- Now Watch Me Whip; Watch Me Nae Nae
- The Importance of Diabetes Screening and Early Detection
- Using SD-OCT Biomarkers and Big Data Analyses to Identify Eyes at Risk for AMD Progression
- Fibro-Dry Eye-Gia?
- DSEK versus DMEK for Endothelial Dysfunction
- The Effect of LASIK on Dry Eye Disease
- Making Recommendations to Patients
- Synergistic Tools for Cataract Surgery
- Creating a Premium Practice
- What’s New in Presbyopia-Correcting IOLs?
- Cataract Surgery in Patients With Meibomian Gland Dysfunction
- Make it Memorable
- Using the VEP for Better Patient Outcomes in Mild Traumatic Brain Injury
- Femtosecond laser-assisted AK After or Concurrent with Phacoemulsification
- Pesky Pingueculas
Diabetes is a major public health concern in the developed world, and its prevalence is steadily increasing. In the United States, as of 2012, more than 29 million people had diabetes, up from 26 million just 2 years earlier. Of those 29 million, more than 8 million with diabetes were undiagnosed, according to the American Diabetes Association.1
The direct medical cost of care for diabetes amounts to close to $50 billion annually, according to a study from Prevent Blindness.2 The health consequences of diabetes are also immense. Eye care providers well know that almost 30% of adults with diabetes develop diabetic retinopathy (DR), which causes about 12% of all new cases of blindness each year. People with diabetes are also 40% more likely to develop glaucoma than people without diabetes. And they are more likely to develop cataracts at a younger age and with faster progression. But DR is associated with problems outside the eye as well. Hearing loss is higher among those with DR. Periodontal disease and albuminuria are associated with DR. Worsening DR is associated with elevated diastolic blood pressure. And vision loss due to DR is associated with major depression.
For all these reasons, early detection and diagnosis of diabetes is an important goal of all health care providers, including eye care professionals. Early diagnosis and treatment can lead to better visual and overall health outcomes.
Optometrists are patients’ primary eye care provider in most cases. We see patients for 66% of all eye care visits and 78% of first-time eye care visits. The optometrist is often the first eye care professional with the opportunity to detect acute or chronic conditions of which patients may not be aware. Patients who perceive themselves as healthy, but who wear glasses or contact lenses, may see their eye doctors more often than their primary care physicians. As such, optometrists can be at the front line in detection of chronic conditions such as diabetes, complications of which may be visible in the eye before symptoms are noted.
Optometrists therefore must be aware of their role in screening for signs of diabetes, so that they can provide integrated care and communicate effectively with patients’ primary care physicians and others.
Screening for diabetes is easily integrated as part of the routine comprehensive eye examination. We check the patient’s vision and intraocular pressures, we look at the anterior chamber and the lens, and finally we look at the back of the eye through a dilated pupil. Here is where we have the opportunity to detect signs of glaucoma, macular degeneration, and diabetes.
If we see retinal hemorrhages, this should prompt questions. Does the patient have frequent urination (polyuria)? Is he or she often thirsty (polydipsia)? Any recent weight loss? Fatigue? Increased appetite? Blurred vision? Sores that do not heal? A yes answer to any of these questions can raise suspicion of the presence of diabetes.
If we see signs of diabetic retinopathy, and the patient’s symptoms raise suspicion but the patient is not aware of a diagnosis of diabetes, this is a cue for us to refer the patient to his or her primary care provider for further evaluation.
Focus on Screening and Prevention
1. Petropoulos IN, Green P, Chan AW, et al. PLoS One. Corneal confocal microscopy detects neuropathy in patients with type 1 diabetes without retinopathy or microalbuminuria. 2015;10(4):e0123517. doi: 10.1371/journal.pone.0123517.
2. Pritchard N, Edwards K, Russell AW, et al. Corneal confocal microscopy predicts 4-year incident peripheral neuropathy in type 1 diabetes. Diabetes Care. 2015;38(4):671-675.
3. Gao Y, Zhang Y, Ru YS, et al. Ocular surface changes in type II diabetic patients with proliferative diabetic retinopathy. Int J Ophthalmol. 2015;8(2):358-364.
4. Ishibashi F1, Kawasaki A1, Yamanaka E1, et al. Morphometric features of corneal epithelial basal cells, and their relationship with corneal nerve pathology and clinical factors in patients with type 2 diabetes. J Diabetes Investig. 2013;4(5):492-501. doi: 10.1111/jdi.12083.
Derek N. Cunningham, OD
• Director of optometry and research at Dell Laser Consultants in Austin, Texas
Beyond the evaluation of symptoms in the undiagnosed diabetic patient, other steps for the primary eye care provider may vary depending on the practice setting and resources available. If the provider is part of a multispecialty group, he or she may want to order blood work that can be sent to the primary care provider.
Another diagnostic tool is the ClearPath lens fluorescence biomicroscope (Freedom Meditech), which detects autofluorescence in the crystalline lens. Elevated levels of lens autofluorescence have been associated with high levels of advanced glycation end products, or AGEs, which are linked to the presence of diabetes and high glucose levels.3
This is a handy test because it is noninvasive. It has not enjoyed widespread adoption yet, but its use is becoming more common. With the rise of accountable care organizations and their focus on prevention to promote affordable care, this type of test and others that facilitate early detection may prove to be valuable.
