The impact of teleophthalmology on rural eye health outcomes through vision centers in Dharwad

Abstract

Purpose:

The purpose of the paper is to evaluate the impact and effectiveness of teleophthalmology services facilitated through vision centers in enhancing access to quality eye care in rural areas of Dharwad district, Karnataka, India.

Methods:

A prospective observational study conducted at four vision centers in Dharwad, Karnataka (Alnavar, Kalaghatagi, Noolvi, and Navalgund). Each center was equipped with a slit-lamp, fundus camera, and real-time teleconsultation system. A total of 398 patients were enrolled. Comprehensive ocular examinations were performed by trained optometrists, and cases requiring specialist input underwent live video teleconsultation with ophthalmologists. Impact was assessed by service uptake (proportion of patients completing teleconsultation). Effectiveness was measured using a validated 5-point Likert-scale patient-satisfaction questionnaire evaluating accessibility, communication, privacy, and overall satisfaction.

Results:

Out of 398 eligible participants, 381 (95.7%) completed teleconsultation. The mean age was 39.3 ± 12.6 years. The mean consultation duration was 20.1 ± 3.2 minutes. The mean satisfaction score was 4.6 ± 0.4, with over 90% of participants rating the service as “Satisfied” or “Very satisfied.” Lens-related disorders (19.8%) and refractive errors (18.7%) were most common.

Conclusion:

Teleophthalmology through vision centers achieved high uptake and patient satisfaction and was operationally feasible in this rural setting.

 

The term “telemedicine” originates from the Greek word tele, meaning “distance,” and the Latin word mederi, meaning “to heal.” Teleophthalmology, a subspecialty of telemedicine, is designed to deliver comprehensive eye care remotely, thereby minimizing unnecessary referrals to tertiary care centers and improving access to quality ophthalmic services within community settings—especially in rural and underserved regions.[1]

According to the World Health Organization, telemedicine is defined as the delivery of healthcare services where distance is a critical factor, using information and communication technologies by all healthcare professionals for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries.[1] In this context, teleophthalmology aims to provide timely and appropriate care closer to the patient’s home, thus reducing logistical and financial burdens on both the patient and the healthcare provider. In India, where a significant portion of the population resides in rural areas, the scarcity of ophthalmologists and inadequate healthcare infrastructure present major challenges in eye care delivery. Teleophthalmology addresses these barriers by facilitating cost-effective, real-time consultations, comprehensive evaluations, and early interventions for both acute and chronic ocular conditions.[2] With advancements in internet connectivity, imaging systems, and telecommunication tools, ophthalmologists are now able to extend their reach into remote communities, thereby enhancing patient outcomes and reducing preventable blindness. As per the International Agency for the Prevention of Blindness, India accounts for one of the highest numbers of individuals affected by visual impairment and blindness globally, with an estimated 80–90% of cases being avoidable with timely medical attention.[2] The National Blindness and Visual Impairment Survey (2015–2019) further highlights that rural populations are disproportionately affected, particularly in hard-to-reach areas lacking consistent eye care services.[2,3] Teleophthalmology offers several advantages: It reduces patient travel and associated costs; ensures continuity of care; enables screening, prioritization, and follow-up supervision; and allows for effective triaging during emergencies. Importantly, it enhances patient compliance by improving accessibility and awareness. Establishing vision centers with teleconsultation capabilities can serve as a sustainable model to overcome the rural–urban healthcare disparity and contribute significantly to the national goal of eliminating avoidable blindness. This study aligns with national priorities, including the Telemedicine Practice Guidelines (2020) and the National Programme for Control of Blindness and Visual Impairment, both of which emphasize technology-enabled care to reduce disparities in eye health. The aim of the study is to evaluate the impact and effectiveness of teleophthalmology services through vision centers in Dharwad district by analyzing service uptake, patient satisfaction, and operational feasibility.

Methods

This prospective, hospital-based observational study was conducted from September 2024 to May 2025 at M. M. Joshi Eye Institute, Hubballi, and four affiliated vision centers were located in Alnavar, Kalaghatagi, Navalgund, and Noolvi.

Ethical approval was obtained from the Institutional Ethics Committee, and written informed consent was secured prior to participation.

The overall process of the study consists of the following five steps.

Each vision center was equipped with standard ophthalmic and telecommunication infrastructure, including a Zeiss slit-lamp biomicroscope, Nikon Optos Daytona Plus ultrawidefield fundus camera, digital refraction equipment (Welch Allyn 3.5V streak retinoscope), and a computer system installed with Vision Centre Management Software (VCMS). All centers were connected to the base hospital through high-speed internet (Jio Fiber) to facilitate live video consultation. Teleconsultations were conducted through a secure Google Meet interface integrated with VCMS and data platforms such as Optusadvance.com and EH-Note. The system enabled secure storage and transfer of clinical data and images. Services were available six days per week (Monday to Saturday) during regular outpatient hours. All processes were carried out in accordance with the Telemedicine Practice Guidelines (2020) issued by the Government of India.[4]

A total of 400 consecutive individuals presenting to the four affiliated vision centers during the study period were screened for eligibility, and 398 who met the inclusion criteria were enrolled. Patients presenting with eye-related complaints—such as refractive errors, anterior segment disorders, raised intraocular pressure, retinal evaluation, cataract assessment or postoperative follow-up, and foreign body removal were included after providing written informed consent. Patients with ocular emergencies (acute vision loss, trauma, or severe pain), those unable to undergo the required examination due to physical disability, and individuals who declined consent were excluded to avoid inaccurate assessment and ensure data reliability.

