To realise its ambition as a proactive partner in eye health, optometry must move from individual optimisation to system-level design, writes Peter Larsen.

Optometry has never lacked capable clinicians, professional commitment, or openness to new technology. Across Australia, optometrists deliver trusted care every day, often as the most accessible eye care providers in their communities.

What the profession has historically lacked is not capability, but health system architecture.

That distinction now matters. As optometry increasingly contributes to chronic disease detection and long-term management – particularly glaucoma and diabetes – expectations are shifting. Modern health systems require consistency, coordination, and accountability across populations, not just excellence within individual consultations. Yet optometry remains largely organised around a model optimised for individual clinical craft rather than collective system performance.

The resulting tension helps explain why system-level transformation in optometry has been uneven. This is not a failure of will or professionalism, but a consequence of how the profession was formed and how it has evolved.

A PROFESSION SHAPED BY ITS ORIGINS

Optometry developed historically as a locally delivered, community-based profession, most commonly operating through small independent practices rather than large institutional systems. This structure conferred a high degree of professional autonomy, with clinical decisions made by individual practitioners and variation in practice patterns regarded as an expected feature of professional judgement rather than a deficiency.1,2

This structure shaped education, governance, technology adoption, and notions of quality. Clinical excellence was – and remains – understood largely as an attribute of the individual practitioner, not of the system in which they work.

Cottage-style models excel at personalised care and strong professional identity. They are less naturally suited to standardisation, shared accountability, and collective learning; features that underpin effective chronic disease surveillance and population-level care.3 As optometry’s role increasingly intersects with these domains, structural limitations that were once invisible are becoming more apparent.

STRENGTHS WORTH PRESERVING

It is important to acknowledge what this heritage has given the profession. Optometry’s emphasis on autonomy has fostered deep clinical ownership, strong patient relationships, and a willingness to adopt new tools early. Australian optometrists have been among the fastest globally to embrace technologies such as optical coherence tomography (OCT), widefield imaging, and advanced diagnostic platforms.

This adaptability reflects a profession that is curious, pragmatic, and clinically engaged. Many of the innovations now discussed at a system level were first explored within individual practices by optometrists motivated to improve care for their own patients.

The challenge, therefore, is not to replace optometry’s strengths, but to translate them into shared structures. Individual excellence does not disappear when systems are introduced; rather, it becomes more visible, more comparable, and more learnable. In other areas of healthcare, standardisation has not suppressed professional judgement, it has elevated it, allowing clinicians to focus on complex decision making rather than repeatedly reconstructing basic processes.

Seen this way, system design should be viewed not as a constraint on professionalism, but as a mechanism that allows professional skill to have greater reach and durability.

THE ‘50% UNDIAGNOSED’ STATISTIC REVISITED

One of the most frequently cited statistics in glaucoma care is that a substantial proportion – often estimated at around 50% – of people with the condition remain undiagnosed, even in well-resourced health systems with high optometric access.4-6

This figure is often interpreted as a call for more testing, more technology, or greater public awareness. Equally important, however, is what it reveals about system consistency.

The core tools required for glaucoma detection – tonometry, optic nerve assessment, visual fields, and OCT – have been widely available for many years. The persistence of a large undiagnosed population therefore points less to technological gaps than to variation in thresholds for suspicion, testing, escalation, and referral across practitioners and practices.

In a profession organised around individual judgement rather than shared pathways, such variation is not anomalous. It is an expected outcome of the structure itself.

EDUCATION, BEHAVIOUR, AND INFRASTRUCTURE LIMITS

Optometry education appropriately prioritises clinical competence. Graduates are trained to examine, diagnose, and manage patients safely and independently in the consulting room.7

What has been far more difficult to embed is standardisation of care across practitioners and over time. This is not primarily an educational failing, but an infrastructural one.

In most cases, optometric practice management software has not historically supported structured clinical data capture, longitudinal tracking, audit, or benchmarking at scale. Clinical findings are often recorded in free text, stored inconsistently, or separated from diagnostic imaging and referral outcomes. As a result, the profession has lacked the basic tools required to routinely measure variation, compare performance, or close feedback loops between decision making and outcomes.

In this environment, it is unsurprising that education has focused on individual clinical judgement rather than system consistency. Teaching standardisation is difficult when the systems required to support, reinforce, and audit standardised behaviour do not exist in everyday practice.8,9

Behaviour follows infrastructure. When systems reward autonomy and do not reveal variation, clinicians naturally develop individual thresholds rather than shared ones. Over time, this becomes professional culture: excellence is demonstrated through personal expertise, not alignment with peers or pathways.

The consequence is not poor care, but uneven care. Graduates emerge as capable clinicians, yet with limited exposure to audit, benchmarking, or population-level feedback. As digital infrastructure matures, education can increasingly be grounded in real-world variation, longitudinal outcomes, and shared learning.

