Diabetic Eye Exam Recall: Closing the Annual Screening Gap

Only 64.8% of US adults with diagnosed diabetes reported having a dilated eye exam in the past 12 months, short of the federal Healthy People 2030 target of 70.3%. That gap is not a knowledge problem — clinicians and patients both know the exam is recommended. It is a tracking problem: the exam usually happens outside the practice that manages the diabetes, and without a system to confirm who went and who didn’t, a meaningful share of patients simply never complete it.

The annual eye exam is standard of care, and vision loss is the price of skipping it

Diabetic retinopathy is the leading cause of new blindness among working-age adults in the United States, and it typically causes no symptoms until damage is already advanced — which is exactly why screening, not symptom-driven care, is the standard. An estimated 9.6 million Americans have some degree of diabetic retinopathy, roughly one in four people with diabetes, and about 1.8 million have vision-threatening disease that needs prompt treatment to prevent permanent vision loss.

The screening interval is not a vague suggestion. The American Diabetes Association’s Standards of Care in Diabetes—2026 sets it out precisely: people with type 2 diabetes should get an initial dilated, comprehensive eye exam at the time of diagnosis; people with type 1 diabetes should get one five years after onset. After that, if one or more annual exams show no retinopathy and glycemic control is at goal, the interval can stretch to every 1–2 years — but if any level of retinopathy is present, the exam is repeated at least annually. The guideline builds in a shorter leash for exactly the patients who need it most, which only works if someone is actually tracking who falls into which category.

Nationally, completion falls short of the guideline — and further short for some patients

The national average also hides how uneven completion is. The American Academy of Ophthalmology’s own analysis puts it bluntly: “only about half” of patients who should be screened routinely are, and the rate splits further by race and ethnicity — 55.6% for non-Hispanic White patients with diabetes, versus 48.9% for Black patients and 48.2% for Hispanic patients. A practice that only looks at its overall completion number can miss that the shortfall is concentrated in a specific slice of its own patient panel.

The gap opens when the exam lives outside the practice managing the diabetes

Most primary care and endocrinology practices don’t have an ophthalmologist or optometrist on-site, so the annual eye exam is typically a referral out — and a referral is where visibility ends for most scheduling systems. The practice sends the order, but there is often no routine mechanism that closes the loop: no automatic flag when the referral isn’t scheduled, no follow-up when the patient never shows, and no easy way to tell “referred” apart from “screened” inside the chart.

This is not a small structural quirk. One study modeling the supply side found that type 2 diabetes prevalence in US adults is expected to grow by roughly 50% by 2025, while the number of practicing optometrists and ophthalmologists is projected to grow only 1–2% over the same period — meaning even a perfectly executed referral increasingly lands on a system with less capacity to absorb it. In a purely referral-based model with no active follow-up, one primary care study measured adherence to the recommended annual exam at just 18.7% at twelve months. That is close to the same order of magnitude as the disparities noted above, and it is consistent with what practices tracking Medicare quality measures already see in Annual Wellness Visit gap-closure work more broadly: a preventive service that depends on the patient independently completing a second appointment, at a second location, tends to fall through unless someone owns confirming it happened.

A recall protocol — not a stronger referral — closes the gap

The evidence on what actually moves the adherence number is specific, and it isn’t “send a stronger referral letter.” In the primary care study cited above, adding automated retinal imaging at the point of care, giving patients their results immediately, and following up by phone within two weeks of an incomplete screening raised adherence from 18.7% to 55.4% at twelve months — nearly a threefold increase.

Other implementations point the same direction at smaller scale. A primary care clinic that added mobile retinal screening plus an EMR-based tracking dashboard — logging completion dates and surfacing them on a quality metric view — raised its average screening rate from 45.3% to 52.1% over five months. A teleretinal screening program across several community health centers with baseline compliance ranging from 25% to 40% increased compliance by an average of 7.2 percentage points once it was running. None of these interventions changed the guideline or the patient’s motivation — they changed whether the practice could actually see, in real time, who was due and who had completed the exam. That same tracking-over-relying-on-memory logic shows up in how practices handle other chronic-disease recall gaps, including the routine screening bundled into chronic disease management more broadly and the reminder cadence built around Medicare Annual Wellness Visits — the mechanism that works is the same regardless of which specific test or visit it’s chasing.

Building the recall protocol: what your practice can do this week

A practice does not need to become an eye-care provider to close this gap; it needs a way to know, for every patient with diabetes, whether the annual exam happened — and a standing process for reaching out again when it hasn’t. If your practice serves patients across the US more broadly and is working through this kind of chronic-disease recall gap, see how Arbol supports US practices.