Douglas Anderson is not someone who emotes about the things that frighten him. Well, he’s a man, a Scot and an entrepreneur, so naturally he tends to exude a bullish air rather than one that dwells on negatives. Yet ask how he felt when he learnt that his myopic small son had lost the sight in one eye and his shock and frustration are transparent.

“We had two healthy kids and suddenly we had a major problem with Leif. I wanted to know what was going on, really intensely interested to observe how difficult it was to examine the retina. I remember a very good surgeon saying ‘You’ve got to bear in mind that I’m getting only a glimpse here’. I thought — a glimpse! This is my son here. A glimpse is not good enough! I want to be able to document every millimetre of the retina. It seems bar-baric that that should not be the case.”

Leif Anderson was 5, dyslexic like his father, unable to follow instructions to look left or right, and unreceptive to having an intense light shone into his eye. “What they really want to do is poke the eyeball so they can see the very farthest extremes of the retina,” his father says. “A child is not going to tolerate that. So when the clinician is trying to reassure me that he’s seen everything he needed to see, I’m intensely sceptical. I’m observing and I’ve seen what’s not happened as much as what has happened.”

Leif had suffered a detached retina in his left eye, and its sight could not be saved. Surgery prevented a second detachment in his right eye, but his father continued to brood on the invasive nature of retinal examinations, and their lack of availability at primary care level.

“You had to be as sick as my son to get a decent retinal exam and I reflected that it wasn’t in the interests of the patients or the healthcare economy to allow disease to progress until it was so advanced that you had to do surgery,” he says. “Intervene earlier and you can make a bigger difference for much less cost.”

Happily, Anderson ran a consulting business that did technological development. This meant that although he wasn’t a doctor, he had experience of producing medical equipment. He decided to “have a go” at creating a piece of kit that would examine the retina without discomforting the patient, and that would produce a record of the examination. In particular it had to be child-friendly.

The result, nine difficult years later, was the Optomap, a laser-scanning system pro- duced by Optos, the company he set up in 1992 in Dunfermline. The Optomap examines up to 80 per cent of the retina in apainless, noninvasive process that takes a fraction of a second. Conventional examination techniques enable a clinician to see only 20 to 25 per cent of the retina: in the words of one optometrist this “is like looking into a large room with a small window”. Ifdilating drops are used on the pupil 70 to 75 per cent of the retina can be examined, but the patient is left with blurred vision for several hours.

The back of the eye is the only part of the body where the health of the vascular system - the body’s blood vessels - can be inspected without an invasive procedure. This means that as well as identifying retinal damage, age-related macular degeneration and glaucoma — and therefore saving sight — the Optomap technology can indicate the presence of conditions that kill, including hypertension, some cancers, diabetes, and a predisposition to stroke and cardiovascular disease. It provides photographic evidence of the condition of the retina in a single image and this facilitates a speedy electronic referral to an ophthalmologist who, on receipt of the e-mail, is able to examine the image and diagnose any condition that needs treatment.

I meet Anderson at the spectacular home he has built on a hillside above Dollar (he has also built a boat — this man is nothing if not resourceful). Leif, now a student of 22, is there too and today he has blurred vision after a manual eye examination that morning. It is an uncomfortable process, he confirms.

“They use a very powerful torch and a hand-held lens to steer inside your eye. They ask you to look to the right, then left, then up, then down. They’re building up a picture of the inside of your eye in their head. It takes 15 to 20 minutes and by the time that they’ve finished you have this halo effect for about six hours. They also manipulate your eye, and that is very unpleasant.”

Leif was born with very short sight assessed at minus 15 (most shortsighted people are between minus 2 and minus 5). This put him at risk of having a retinal detachment, and had he lived in the US he would have had regular dilated examinations. The Andersons were not told of the risk. “Even now, as parents we wouldn’t be advised of the risk and probably wouldn’t get the examination so wouldn’t have the opportunity for treatment,” says Anderson. “If a small child has a retinal detachment they don’t tend to comment on it because it’s not painful. They just work around it. So by the time it was detected it had been detached for a number of months. Surgery was done but it was too late. You can put a retina back on 24 hours, 48 hours, a week after it comes off. Three months and the chances of there being any nerve cells left to function . . .

“That’s the problem we’ve been trying to solve. If you wait for an eye disease to be symptomatic, you’re pretty stumped.”

