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One in ten of all patients referred to hospitals in the UK are for problems involving the eyes. Many of the most urgent referrals are for problems in the retina, a light-sensitive layer at the back of the eye which allows us to see. We can now detect and diagnose these diseases earlier than ever before thanks to a technology called Optical Coherence Tomography (OCT). This light-based technology is safe, comfortable and quick.

Excitingly, OCT is increasingly being installed in high street optometry practices, and is no longer limited to hospital eye clinics. This could transform the way we detect patients with retinal diseases, but only if these scans are accurately interpreted enabling early diagnosis and correct decisions over who should be referred to the hospital eye service, and how urgently. Currently however the introduction of this new technology on the high street is not always matched by the availability of those skilled at interpreting these scans. This is leading to a large number of patients being referred inappropriately, which is increasing the pressure on hospital eye services and delaying access to care for patients that do need treatment. Additionally unnecessary referral causes distress and inconvenience.

The Tele-opHthalmology-enablEd and ARtificial Intelligence-ready referral pathway for coMmunity optomEtry referralS of retinal disease study (HERMES) aims to use new technologies to improve this referral process, moving hospital-level expertise to the high street without the specialist needing to leave the hospital, and helping hospitals and high street optometrists to work together to refer the 'right patient at the right time'.

The first technology we will evaluate is 'tele-ophthalmology' in which OCT scans taken by high street optometrists are reviewed by hospital specialists remotely. In this part of the study high street optometrists with OCT will be divided into two groups: half of the practices, selected by chance, will continue to refer patients using the existing paper-based system, with the other half installing a leading tele-ophthalmology platform ('Big Picture') to allow instant transfer of scans to the eye hospitals for review and advice within 24 hours.

We will then check whether the new referral system can safely lead to fewer unnecessary visits to the eye hospitals and whether it improves the time it takes for referred patients to be seen or treated. We will also assess the cost of the new system and ask what patients and health practitioners think about it -confidence in its safety and data privacy, and effect on patient experience.

The second technology we will evaluate is interpretation of retinal scans by 'Artificial Intelligence' (AI).In a recent study from the UK, members of our team and a leading technology company worked together to develop an AI algorithm that can diagnose retinal diseases and provide referral advice to the same standard as leading UK experts. This exciting development could enable expert-level care to be digitally embedded into this referral pathway but first we need further evidence of how this AI technology would perform in the real world.

In this part of our study, we will use AI ('the Moorfields-DeepMind algorithm') on all the OCT scans collected from our participating high street optometrists and we will assess how accurate it is in providing the correct advice for referral. A key part of this study is to collect opinions of patients and practitioners on the potential role of Artificial Intelligence for eye referrals.

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