This study determined the effectiveness of one Veterans Affairs Medical Center facility at providing annual diabetic eye examinations. A medical records review of a simple random sample of 350 diabetic patients was conducted to assess the impact of delayed access to care, practitioner referral patterns, patient no-show rates, and sample sizes used in performance reports. A 55.6% adherence rate was found, which increased to 81% when adjusted for future scheduled appointments. A high rate of physician referral for diabetic eye care was documented (68.9%), with a 10.2% patient no-show rate. The primary factor adversely affecting diabetic eye examination rates at this facility was a delayed access to care, complicated by an increased demand for eye care services. Also, sample sizes used in official performance reports were not sufficient to accurately determine true examination rates at the local level.