Anderson opens his laptop and shows me a series of Optomap retinal images: a 12-year-old whose leukaemia was undiagnosed and was treated; a seven-year-old who had undetected bowel cancer; an adult who had high cholesterol and would benefit from a daily aspirin or statin to prevent stroke; a tumour behind the retina that had been undetected by a dilated retinal examination two weeks previously.

Leif too has benefited from the technology. After 15 years of stable eye health, he suffered a detached retina in his right eye two years ago, leaving him temporarily blind. Again his sight was saved by surgery but three months later the Optomap picked up an emerging shadow. Another operation fixed the retina in position, though six months later he was blinded again by a cataract. Leif elected for further risky surgery, which was successful, taking his sight from minus 18 to minus 0.25.

Optos is now a success. After 60 million scans, the company went public last year and has delivered a healthy return to shareholders. Yet Anderson remains a frustrated man: six years after the Optomap was launched, and only after the $150,000 (£80,000) equipment was made available through a pay-per-use scheme, there are only 3,000 machines in the US, and a paltry 80 in the UK. He believes that his product should be part of every eye and general health check — yet he has repeatedly been told that there is no need for it.

Anderson remarks that the US is more receptive to the Optomap because its optometrists are more geared up to eye care as preventative medicine, and do dilated examinations routinely. He points out too that US primary care optometrists do a four-year postgraduate degree, as opposed to three years as an undergraduate in Britain.

“In the US there’s a pretty straightforward referral process to the next level of care if something is detected. In the UK it’s diabolically protracted and there’s often a lack of respect from the ophthalmologists in secondary care to those in primary care. So there’s a nervousness on the part of some practitioners who are trying to improve their clinical performance, and a lot won’t make the clinical decision. They just refer. The consequence is that 60 per cent of the referrals into the NHS are unnecessary, and if you consider the average waiting time for an ophthalmologist in the UK is 22 weeks, a lot can happen in that time.

“A tumour can communicate itself to the brain in that time. Retinal detachments go from being treatable to untreatable. If you take the 60 per cent out of the waiting list you immediately drop to seven weeks, though even that’s not acceptable. And if you were doing proper examinations and you were competent diagnostically you would not only pull out the 60 per cent but you’ll put in an extra 5 to 6 per cent that really need to be seen. You would pick up on systemic disease as well as eye disease — but up to now some practitioners have considered that’s not their business.

“I don’t care whether they do dilated exams well or whether they use our technology — I just want them to do something. Of course, the NHS gives low remuneration for eye tests, and that has been followed by the free eye test approach, which has driven the quality of eye examinations down.”

This is surely the root of the debate: money. Kevin Lewis, president of the College of Optometrists, uses the Optomap for about 1,000 patients a year at his practice in Thurrock, Essex, and says that in less than four years “I have picked up 150 things I would have missed, 12 have been immediately life saving”.

He recommends it to all his patients; 50 to 60 per cent take it up at a cost of £25, which means that the machine pays for itself, he says. “In the UK we don’t have a culture of charging people for examinations and there’s a certain amount of cross subsidy because it’s the spectacle-selling that makes the money. The other thing is time. A lot of practitioners would rather through-put more patients than take up time with another examination.”

Optos has a display on scanning at the Science Museum, London www.optos.com; 01383 843300 or e-mail info@optos.com

Retinal detachment

Retinal detachment affects one person in 10,000 — usually middle-aged, shortsighted people — and occurs when the retina, the light-sensitive inner lining of the back of the eye, becomes separated from the underlying tissue. This may be caused by a hole or tear in the retina that allows fluid to get underneath, weakening the attachment of the retina, which then becomes detached and unable to compose a clear picture from the incoming rays. Vision becomes blurred and dim. Detached retina can also be caused by an injury or may be a consequence of other eye conditions or surgery.

Using the Optomap

I had my eyes checked by an Optomap at N. F. Burnett Hodd in London, which charges £51 for the examination. The machine looks like a friendly alien and once a technician has got your eye lined up with the machine, you press the button which takes the image. The process takes a few minutes. My eyes were declared healthy by David Raz-Rhodes, one of the practice’s optometrists. “The Optomap has helped us to discover retinal tears that we wouldn’t have discovered otherwise,” he says. “Using an ophthalmoscope is a very transient way of doing the examination. The beauty of the Optomap is the photographic record because it enables you to refer straight away. We got a woman with a retinal haemorrhage to an ophthalmologist on the same day.”