Tele-Optometry and Mobile Eye Care Units: A Rural Vision Care Model for India

INTRODUCTION

Visual impairment and blindness are major public health concerns in India, having a greater impact on rural and marginalized communities. Around 34 million individuals in the country suffer from blindness or moderate to severe visual impairment, with over 85% of these cases being preventable or treatable conditions.^[1] Based on the National Blindness and Visual Impairment Survey 2015–2019, blindness prevalence among those aged 50 years and above was at 1.99%, with rural areas carrying a higher burden (2.14%) than urban areas (1.80%).^[2] Nearly 93% of blindness and 96.2% of visual impairment cases in this age group are avoidable.^[2] Cataract, being the biggest reason for blindness, accounts for 66.2% of all blindness cases in India, whereas uncorrected refractive errors are responsible for 18.6% of the blindness cases and 70.6% of the visual impairment cases.^[1,2] On top of that, glaucoma and diabetic retinopathy have been attributed to 6.7% and 3.3% of the blindness cases, respectively, and more than 90% of glaucoma cases are not diagnosed in the community.^[1] For children, India leads the world in the number of blind children, with almost 270,000 of them suffering from blindness. And, 9.3 million children are visually impaired, and out of these, 75% are due to avoidable causes, which are mainly uncorrected refractive errors.^[3]

Despite such a huge problem, the supply of eye care is highly unequal. There are only 15 ophthalmologists for a million people in India, and with very few ophthalmologists scattered irregularly in each state. The density of ophthalmologists is as high as 127/million population in Puducherry, whereas in Ladakh, there are only 2/million. Most of the states that are predominantly rural, such as Bihar, Uttar Pradesh, Madhya Pradesh, Assam, and West Bengal, are experiencing the most severe shortage of ophthalmologists.^[4] The current national ratio of optometrists to ophthalmologists is 0.85, which is much below the Vision 2020 goal of three paramedical staff per ophthalmologist.^[4] Moreover, virtually 70.6% of eye care units are running under the private sector against a mere 15.6% in the public sector and 13.8% under the NGO sector, out of the 7,901 eye care institutes surveyed, which strongly suggests that the vast majority of rural communities are deprived of cheap and easily available services.^[4] Furthermore, most of the field data show that only about 7% of those who need eye care in rural regions actually go to the screening camps that are set up temporarily, which highlights the fundamental shortcoming of the episodic outreach model, where there is still no permanent infrastructure.^[5]

Conventionally, eye care in India has largely depended on health institutions, and these have almost never been able to reach populations living in remote or socioeconomically deprived areas. Tele-optometry - optometric service delivery through digital communication platforms - and mobile eye care units equipped with portable diagnostic equipment are becoming useful means of expanding vision screening, diagnosis, and consultation to communities that do not usually have access to traditional facilities.^[6,7] A combination of these two approaches creates a hybrid care model that can tackle problems of geographic distance and specialist unavailability. Indian pilot initiatives and non-governmental organization (NGO) outreach programs show that this model allows for the timely diagnosis of eye diseases, helps with vision correction, and strengthens referral systems.^[8]

However, tele-optometry and mobile eye care services still represent a very small fraction of eye care services in India. Uncertain digital infrastructure, regulatory issues, data privacy concerns, and varying levels of digital literacy among end-users continue to hamper wider adoption. A narrative review was the most appropriate method for this study because the evidence was heterogeneous, the question was exploratory and policy-oriented, and there was a need to examine grey literature, including government program reports and institutional data, in addition to peer-reviewed sources. This review highlights how tele-optometry and mobile eye care units can serve as a sustainable and inclusive public health model to improve equitable access to vision care in India.

METHODOLOGY

This study used a narrative review design method to integrate published literature, program board and policy system of the tele-optometry and mobile eye care services in the Indian public health. The nature of the available evidence, the policy-oriented scope of the inquiry, and the need to use grey literature with peer-reviewed sources to capture implementation examples in the Indian context made the authors decide to use a narrative review approach.

A systematic search of the literature was conducted in three electronic databases, PubMed, Scopus, and Google Scholar, from January 2015 to December 2025. These keywords were used either independently or in combination: Tele-optometry, mobile eye care, teleophthalmology, vision screening, and rural eye health in India. Papers published before 2015, non-English language publications, studies conducted exclusively outside India unless directly comparative to the Indian context, and opinion pieces or commentaries without empirical or programmatic evidence were excluded.