Optos ultrawide-field fundus imaging (Optos) is another useful screening tool that is increasingly present in optometric and primary care physicians’ offices. With this modality, an optomap 200° widefield image of the patient’s retina is obtained and sent for remote screening. If any diabetic retinopathy or other type of retinal pathology is identified that would warrant further evaluation with a dilated examination, the appropriate referral can be made.
Although the Optos is a helpful tool, it does not replace a dilated eye exam because it does not provide a three-dimensional view of the retina. If patients undergo Optos imaging and screening in their primary care provider’s practice, they may think they have had an eye exam. In reality, however, this is only a remote screening for back-of-the-eye pathology. Patients should be made aware that they still need to visit their eye care practitioner regularly for comprehensive eye exams. This is where clinical integration is important—networking and communication among different medical groups to ensure that patients do not slip through the cracks.
IMPORTANCE OF COMMUNICATION
In addition to detecting diabetes in undiagnosed patients, primary eye care providers also play a role in the ongoing evaluation of patients with established diagnoses. Primary care physicians often refer diabetic patients for a comprehensive eye exam after a diagnosis is established, and yearly eye exams are recommended in the care continuum for diabetic patients. A vital part of coordinated care of diabetic patients, whether new or established, is good communication among providers.
Whatever the direction of the referral, the importance of good communication remains paramount. Whether we are identifying diabetes for the first time or detecting the progression of diabetic retinopathy in an established patient, the primary eye care provider must communicate his or her findings to the patient’s primary care provider. If we notice progression of diabetes, this may warrant referral to a retina specialist in addition to communicating with the primary care doctor, who may have to be more aggressive in the treatment and control of the patient’s blood sugar. In this type of coordinated care, communication among all parties is essential.
Clinical guidelines for coordinated care are available from the America Optometric Association, and the American Academy of Ophthalmology publishes a preferred practice pattern for diabetic retinopathy.4,5 These guidelines dictate the frequency of exams and whether referral to specialists is warranted depending on the severity of the condition. Familiarity with these clinical guidelines is essential.
One helpful communication resource is OcuHub (http://ocuhub.com), a recently developed health care information technology solution that connects eye care professionals and integrates their communications within and between health care systems. With OcuHub, eye care practitioners can share and exchange clinical information electronically with other providers. This cloud-based web-portal system allows direct messaging from primary eye care providers to specialists, and vice versa, as well as allowing scheduling coordination between practices. All of this helps practitioners coordinate their care, track outcomes, and provide primary care providers and medical groups the information they need to effectively manage each patient’s condition. OcuHub is a HIPAA-compliant resource that provides opportunities to improve gaps in care, boost Healthcare Effectiveness Data and Information Set, or HEDIS, ratings, and decrease the costs of patient care.
EMPHASIS ON EDUCATION
As primary eye care providers, when we see patients with diabetes for their annual eye examination, part of our role is emphasizing controlling all the risk factors: keeping blood sugar down, maintaining healthy weight, stopping smoking, etc.
Many large multispecialty medical groups employ diabetes educators, and even some large eye care practices have nurses or physician assistants who are diabetes educators. This is another resource we can offer to patients to help them with controlling and managing their diabetes.
However many providers are involved, and whatever the resources available, the greatest asset in the care of patients with diabetes is communication. Open lines of communication among primary care providers, primary eye care providers, and specialists, will help to ensure that patients with diabetes are getting the quality care that they need. n
1. Statistics About Diabetes; Data from the National Diabetes Statistics Report, 2014. http://www.diabetes.org/diabetes-basics/statistics/. Accessed September 4, 2015.
2. Cost of Vision Problems. The economic burden of vision loss and eye disorders in the United States. June 11, 2013. http://tinyurl.com/q3f5xj5. Accessed October 26, 2015.
3. Scientific rational for screening patients using autofluorescence to identify patients who may have diabetes. Freedom Meditech. http://www.freedom-meditech.com/clientuploads/documents/2010%20Scientific%20Rational%20for%20Screening.pdf. Accessed September 7, 2015.
4. Eye Care of the Patient with Diabetes Mellitus. American Optometric Association. http://aoa.uberflip.com/i/374890-evidence-based-clinical-practice-guideline-diabetes-mellitus. Accessed September 7, 2015.
5. Preferred Practice Pattern: Diabetic Retinopathy. American Academy of Ophthalmology. http://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp--2014. Accessed September 7, 2015.
Section Editor Derek N. Cunningham, OD
• Director of optometry and research at Dell Laser Consultants in Austin, Texas
• Founding member and chair of the American Society of Cataract and Refractive Surgery’s Integrated Ophthalmic Managed Eyecare Delivery Task Force
• Chief medical editor of Advanced Ocular Care
Medical Editor Alan Franklin, MD, PhD
• Practices at the Retina Specialty Institute in Mobile, Alabama
Walter O. Whitley, OD, MBA, FAAO
• Director of optometric services, Virginia Eye Consultants, Norfolk, Virginia
• firstname.lastname@example.org; (757) 961-2944; www.virginiaeyeconsultants.com
• Financial interest: none acknowledged