Because diabetic retinopathy often goes unnoticed until vision loss occurs, people with diabetes should get a comprehensive dilated eye exam at least once a year.
Diabetic eye disease comprises a group of eye conditions that affect people with diabetes, and that can cause severe vision loss or blindness:
- Diabetic retinopathy.
- Diabetic macular edema (DME)
- Cataract
- Glaucoma
Diabetic retinopathy is the most common cause of vision loss among people with diabetes and the leading cause of vision impairment and blindness among working-age adults. Chronically high blood sugar from diabetes is associated with damage to the tiny blood vessels in the retina, leading to diabetic retinopathy.
The retina detects light and converts it to signals sent through the optic nerve to the brain. Diabetic retinopathy can cause blood vessels in the retina to leak fluid or hemorrhage (bleed), distorting vision. In its most advanced stage, new abnormal blood vessels proliferate (increase in number) on the surface of the retina, which can lead to scarring and cell loss in the retina.
People with all types of diabetes (type 1, type 2, and gestational) are at risk for diabetic retinopathy. Risk increases the longer a person has diabetes. Between 40 and 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy, although only about half are aware of it. Women who develop or have diabetes during pregnancy may have rapid onset or worsening of diabetic retinopathy.
The early stages of diabetic retinopathy usually have no symptoms. The disease often progresses unnoticed until it affects vision. Bleeding from abnormal retinal blood vessels can cause the appearance of “floating” spots. These spots sometimes clear on their own. But without prompt treatment, bleeding often recurs, increasing the risk of permanent vision loss. If DME occurs, it can cause blurred vision.
- Diabetic macular edema (DME) is the build-up of fluid (edema) in a region of the retina called the macula. The macula is important for the sharp, straight-ahead vision that is used for reading, recognizing faces and driving. About half of all people with diabetic retinopathy will develop DME. Although it is more likely to occur as diabetic retinopathy worsens, DME can happen at any stage of the disease.
- Cataract is a clouding of the eye’s lens. Adults with diabetes are two to five times more likely than those without diabetes to develop cataract. Cataract also tends to develop at an earlier age in people with diabetes.
- Glaucoma is a group of diseases that damage the eye’s optic nerve – the bundle of nerve fibers that connects the eye to the brain. Some types of glaucoma are associated with elevated pressure inside the eye. In adults, diabetes nearly doubles the risk of glaucoma.
Detection
Diabetic retinopathy and DME are detected during a comprehensive dilated eye exam that includes:
- Visual acuity testing. This eye chart test measures a person’s ability to see at various distances.
- Tonometry. This test measures pressure inside the eye.
- Pupil dilation. Drops placed on the eye’s surface dilate (widen) the pupil, allowing a physician to examine the retina and optic nerve.
- Optical coherence tomography (OCT). This technique is similar to ultrasound but uses light waves instead of sound waves to capture images of tissues inside the body. OCT provides detailed images of tissues that can be penetrated by light, such as the eye.
A comprehensive dilated eye exam allows the doctor to check the retina for:
- Changes to blood vessels.
- Leaking blood vessels or warning signs of leaky blood vessels, such as fatty deposits.
- Swelling of the macula (DME).
- Changes in the lens.
- Damage to nerve tissue.
If DME or severe diabetic retinopathy is suspected, a fluorescein angiogram may be used to look for damaged or leaky blood vessels. In this test, a fluorescent dye is injected into the bloodstream, often into an arm vein. Pictures of the retinal blood vessels are taken as the dye reaches the eye.
Prevention
Vision lost to diabetic retinopathy is sometimes irreversible. However, early detection and treatment can reduce the risk of blindness by 95 percent.
Because diabetic retinopathy often lacks early symptoms, people with diabetes should get a comprehensive dilated eye exam at least once a year. People with diabetic retinopathy may need eye exams more frequently. Women with diabetes who become pregnant should have a comprehensive dilated eye exam as soon as possible. Additional exams during pregnancy may be needed.
Studies have shown that diabetic patients who keep their blood glucose level as close to normal as possible are significantly less likely than those without optimal glucose control to develop diabetic retinopathy, as well as kidney and nerve diseases. Other trials have shown that controlling elevated blood pressure and cholesterol can reduce the risk of vision loss among people with diabetes.
Source: National Eye Institute, part of the National Institutes of Health, https://nei.nih.gov/health/diabetic/retinopathy
Points to remember
- All forms of diabetic eye disease have the potential to cause severe vision loss and blindness.
- Diabetic retinopathy involves changes to retinal blood vessels that can cause them to bleed or leak fluid, distorting vision.
- Diabetic retinopathy is the most common cause of vision loss among people with diabetes and a leading cause of blindness among working-age adults.
