Advanced Teleophthalmology to Improve Cataract Referral Attendance From ECCs to Base Hospital

Although cataract remains the leading cause of avoidable blindness in Nepal, completion of referral from peripheral Eye Care Centers (ECCs) to Bharatpur Eye Hospital (BEH) for cataract surgery remains very low, with only about 3% of referred patients attending the hospital. Poor referral completion is influenced by barriers such as long travel distances, transportation costs, inadequate counselling, fear of surgery, and limited communication between peripheral eye care providers and ophthalmologists. This study aims to evaluate whether an enhanced tele-ophthalmology model improves cataract referral completion compared with the existing referral system. A stratified matched-cluster quasi-experimental study will be conducted in 12 satellite ECCs of Bharatpur Eye Hospital, comprising six intervention ECCs and six matched control ECCs. Adults aged 40 years or older diagnosed with visually significant cataract or other conditions requiring ophthalmological consultation will be enrolled. Participants in intervention ECCs will receive real-time tele-ophthalmology consultation using slit lamp-mounted anterior segment cameras, allowing ophthalmologists to remotely examine patients, confirm the diagnosis, provide counselling, and support referral planning. Control ECCs will continue the existing standard referral process without real-time ophthalmologist-patient interaction. The primary outcome is referral completion, defined as attendance at Bharatpur Eye Hospital or a designated secondary hospital within 12 weeks of referral. Secondary outcomes include patient-reported barriers to referral completion, time to hospital attendance, acceptance of tele-ophthalmology, and diagnostic confidence among ECC staff. A total of 396 participants (198 per group) will be enrolled. Referral completion rates between groups will be compared to determine whether enhanced tele-ophthalmology improves access to cataract surgical services and strengthens referral systems in rural Nepal.