Besides peer-reviewed articles, relevant gray literature was sourced, including government policy documents and institutional reports from the Ministry of Health and Family Welfare, National Programme for Control of Blindness and Visual Impairment (NPCBVI), Ayushman Bharat Health and Wellness Centres, the e-Sanjeevani platform, and the National Digital Health Mission. All the sources that were included were assessed based on their relevance to service delivery models, operational feasibility, policy alignment, and implementation challenges specific to the Indian context.

TELE-OPTOMETRY IN INDIA

Tele-optometry has become a major part of the Indian eye health care delivery system, mainly after the COVID-19 lockdown period, when digital health was pushed forward. Government-led vision programs and non-governmental innovations among the remote population groups were the main channels creating access to these services. Through the Ayushman Bharat program, e-Sanjeevani provides doctor-to-doctor and doctor-to-patient teleconsultation services through Ayushman Arogya Mandirs (formerly health and wellness Centers). These centers are mandated to provide comprehensive primary healthcare, including eye care, while telemedicine facilitates access to higher levels of care and specialist consultations.^[9] LV Prasad Eye Institute, for one, has used a tele-optometry institutional model with their Eye Smart software, which is an electronic medical record and tele-consultation system that helps in reducing referral delays and making timely clinical decisions. Still, digital illiteracy and image quality remain major challenges.^[10] In the same way, Dr. Aravind Eye Care System has networks of vision centers linked with base hospitals through which the patient travel burden was reduced and follow-up adherence improved.^[11] Tele-ophthalmology has become one of the direct-of-the-eye methods for diabetic retinopathy screening. The pilot projects in Tamil Nadu and Telangana were able to diagnose more cases and increase the referral efficiency by going through remote expert assessment of the non-mydriatic fundus images, which had been taken at primary care facilities.^[12] However, in reality, these are the reasons why tele-optometry has not been adopted more widely yet^[13]: people’s internet connections are not stable, the people who use the internet are not educated enough to utilize it, there are legal issues, there are no clear optometry telemedicine provisions, and there are shortages of personnel and equipment for diagnostic imaging.

MOBILE EYE CARE UNITS IN INDIA

Mobile eye care units extend essential vision-related services to isolated, tribal, and rural communities. Besides reducing travel-related barriers, these units also make it possible for comprehensive eye examinations to be conducted in community setups. For instance, the Aravind Eye Care System and the LV Prasad Eye Institute have mobile units that operate in schools to do vision screenings, diabetic retinopathy screenings, and general eye examinations. Cases needing complex interventions are referred to secondary or tertiary centers.^[14] A major use of mobile eye care is in school eye health programs, where mobile teams detect refractive errors and amblyopia in children through the Rashtriya Bal Swasthya Karyakram. Often, corrective spectacles are provided on-site or soon after the screening.^[15] Besides this, these units also cater to the elderly population by performing many checks, such as cataract screening, intraocular pressure measurement for glaucoma detection, and community health education. In fact, some communities have even used mobile surgical units to carry out cataract surgeries in temporary operating theaters.^[16] Task-sharing with skilled mid-level ophthalmic personnel is the foundation of mobile eye care services. For example, technicians with the help of hybrid models carry out initial examinations and imaging, while clinical results are either checked on-site or sent for remote interpretation.^[17-20] Despite its potential, sustainable mobile eye care is a bit hampered by the logistical and operational aspects, such as the recurring cost of fuel, maintenance equipment calibration, and workforce deployment.^[21]

HYBRID MODEL: INTEGRATION OF TELE-OPTOMETRY AND MOBILE EYE CARE UNITS

By combining tele-optometry and mobile eye care units, a hybrid service delivery model that digitally consults and conducts diagnostics out in the field is created. Mobile units travel to rural villages, schools, and community health centers for vision screening and basic eye examinations. After collecting ophthalmic data and retinal images, which have been captured by a trained technician or optometrist, these are sent to doctors at secondary or tertiary locations for either a live or delayed review. Afterward, the specialists can give their diagnosis, treatment advice, or referral decisions [Figure 1].^[22] This setup can also feature AI-driven diagnosis help and dovetail with health and wellness centers and the national digital health mission for referral support and subsequent care monitoring. People who have diabetic retinopathy, glaucoma, or cataract are referred to a higher level of care, and those who simply need correction to their vision are handled locally. This way increases efficiency and customer satisfaction.^[23] Hybrid models that are linked to centralized reading centers, which were implemented in pilot states such as Tamil Nadu and Odisha, showed increased screening participation, reduced patient travel times, and improved patient follow-up abilities.^[24-26] Further integration with national digital platforms such as e-Sanjeevani and Ayushman Bharat Digital Mission’s electronic health records will enable better patient tracking and continuity of care over time; however, this will require continued connectivity, a skilled workforce, data privacy measures, and interoperable digital systems.^[27-29] Long-term research still supports the ongoing effectiveness of this hybrid model even after the initial screening phase. With Sankara Nethralaya’s mobile tele-ophthalmology unit in Tamil Nadu, 105,827 patients were screened in 1,061 camps in 5 years (2015–2019). A total of 13,536 cataract patients were directed to free surgery, and 3,280 retinal cases were identified through teleconsultation.^[30]

