The findings of this study provide robust empirical support for the effectiveness of optometry-integrated primary eye care at Rural Health Centres in Sindh, Pakistan, and contribute to a growing body of international evidence on the value of task-sharing in low-resource eye health systems. The central finding that optometrists independently managed 76% of patients presenting at RHCs validates the clinical scope and utility of trained optometrists as first-contact providers in rural healthcare settings, consistent with evidence from comparable programmes in South Asia and sub-Saharan Africa [8,9,10].

The scale of independent case management documented in this study has direct implications for the efficiency of the healthcare system. In Pakistan’s predominantly specialist-centric eye care model, the absence of primary-level providers creates a cascade effect in which routine cases, such as refractive errors, presbyopia, and minor anterior segment conditions, are unnecessarily escalated to tertiary facilities, leading to overcrowding, long waiting times, and inefficient use of ophthalmologists’ time [14]. The SIOVS model inverts this dynamic: by resolving 76% of cases at the primary level, it frees ophthalmologists to focus on surgical and complex medical cases, optimising the entire care continuum. This finding aligns with WHO’s Integrated People-Centred Health Services framework, which emphasises that reorienting care towards the primary level is essential for achieving universal health coverage [2].

The cataract management data are particularly noteworthy. A 100% pre-registration, surgical completion, and post-operative follow-up rate among 118 cataract patients represents a standard of care coordination that is challenging to achieve even in well-resourced urban settings. In rural Pakistan, where cataract surgical uptake is estimated to be below 35% of identified cases due to logistical, financial, and informational barriers [16], this outcome reflects the transformative potential of optometrists functioning as care coordinators rather than merely as examiners. The optometrist’s dual role as clinical identifier and logistical facilitator addressed the classic ‘last mile’ challenge in cataract surgery programmes, ensuring that identification translated into intervention [17,18].

The demographic profile of patients served warrants careful interpretation. The predominance of patients aged 50 years and above (55%) aligns with the epidemiology of cataract, presbyopia, and age-related macular degeneration in Pakistan. It underscores the critical importance of accessible primary eye care for older adults [3]. Many of these individuals had likely never previously received a formal ocular examination, and the findings suggest that age-related conditions were being detected and managed for the first time through RHC-based services. This has important implications for planning: optometry services in RHC settings must be equipped and staffed to provide high-volume geriatric eye care, including fundus assessment for diabetic retinopathy and glaucoma screening.

The slight female majority among patients (52%) is a finding of particular policy relevance. Studies consistently document that women in rural Pakistan face greater structural barriers to accessing healthcare than men, due to mobility constraints, financial dependency, and prevailing cultural norms that deprioritise women’s health needs [19]. The fact that women utilised RHC-based optometry services at rates that approximated or slightly exceeded their population share suggests that local service delivery, which eliminated the need for long-distance travel to urban centres, meaningfully reduced these barriers. This aligns with international evidence that geographic proximity is the single most important determinant of healthcare utilisation among rural women in LMICs [9,11] and underscores the gender equity dimensions of primary care-integrated optometry.

The study also identified several operational challenges that temper an otherwise encouraging picture. Many RHCs lacked advanced diagnostic instruments such as slit-lamp biomicroscopes, non-contact tonometers, and digital fundus cameras, limiting optometrists’ ability to conduct comprehensive ocular health assessments and potentially resulting in under-detection of early glaucoma and diabetic retinopathy. The 5.8% and 4.7% rates of suspected glaucoma and diabetic retinopathy referrals, respectively, are lower than epidemiologically expected population rates, suggesting that detection may be constrained by equipment limitations rather than by the absence of disease [1]. Investment in diagnostic equipment and maintenance protocols is a prerequisite for the model to achieve its full potential.

Integrating tele-ophthalmology into the RHC optometry network is a high-priority opportunity for improvement. As demonstrated in Pakistan’s northern areas, asynchronous tele-consultation platforms enable optometrists to transmit retinal images and clinical data for specialist review, substantially improving diagnostic accuracy for posterior segment conditions without requiring patient travel [20]. Embedding this capacity within the SIOVS RHC network would extend the clinical reach of deployed optometrists, support their professional development through specialist feedback, and provide a scalable mechanism for managing the growing burden of diabetes-related eye disease in rural Sindh [21].

Finally, the model’s institutional sustainability warrants attention. SIOVS’s ability to deploy and sustain 100 optometrists at RHCs reflects extraordinary institutional capacity that cannot be assumed across all health system actors in Pakistan. Transitioning from an institutionally driven initiative to a government-mainstreamed programme, with optometry posts formally embedded within the provincial RHC establishment, under government salary scales and standardised job descriptions, is essential for long-term sustainability and national-scale replication [12,13].