- DME is a consequence of diabetic retinopathy that causes swelling in the area of the retina called the macula.
- Controlling diabetes – by taking medications as prescribed, staying physically active, and maintaining a healthy diet – can prevent or delay vision loss.
- Because diabetic retinopathy often goes unnoticed until vision loss occurs, people with diabetes should get a comprehensive dilated eye exam at least once a year.
- Early detection, timely treatment, and appropriate follow-up care of diabetic eye disease can protect against vision loss.
Source: National Eye Institute, part of the National Institutes of Health, https://nei.nih.gov/health/diabetic/retinopathy
Four reasons why patients don’t schedule their diabetic eye exams
Historically only 40-50 percent of diabetic patients receive the annual eye test for diabetic retinopathy, despite a recommendation by the American Academy of Ophthalmology that all patients with diabetes or pre-diabetes receive an annual retinal eye exam. Here are four reasons why.
- Patients are typically asymptomatic until diabetic retinopathy has done damage to the retina.
- Patients are also often uncomfortable making an appointment with a new, unfamiliar physician.
- Many have transportation or proximity issues getting to the eye specialist. Patients are also challenged with finding a ride home after their eyes are dilated.
- Patients can’t or don’t want to take time off work for an eye test that doesn’t seem urgent.
Source: Intelligent Retinal Imaging Systems, http://blog.retinalscreenings.com/4-reasons-why-patients-dont-schedule-their-diabetic-eye-exams
Eye exams in the primary care office
Patients with diabetes should have a dilated retinal examination by an ophthalmologist or optometrist usually on an annual basis if no disease is present, and more often if warranted by the level of disease, according to the current standard of care.
“This standard might be adequate if every person living with diabetes complied with their annual referral to visit the eye specialist,” says Chuck Witkowski, vice president and general manager, new healthcare delivery solutions, Welch Allyn. “But only 20 percent to 50 percent comply.” That’s true for a variety of reasons, including:
- Lack of insurance or healthcare access.
- Lack of knowledge of diabetes-specific ocular risk and health literacy.
- Socioeconomic factors, cultural, and language barriers.
- Patient logistics, time and cost associated with a separate office visit to a specialist.
A solution – and macro trend – is to implement patient-centered systems in the right locations to deliver high-value care, says Witkowski. In many cases, that right location is the patient’s primary care physician’s office. In fact, implementing patient-centered systems to increase access to diabetic retinal exams in primary healthcare locations may help providers achieve the elusive “Triple Aim” of healthcare – improving the patient experience, improving population health, and reducing the cost of healthcare, he says.
A primary care solution
Welch Allyn acquired Hubble Telemedical, Inc. in January 2015 and rebranded the solution offered by Hubble as RetinaVue™ Network, explains Witkowski. At the time of the acquisition, Hubble Telemedical’s services and technology had been refined for nearly a decade, started by a pioneer of teleretinal screening – Edward Chaum, M.D., Ph.D., who currently serves as chief medical officer of RetinaVue P.C.
Advancements in non-mydriatic camera technology now make it more simple and affordable to offer diabetic retinal exams in primary care settings, says Witkowski. At $4,995, the suggested list price for the RetinaVue 100 Imager is two-thirds less than desktop fundus cameras, he says.
The RetinaVue solution can be customized for regional or national integrated delivery systems or accountable care organizations, says Witkowski. Elements of a systemwide implementation can include:
- A dedicated project management team, which scopes and fully operationalizes a solution that complements existing clinical workflow.
- A mix of desktop and handheld retinal cameras, which are deployed based on the patient volume and workflow requirements of individual clinics.
- Comprehensive population-health-management and quality-reporting tools, which allow systems to view average image-quality scores, unreadable exam rates, exam volume, detected pathologies, and more – by clinic and by patient.
- A fully supported, bi-directional EMR interface, which can be incorporated to efficiently place exam orders and return diagnostic reports to the EMR for easy access and review.
- Evaluation of images by a board-certified ophthalmologist at RetinaVue P.C. (or by an ophthalmologist in the provider’s system). Reports are generally returned within one business day.
The RetinaVue solution can help the physician practice improve its HEDIS scores/ratings, says Witkowski. The NCQA® /HEDIS® quality measure for the annual diabetic retinal exam (NQF #0055) is included in Medicare Advantage STAR Ratings, CMS Quality Payment Program, and Medicare Shared Savings Program measures for diabetes management.
In addition, he says, NQF #0055 is a quality measure in the CMS Quality Payment Program: Percentage of patients 18 to 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period.
Distributor reps should focus on family physicians, internal medicine, multi-specialty, CHC, and endocrinology, says Witkowski. Any primary-care facility with a high population of diabetic patients and any facility with a high volume of A1C test-kit purchases is another high-potential customer.