The overall study workflow consisted of five sequential steps: patient registration, comprehensive ocular examination by trained optometrists, digital acquisition and transmission of clinical data and images, real-time teleconsultation with ophthalmologists, and administration of the patient satisfaction questionnaire. The detailed study procedure, patient recruitment, teleconsultation process, and referral outcomes are illustrated in Flow Charts 1-3.

Flow Chart 1.

Study procedure

Flow Chart 3.

Patient recruitment and teleconsultation flow diagram

Flow Chart 2.

Patient flowchart

Comprehensive ocular examination was conducted by trained optometrists at each vision center. Optometrists underwent structured training under ophthalmologist supervision in slit-lamp biomicroscopy, fundus imaging, and intraocular pressure assessment. Each examination included distance and near visual acuity using Snellen charts at 6 m and 35–40 cm, respectively. Objective and subjective refraction were performed, followed by binocular balancing to finalize the refractive correction. Anterior segment evaluation was done with a Zeiss slit-lamp biomicroscope. Intraocular pressure measurement was done in patients suspected of glaucoma. Posterior segment evaluation was done through ultrawide field fundus imaging using the Nikon Optos Daytona Plus camera. All findings and images were recorded in VCMS and transmitted to the base hospital for review.

Patients requiring specialist input underwent real-time video consultation with ophthalmologists at the base hospital. The process included digital registration, history review, image evaluation, and direct live interaction between the patient and ophthalmologist.

The ophthalmologist confirmed the diagnosis, discussed findings, and formulated a management plan, which was electronically documented and shared with the patient.

Data transmission was end-to-end encrypted to ensure patient privacy and data security.

To assess the quality and impact of teleophthalmology services, a structured patient satisfaction questionnaire was administered at the end of each consultation.

The tool was adapted from previously validated telemedicine satisfaction instruments used in Indian and international studies.[5,6] The questionnaire consisted of six items rated on a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied) assessing domains such as:

• I was comfortable throughout the teleconsultation process.

• Were you able to discuss your concerns with the ophthalmologist?

• Were you able to ask all your questions?

• Were you satisfied with the time given to discuss with your ophthalmologist?

• Did you feel your privacy was protected during teleophthalmology?

• Overall, were you satisfied with the teleophthalmology service and guidance provided by the team?

The questionnaire was pretested on 20 participants to ensure clarity and reliability before implementation. The quality of teleophthalmology services was evaluated using the mean satisfaction score obtained from the questionnaire. Higher satisfaction scores and service uptake rates were interpreted as indicators of effective and acceptable teleophthalmology services among rural populations.

All data were entered in Microsoft Excel 2021 and analyzed using descriptive statistics. Continuous variables were summarized as mean ± standard deviation, and categorical data were presented as frequencies and percentages.

Result

A total of 398 participants were enrolled across four affiliated vision centers. Of these, 381 patients (95.7%) successfully completed real-time teleconsultations with ophthalmologists at the base hospital, while 17 patients (4.3%) were referred directly for in-person evaluation due to technical limitations or the need for detailed assessment.

Participants were stratified according to age, gender, occupation, diagnosis, consultation duration, and satisfaction with teleophthalmology services. The mean age of the study population was 39.35 ± 12.6 years, with the majority in the 36–59 years’ group (55.4%), followed by 16–35 years (37.0%). Children below 15 years constituted 0.8% (n = 3), and participants aged ≥60 years comprised 6.1% (n = 23).

In terms of occupational distribution, the highest representation was among farmers, followed by students, homemakers, and vendors. Moderate representation was observed among private employees, teachers, and small business owners, while salespersons, IT professionals, painters, and retired individuals represented a smaller proportion [Fig. 1].

Figure 1.

Occupational distribution of study participants

The mean duration of teleconsultation was 20.1 ± 3.2 min (interquartile range: 14–26 min). The Kalaghatagi Vision Centre reported the longest mean consultation duration (21.4 min).

Patient satisfaction was assessed using a validated 6-item questionnaire rated on a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied). The mean satisfaction score was 4.6 ± 0.4, indicating a high level of acceptance and confidence in teleophthalmology services.

A total of 91.4% of participants rated the teleconsultation experience as either “Satisfied” or “Very Satisfied.” The most positively rated aspects included comfort and privacy during consultation, ease of communication, and clarity of instructions provided by the ophthalmologist [Fig. 2].