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Figure 1: Indian workflow hybrid tele-optometry and mobile eye care delivery. The diagram shows how the patients are screened at community or school locations, the staff of a mobile eye care unit captures data, and optional artificial intelligence-assisted screening, video conferencing with an expert in an ophthalmology hospital, local treatment with dispensing of spectacles and counseling, referral to secondary or tertiary hospital, and a connection with national electronic health records.

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Regular reviews of Aravind Eye Care System’s permanent vision centers reveal that after 4 years of operation, they not only reached over 90% of their target population but also successfully diagnosed and treated 85–90% of the patients, while <15% needed to be referred to a base hospital.^[31] The REACH school-based mobile intervention conducted over 7 years screened more than five million children and referred 2,400 for surgeries; approximately 70% of the children were found to be wearing their prescribed spectacles during the unannounced long-term compliance audits.^[32] Then again, a study of mobile diabetic retinopathy in rural India found that not only 95% of patients who underwent the treatment also turned up on the prescribed dates for the pan-retinal laser photocoagulation, but the whole 100% was treated within 3 months.^[33] Hence, when we look at the combined picture of all these findings, the first thought that comes to mind is that structurally integrated hybrid models are capable of maintaining both screening coverage and treatment follow-through for multiple years.

BARRIERS AND CHALLENGES TO IMPLEMENTATION IN INDIA

Despite tele-optometry and the deployment of eye care through mobile units holding great promise in delivering vision services to underprivileged groups, many systemic and operational obstacles still limit the adoption of these interventions on a large scale across India. These difficulties are of various kinds - technological, infrastructural, regulatory, workforce-related, and sociocultural. The unreliable broadband and mobile network quality in tribal regions, mountainous areas, and economically backward zones do not support real-time teleconsultation, thus resulting in the use of asynchronous modes that may cause a delay in diagnosis and lower patient satisfaction.^[34,35] The ongoing expenses for fuel, maintenance wages, and use of sophisticated equipment such as non-mydriatic fundus cameras, autorefractors, and tonometers, which require a heavy initial investment, limit the scaling-up of these practices through financial means alone and call for consistent public financing or public–private partnerships.^[36]

Shortages of personnel pose another serious problem. Most of the optometrists with training are located in the cities, while nearly all the districts have huge competence gaps in areas such as digital imaging, electronic health records, and telemedicine protocols that are available to the personnel, necessitating uniform capacity-building across the workforce.^[27,37-39] A further challenge comes from unclear regulations, as the Telemedicine Practice Guidelines 2020 focus on physicians and do not contain any specific elements related to optometrists or allied eye care professionals, which are partly responsible for the limitation of cross-state service delivery and professional autonomy.^[40] Data privacy concerns when transmitting sensitive retinal images and clinical data, and the lack of adequate control mechanisms threaten patient confidentiality and could bring mistrust in virtual care.^[41] Sociocultural factors act as inhibitors of adoption as well, since insufficient digital literacy, mainly among women, the elderly, and those who are less educated, reduces the acceptance of virtual consultations. Yet, if community health workers or on-site facilitators are present, the uptake is a lot higher.^[42] Tackling these interwoven issues using coordinated policy reform, workforce investment, and multisectoral partnerships will result in not only the creation of a strong but also equitable tele-optometry system throughout India.

POLICY FRAMEWORK AND NATIONAL PROGRAMS SUPPORTING EYE CARE IN INDIA

India’s current national healthcare initiatives can greatly support the integration of tele-optometry and mobile eye care in regular service delivery. Following its revision in 2017, the NPCBVI is providing support in several areas, such as cataract surgery, school eye screening, diabetic retinopathy care, and mobile ophthalmic outreach through NGO collaboration. The program has also recently been focusing on convergence with telemedicine systems and electronic reporting.^[27,43] Using fixed primary care infrastructure, the primary care of Ayushman Bharat Health and Wellness Centres can be used for mobile eye care and tele-consultation services. These services can be connected to the secondary and tertiary referral modes. This will help make primary eye care universal health coverage in our country.^[44] The e-Sanjeevani platform and the National Digital Health Mission offer a comprehensive digital ecosystem that makes it possible to conduct longitudinal ocular health monitoring, interoperates electronic health records, and securely shares data. All these features could be extended to tele-optometry with the proper training.^[45,46] Initiatives by public-private partnerships with institutions such as the Aravind Eye Care system and LV Prasad Eye Institute are proof that policy alignment and operational cooperation can act as catalysts for the hybrid service delivery model. Enhanced inter-sectoral coordination with the integration of vision indicators into national health information systems will be necessary to align these models with international eye health priorities.

