A retinal camera does not shorten the highway between a rural clinic and an eye specialist. It can, however, allow the first stage of diabetic eye screening to happen during a visit a patient is already making.
That matters because diabetic retinopathy often develops before a person notices blur, dark spots, or other vision changes. By the time symptoms appear, the disease may have progressed [2].
Jennifer H. Jacobs, M.D., from NOVA Eye Experts, provides comprehensive examinations and subspecialty corneal care [1]. Practices offering comprehensive eye care may become part of the referral pathway when screening reveals a finding that requires direct examination, additional testing, or treatment.
Teleophthalmology can help identify which patients need that next step. Taking the photograph is only the beginning. The clinic still needs a reliable way to interpret the result and arrange follow-up care.
Diabetic eye disease can advance before vision changes
Diabetes can damage the small blood vessels that nourish the retina, the light-sensitive tissue at the back of the eye. Early diabetic retinopathy may cause no symptoms. The National Eye Institute advises people with diabetes to receive a comprehensive dilated eye examination at least once a year, with more frequent follow-up when retinal changes are present [2].
For some patients, a separate specialty visit creates another transportation and scheduling barrier. IHS notes that travel to an eye clinic can be difficult enough that patients defer recommended examinations [6].
Placing retinal imaging in a primary-care or diabetes clinic can remove the need for every patient to begin with a separate specialty visit.
A trained staff member uses a retinal camera to photograph the back of the eye. Some programs, including the Indian Health Service-Joslin Vision Network, use cameras that usually capture the images without dilating the pupils [6]. The photographs and relevant medical information are then sent securely to a qualified eye-care professional for interpretation.
Remote retinal photography is recognized by the American Diabetes Association as a screening option when qualified eye-care professionals are not readily available. These programs must also provide a way to refer patients for comprehensive examinations when images show possible disease or cannot be interpreted [3].
Research supports that approach. A diagnostic-accuracy meta-analysis found that teleretinal screening performed well in detecting diabetic retinopathy and disease serious enough to warrant referral [4]. It can help determine who needs specialty care, but it does not provide every examination or treatment a patient may require.
A retinal camera can move screening beyond the specialist’s office
The IHS-Joslin Vision Network shows how retinal imaging can be incorporated into Native-serving primary care.
Established in 2000, the national program allows patients to receive diabetic retinal imaging during a primary-care appointment or on a walk-in basis. Images are transmitted to the IHS-JVN National Reading Center, where trained eye doctors interpret them and return reports with management recommendations [5].
According to an IHS update from April 2025, the program included 104 fixed or hybrid locations and 20 portable or mobile sites across 25 states. Diabetic retinopathy was identified in 24 percent of the patients who were imaged [5].
Those numbers describe one federal program. They are not a summary of every Tribal Nation, urban Indian health organization, or Native-serving clinic. They do show that primary-care retinal imaging can operate across a large and geographically dispersed healthcare system.
The program’s research has included patients receiving care through Indian Health Service, Tribal, and Urban Indian facilities. One study examined results from 53,998 American Indian and Alaska Native patients with diabetes who underwent imaging during routine care between 2011 and 2016 [9].
The system uses store-and-forward telemedicine, so the patient and reviewing eye doctor do not need to be available at the same time. Clinic staff capture the images, and a certified reader examines them from another location [7,8].
Successful screening relies on coordination among trained imagers, primary-care providers, and teleophthalmology staff [6]. Image quality is important because the reader needs a clear view of the retina before making a screening recommendation.
Insufficient image quality, missing photographs, or other technical problems can leave too little information for a conclusive reading [9]. Within the IHS-JVN program, an ungradable image set leads to referral for a conventional dilated retinal examination rather than being treated as a normal result [9].
Primary-care screening still needs a clear referral path
A screening report may show no detectable disease, recommend another image at a set interval, or identify a concern that requires an in-person examination. Some findings need quicker attention than others.
The IHS-JVN system returns standardized findings and management recommendations to the referring primary-care provider. Clinic staff can also flag an image for priority review when a faster response is needed [7].
The harder part may begin after the report arrives.
A referral can be medically appropriate and still be difficult to complete. Research has identified access, information-sharing, service-delivery, and follow-up problems as recurring barriers in diabetic-retinopathy screening programs [10].
Before introducing retinal imaging, a clinic needs to decide who will explain the result, how the report will enter the patient’s regular medical record, where abnormal or unreadable studies will be sent, and who will follow up when a referral is not completed. Transportation and patient-navigation support may also need to be built into the process.