Figure 2.

Patient satisfaction with teleconsultation

Male participants demonstrated marginally higher satisfaction scores (mean 4.7 ± 0.3) compared with females (mean 4.5 ± 0.4). Among age groups, participants aged 30–49 years reported the highest satisfaction levels, whereas neutral or lower ratings were more frequently noted among 20–29-year-olds [Fig. 3].

Figure 3.

Overall satisfaction (Q 7) by age group

The distribution of clinical diagnoses is summarized in Table 1. The most frequently encountered conditions included lens-related disorders (19.8%) and refractive errors (18.7%). Additional diagnoses comprised ocular surface pathologies (13.2%), lid and adnexal conditions (11.6%), corneal pathologies (8.2%), and retinal disorders (6.6%), among which nonproliferative and proliferative diabetic retinopathy were most common.

Table 1.

Distribution of clinical diagnoses among patients undergoing teleconsultation

Diagnosis		Teleophthalmology consultation done
Emmetropia		25 (6.61%)
Lens-related conditions		75 (19.84%)
Refractive error		71 (18.78%)
Ocular surface pathologies		50 (13.22%)
Lid and adenexa		44 (11.64%)
Corneal pathologies		31 (8.20%)
Retinal pathologies		25 (6.61%)
Surgical follow-up		57 (15.07%)

Discussion

This study demonstrates that teleophthalmology delivered through vision centers can substantially broaden access to specialist eye care in rural settings. In our cohort, service uptake—defined as the proportion of eligible patients who completed a real-time teleconsultation—was 95.7% (381/398), and the mean overall patient satisfaction score (5-point Likert scale) was 4.6 ± 0.4, with 91.4% of respondents reporting “Satisfied” or “Very satisfied.” These findings indicate strong community acceptance of the model and a high level of perceived service quality.

Our results align with prior Indian studies such as the EyeSmart Study-I Misra et al. (2020).[4] and recent teleophthalmology initiatives in Gujarat Shah and Shroff (2023).[5] which reported high acceptance and practical benefits when trained allied personnel facilitate remote specialist input. In common with these reports, the principal drivers of success in our model were trained optometrists at the periphery, robust digital imaging (anterior and ultrawide field posterior segment photography), reliable internet connectivity, and scheduled availability of base-hospital ophthalmologists for live consultations.

It is important to clarify what is meant by “operational viability” in the present study. Operational viability here refers to the ability to deliver consistent teleconsultation services using existing infrastructural and human resources.[7,8,9] Key enabling factors observed were: Availability of essential diagnostic equipment at the vision centers (slit-lamp, refraction set, ultrawidefield fundus camera), trained optometrists able to perform standardized examinations and capture diagnostic images, secure and reasonably high-speed internet links (Jio Fiber) enabling synchronous video consultations, and integration with a VCMS for data transfer and record keeping. While these factors supported daily service delivery (Monday–Saturday), operational viability in other settings will depend on local resource availability, equipment maintenance, and ongoing training—factors that require prospective assessment in implementation studies.

The observed variation in satisfaction across centers—most notably the higher satisfaction at Kalaghatagi, which had longer mean consultation durations—suggests that interpersonal elements (time spent, clarity of communication, and patient counselling) are as influential on perceived quality as technical factors. This underscores the need to standardize consultation processes and communication training for staff to optimize patient experience.

We reframed claims regarding diagnostic and therapeutic equivalence to in-person care: Although comprehensive clinical data (including slit-lamp and fundus images) were obtained remotely and used to guide management for most routine conditions, this study did not include a direct comparison of diagnostic accuracy or therapeutic outcomes with face-to-face consultations. Therefore, statements asserting equivalence in diagnostic or therapeutic outcomes have been tempered; further research—ideally prospective studies comparing telediagnoses with gold-standard in-person assessments and measuring clinical outcomes—is warranted.

Regarding improved access, the teleophthalmology network provided specialist consultation to patients from 26 rural villages, many of whom would otherwise travel considerable distances to the base hospital. While we did not perform a pre–post population-level access analysis, the high uptake and the number of villages reached indicate a meaningful expansion of service reach. Future studies could quantify reductions in travel time, out-of-pocket expenses, and delays to care attributable to teleservices.

Conclusion

This present study highlights the pivotal role of teleophthalmology in addressing longstanding disparities in rural eye care delivery. By leveraging vision centers equipped with reliable digital infrastructure and trained personnel, telemedicine emerges as a sustainable model for enhancing access to specialist care, optimizing service utilization, and ensuring continuity of follow-up. The high rate of teleconsultation uptake and the strong patient satisfaction reported in this study reflect the growing acceptance and trust in this care model among rural communities in Dharwad, underscoring its tangible impact on improving eye health outcomes in underserved regions.

Conflicts of interest: There are no conflicts of interest.

Funding Statement

Nil.