of OCT scans were generally reported as rare or occasional (8 out of 11). Two (2 out of 11) newer users did not experience any problems. One respondent reported frequent rendering delays and suggested optimization of server performance. Overall screening quality following OCT introduction was most often rated as “improved” or “slightly improved” (8 out of 11). However, “no difference” was stated in 3 out of 11. All 11 respondents reported being satisfied with the integration of OCT into optometrist-facilitated screening. In the free text in Q13, two of the respondents described OCT as essential within this telemedical screening context and expressed interest in future integration of OCT angiography and standardized 3D macular scan protocols. One stated that, “OCT is often the only available image modality as fundus photographs are often prone to shadow artifacts with dark centers”. Lastly, one stated, “I think it is an absolute must-have in optometrist-facilitated retinal screening”. No further comments were added.

Discussion

In this teleophthalmology service evaluation, integration of OCT into optometrist-facilitated retinal screening was associated with a coherent pattern of perceived benefits among ophthalmologist screeners, particularly with respect to diagnostic ease, confidence, and overall screening quality. These benefits were accompanied by a universal perception of increased review time per case, reflecting increased data volume and the need for careful interpretation of cross-sectional B-scans. Within an opportunistic community-based screening context, this trade-off between efficiency and richer diagnostic information appeared acceptable to clinicians. However, this study does not investigate the objective clinical outcome of integrating OCT into optometrist-facilitated teleophthalmology service. Further objective studies are planned on this topic.

The disease entities identified as benefiting most from OCT align closely with conditions for which OCT is considered standard of care in hospital-based ophthalmology (7), including age-related macular degeneration, central serous chorioretinopathy, epiretinal membrane, vitreomacular traction, macular hole, macular oedema, and glaucoma. The perception that OCT improves diagnostic confidence even in the absence of detailed clinical context is particularly relevant for teleophthalmology, where referral information may be limited. Enhanced characterization of macular and optic nerve pathology may support more precise triage, improving referral specificity to hospital eye services while increasing confidence in reassuring patients without sight-threatening disease.

Respondents’ generally favorable assessments of OCT image quality and their unanimous overall satisfaction support the feasibility of OCT-based community teleophthalmology in Denmark. At the same time, reported technical issues and comments regarding scan protocols underscore the importance of robust information technology infrastructure and standardized acquisition protocols. The small sample size and self-reported, cross-sectional design limit generalizability, and the study does not assess objective diagnostic accuracy or patient outcomes. Nevertheless, as an evaluation from a mature national teleophthalmology program, these findings provide practical insights for systems considering OCT implementation in optometrist- or primary care-based screening pathways.

Conclusions

Within a Danish optometrist-facilitated teleophthalmology service, ophthalmologist screeners reported that OCT integration modestly increased case review time but clearly improved diagnostic ease, clinical confidence, and perceived screening quality. OCT was particularly valued for macular and optic nerve disease and was widely regarded as an essential component of high-quality telemedical retinal screening in this setting.

Acknowledgments

A large language model-based assistant (Perplexity AI) was used to help structure, phrase, and draft parts of the questionnaire and the result section. All analyses, interpretations, and final wording were reviewed and approved by the authors, who accept full responsibility for the work.

Footnote

Peer Review File: Available at https://aes.amegroups.com/article/view/10.21037/aes-2026-1-0009/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aes.amegroups.com/article/view/10.21037/aes-2026-1-0009/coif). Y.S. serves as an unpaid editorial board member of Annals of Eye Science from January 2026 to December 2027. Y.S. declares receiving speaker fees from Bayer and Roche. M.L.R.R. declares receiving speaker fees from Santen and serves on the advisory board of Santen. D.V.M. declares receiving consultancy fees from Alcon, MicroSurgical Technology, and Johnson & Johnson. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The questionnaire involved only ophthalmologists and did not include patient data. According to local regulations, formal research ethics committee approval was not required, and completion of the questionnaire was considered implied consent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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