TECHNOLOGY ADOPTION WITHOUT SYSTEM ALIGNMENT

Optometry has been enthusiastic in its adoption of diagnostic technology. OCT, widefield imaging, automated perimetry, and emerging artificial intelligence (AI) tools are now routine in many practices.

Yet substantial evidence demonstrates significant inter-observer variability in the interpretation of these technologies, even among experienced clinicians.10-14

Without shared thresholds, structured workflows, and feedback mechanisms, technology can amplify rather than reduce unwarranted variation.

For chronic, slowly progressive diseases such as glaucoma, this variability has direct implications for equity, safety, and long-term outcomes. The challenge is not technological ambition, but alignment.

THE AUSTRALIAN OCT EXPERIENCE

The Australian study, ‘Increased glaucoma case-finding through routine optical coherence tomography in optometry practice’, is often summarised as evidence that OCT increases glaucoma referrals.15 That observation is accurate, but incomplete.

The improvement in case-finding did not arise from the deployment of OCT devices in isolation. Rather, it resulted from the deliberate implementation of an end-to-end clinical system that included routine (rather than discretionary) imaging, structured clinical workflows, decision support guiding visual field testing, individual benchmarking of clinician behaviour, ongoing education and feedback, and digitally enabled referral pathways.15-17

In this context, OCT functioned as an enabling technology rather than the primary intervention. The causal mechanism was system design. The study demonstrated that meaningful and consistent improvements in glaucoma detection emerge when unwarranted variation is addressed through infrastructure, feedback, and accountability, rather than left to individual discretion or optimised solely through interpretive decision rules.15-17

DIGITAL REFERRALS, MOMENTUM, AND INVISIBLE VALUE

Digital referral platforms further illustrate a central tension. Some of the most important system improvements deliver limited immediate commercial return to optometric practices. Their value accrues downstream – to ophthalmology services, hospitals, and patients – through improved triage accuracy and earlier access to care.

In Australia, the widespread adoption of Oculo, now increasingly embraced by ophthalmology across both private and public sectors, provides tangible evidence that when optometry is proactive in building system-ready solutions, upstream partners respond. Major public services, including the Royal Victorian Eye and Ear Hospital, are now actively connecting through digital referral pathways. This momentum demonstrates that when optometry leads with reliable, structured infrastructure, specialist services are willing – and often eager – to engage.

DIGITAL INFRASTRUCTURE AS STRATEGIC CAPABILITY

Australia’s National Digital Health Strategy (2023–2028) prioritises interoperability, structured data capture, and longitudinal care.18 Yet most optometric practice management systems remain optimised for transactions rather than outcomes.

Without shared clinical data structures aligned to national standards, benchmarking remains optional and quality improvement episodic. Digital transformation, in this sense, is less about software procurement and more about professional commitment to system participation.

LEARNING FROM THE UK

The United Kingdom’s National Health Service Diabetic Eye Screening Programme illustrates what happens when systems are designed under pressure for reliability and scale. Screening was delivered through technician-led image capture and centralised grading – not because optometry lacked expertise, but because consistency could be demonstrated more readily through standardised, auditable pathways.19-21

More recently, this logic has extended into broader ophthalmic triage. At Moorfields Eye Hospital, the SPARC (single point of access for referrals to community and hospital eye services) model consolidates referrals into a single structured intake system, increasingly supported by AI.22-24

Importantly, this trajectory is not inevitable in Australia. The lesson from SPARC is not that hospital-led systems are superior, but that health systems centralise control when consistency cannot be demonstrated upstream.

Australia has a genuine opportunity to take a different path – one that strengthens, rather than bypasses, community-based optometry. By enabling structured, grassroots interaction between optometrists, supported by shared data standards, benchmarking, and digital infrastructure, system reliability can be built where care is actually delivered.

In this model, optometry’s value is not confined to improving referrals. It lies in improving health outcomes within communities: earlier detection, more consistent monitoring, better-informed follow up, and continuity of care closer to home.

CHOOSING THE NEXT CHAPTER

Optometry is not broken. It is highly skilled, trusted, and central to community eye care. But it is being asked to deliver population-level outcomes using structures designed for individual practice.

Some of the most important steps ahead will not immediately increase practice revenue. They will, however, determine whether optometry remains a central clinical decision-making profession within eye-care pathways, or becomes peripheral to systems designed elsewhere.

The opportunity now is not to defend history, but to build on it: to combine the strengths of individual clinical craft with the infrastructure required for collective impact.

That choice – and that opportunity – remain firmly in the profession’s hands.

Peter Larsen BOptom is a health-system leader with extensive experience transforming eye care workforces and organisations across retail optics, medical technology, and digital health. He has held senior executive roles in global eye care companies and is currently focused on designing scalable, data-driven models that integrate optometry, ophthalmology, and digital infrastructure to improve population eye-health outcomes.

References available at mivision.com.au.