RECOMMENDATIONS AND FUTURE DIRECTIONS

Promoting tele-optometry and eye care through mobiles in India is a complex issue that calls for policy changes, technological advances, workforce training, and research efforts. The telemedicine practice guidelines should be amended to explicitly recognize optometrists and vision technicians, laying down their scopes of practice, licensing portability, as well as medico-legal protections to allow remote eye care delivery with legal safeguards.^[47,48] Video oculomics and artificial intelligence-based image analysis systems for diabetic retinopathy, glaucoma, and age-related macular degeneration can be game-changers in mobile eye care workflows, mainly the asynchronous mode, by delegating to non-specialists certain diagnosis roles in eye care in locations with a shortage of ophthalmologists.^[49] The integration of different databases or data formats on a national level and the use of cloud servers for the secure transfer of patient data will allow for continuous patient care, minimizing duplications of services, and making the tracking of treatment outcomes over time possible.^[50] Skills of clinical staff in telemedicine procedures, usage of portable diagnostics, digital literacy, as well as knowledge of data privacy, should be part of formal optometry education and ongoing professional development curriculum.^[51]

Major monitoring and evaluation systems are the backbone of effectiveness, cost-efficiency, and equity assessment. Longitudinal studies should also encompass screening coverage, compliance with referrals, visual outcomes, and exposure to financial risks, and implementation research must back up the financing of scalable public-sector and public–private-partnership models.^[52] Cost-effectiveness studies are a strong rationale for continuous funding: telemedicine-based diabetic retinopathy screening costs $2,435/QALY gained over a 25-year horizon, community glaucoma screening yields an incremental cost-effectiveness ratio of INR 7,292.30/QALY over 10 years, and rural vision centers treating corneal disorders generated cumulative community savings of USD 94,112/center over 10 years through reduced patient travel and clinical costs.^[53,54] Mobile diabetic retinopathy screening units became financially self-sufficient in <3 years as they used cross-subsidization to fund their operations, with program-generated income covering monthly running costs, which amounted to approximately USD 1,200.^[33] That means, future programs should have built-in longitudinal evaluation systems that measure visual acuity outcomes, referral-to-treatment conversion, spectacle compliance, and the cost per disability-adjusted life year averted at 12 and 24-month intervals. Community engagement by way of awareness programs, culturally appropriate health education, and involvement of local governance, schools, and women’s self-help groups is crucial for better acceptance of the marginalized groups.^[55] Collaborative networks involving government agencies, academic institutions, non-profits, and health technology developers, first launched in high-need districts, can provide the strong implementation evidence on which to base responsible nationwide expansion.^[56-60]

CONCLUSION

India’s rural and underserved populations still disproportionately suffer from avoidable blindness because of continuing barriers in the availability of specialists, physical infrastructure, and equitable service delivery. The experience of institutional and pilot projects in Tamil Nadu, Telangana, and Odisha indicates that adding tele-optometry to mobile eye care units increases screening attendance, makes people more aware of eye problems at an earlier stage, and helps patients keep up with treatment even after several years. Still, the current findings should be interpreted with care. Most of the existing data come from pilot studies of short duration rather than controlled longitudinal ones, and data on the long-term effects of such interventions, like improvement in visual acuity, conversion from referral to treatment, and compliance with the use of spectacles over time, are scarce. Cost-effectiveness analyses are favorable, telemedicine-based diabetic retinopathy screening costs $2,435/QALY over 25 years, but it has not yet been demonstrated that this can be done on a large scale across diverse geographic and demographic contexts. Besides the unreliable digital connectivity, shortage of the optometry workforce, lack of optometry-specific telemedicine regulations, high operational costs, and differing levels of digital literacy are the main barriers that need to be systematically addressed before this model can be responsibly positioned for adoption at the national level. Alignment with NPCBVI, Ayushman Bharat, and the National Digital Health Mission, with regulatory changes, enhancing the workforce, and developing structured long-term evaluation structures for clinical outcomes and cost per disability-adjusted life year averted, are critical for making this hybrid model a formal part of the system and advancing vision equity in India.