Those decisions will vary among Tribal Nations, IHS facilities, urban Indian organizations, and other Native-serving systems. Geography, staffing, governance, community priorities, and available referral partners differ across Indian Country.
What Native-serving programs can teach about reaching rural patients
The IHS-JVN model places screening inside care patients already use. Someone may be able to have retinal images taken during a diabetes appointment instead of arranging a separate trip simply to learn whether specialty care is necessary.
Local staff capture the photographs, trained readers assess them elsewhere, and the report returns to the referring clinic with a recommendation [7,8]. Limited eye-care resources can then be directed toward patients whose results show that direct examination is needed.
The arrangement also keeps the primary-care team involved. Retinal findings can be considered alongside blood-sugar results, blood-pressure management, medication use, and other parts of diabetes care.
Still, the model cannot simply be copied from one community to another. Tribal Nations are sovereign governments, and Native-serving health organizations operate under different authorities and local conditions. Decisions about staffing, consent, data governance, referral partnerships, and patient communication belong with local leadership.
Remote retinal imaging should not become a lower standard of care offered because a community is rural. IHS guidance recommends imaging when a comprehensive dilated examination is not available, while also advising periodic examinations by an eye-care professional for conditions camera-based screening may not assess [6].
Patients with abnormal or unreadable photographs still need access to qualified clinicians. Depending on the finding, follow-up may include dilation, additional retinal imaging, injections, or laser treatment [2].
The Northern Virginia practice mentioned earlier includes comprehensive examinations and medical-retina services for patients who require further evaluation after an abnormal screening result [1]. This kind of specialty capacity allows screening findings to lead to diagnosis, monitoring, and treatment rather than ending with a report.
The measure of a screening program is not how many photographs it captures. It is whether patients receive the examination and care those photographs show they need.
References
[1] NovaEyeExperts.com. (n.d.). [Provider credentials, services, and practice facts]. https://www.novaeyeexperts.com/facts/;
[2] National Eye Institute. (2025). Diabetic retinopathy. National Institutes of Health. https://www.nei.nih.gov/eye-health-information/eye-conditions-and-diseases/diabetic-retinopathy
[3] American Diabetes Association Professional Practice Committee. (2026). Retinopathy, neuropathy, and foot care: Standards of Care in Diabetes—2026. Diabetes Care, 49(Supplement 1), S261–S276. https://doi.org/10.2337/dc26-S012;
[4] Far, P. M., Tai, F., Ogunbameru, A., Pechlivanoglou, P., Sander, B., Wong, D. T., Brent, M. H., & Felfeli, T. (2022). Diagnostic accuracy of teleretinal screening for detection of diabetic retinopathy and age-related macular degeneration: A systematic review and meta-analysis. BMJ Open Ophthalmology, 7(1), e000915. https://doi.org/10.1136/bmjophth-2021-000915;
[5] Indian Health Service. (2025). IHS-Joslin Vision Network Teleophthalmology Program. https://www.ihs.gov/teleophthalmology/;
[6] Indian Health Service. (n.d.). Increasing access to eye care. https://www.ihs.gov/teleophthalmology/eyecareaccess/;
[7] Indian Health Service. (n.d.). How JVN works. https://www.ihs.gov/teleophthalmology/programarchitecture/;
[8] Fonda, S. J., Bursell, S.-E., Lewis, D. G., Clary, D., Shahon, D., & Horton, M. B. (2020). The Indian Health Service primary care-based teleophthalmology program for diabetic eye disease surveillance and management. Telemedicine and e-Health, 26(12), 1466–1474. https://doi.org/10.1089/tmj.2019.0281;
[9] Bursell, S.-E., Fonda, S. J., Lewis, D. G., & Horton, M. B. (2018). Prevalence of diabetic retinopathy and diabetic macular edema in a primary care-based teleophthalmology program for American Indians and Alaskan Natives. PLOS ONE, 13(6), e0198551. https://doi.org/10.1371/journal.pone.0198551;
[10] Egunsola, O., Dowsett, L. E., Diaz, R., Brent, M. H., Rac, V., & Clement, F. M. (2021). Diabetic retinopathy screening: A systematic review of qualitative literature. Canadian Journal of Diabetes, 45(8), 725–733.e12. https://doi.org/10.1016/j.jcjd.2021.01.014
