(PDF 128 KB)
A recent report in the journal Diabetes Care states the problem in stark terms: The number of Americans with diabetes will double within 25 years, the cost of caring for people with the disease will nearly triple and, as individuals develop diabetes earlier and live longer, they will experience more diabetes complications requiring treatment.1 Over time, these trends are expected to increase the need for retina specialists and shift more of the burden of managing earlier-stage diabetic retinopathy to comprehensive ophthalmologists.
A more immediate problem in providing eye care to people with diabetes is the current economic downturn. With job layoffs, lost health insurance and home foreclosures, many of the people who have been most affected by the recession are going without needed medical care. The silent nature of early diabetes and the vague symptoms of incipient retinopathy make these problems easy for patients to overlook or ignore. On a societal level, this deferred eye care will only exacerbate the looming challenge of preventing diabetes-related blindness and increase the costs of the long-term disability that accompanies it.
The Academy is involved. Organized medicine is addressing patient education with programs like the Academy’s new EyeSmart initiative regarding diabetic retinopathy (www.geteyesmart.org.). Entitled EyeCommitted, the program is supported by the American Society of Retina Specialists, the Macula Society and the Retina Society and is raising patient awareness of how yearly dilated eye exams and prompt treatment help prevent diabetes-related blindness. The program provides supportive education materials and urges people with diabetes to make a formal pledge to have a dilated eye exam every year. The EyeCare America program, now in its 25th year, can help qualified individuals obtain free or reduced-cost eye examinations. (More information is available at www.eyecareamerica.org.)
Hands-On Help to Save Sight
Some individual ophthalmologists are finding innovative ways of helping the unemployed and uninsured obtain vision screening and follow-up exams. Retina specialist Jonathan D. Walker, MD, and his partner Matthew E. Farber, MD, have teamed up with health care providers at local free health clinics to screen diabetic patients for signs of retinal disease. The collaboration came about because both doctors had been seeing a marked increase in uninsured patients presenting with advanced disease. “Whether it was a retinal detachment that had been there for a month, a choroidal neovascular membrane that had eaten away at the fovea or advanced diabetic retinopathy, we were seeing more and more people coming into the system like that, and it was really frustrating for us,” said Dr. Walker, an assistant clinical professor of ophthalmology at Indiana University in Fort Wayne. “Then we learned that hundreds of diabetics in our community were being seen at free clinics, but no one was screening them for eye disease.”
Wanting to help, the two retina surgeons initially did the vision screening themselves but soon realized that another approach was needed. With the help of Dr. Walker’s high school–age son, they wrote a grant application requesting money to buy fundus cameras and submitted it to the Lutheran Foundation. Today, two free clinics in Fort Wayne have the cameras.
“When the grant came through four years ago, we bought our first camera, put it at the main free clinic and wrote a little instruction manual that showed the clinic staff how to take the photographs,” Dr. Walker said. “Now, every diabetic patient who goes through the clinic has pictures taken, and then I read the pictures on the Internet. When there is a problem, we bring patients in and treat them gratis. We are now monitoring about a thousand patients at the clinic through the photographs. Only about 10 percent have notable retinopathy, and many of those can simply be followed with more frequent photographs. Only a small percentage actually have something that needs to be brought into the practice for monitoring and treatment—it has been very easy to incorporate these patients into our practice without having to worry about the bottom line.”
When health care happens late. Dr. Walker noted, “As retina specialists, we particularly tend to see the disasters of the health care system because people are relatively asymptomatic and then come in too late out of fear of going bankrupt. Unfortunately, tragedies like this are not limited to ophthalmic complications. These patients end up costing society far more because their systemic comorbidities were never properly addressed.
“In the bigger cities, there may be county hospitals that can absorb the uninsured,” he continued. “But certainly for doctors in mid-size communities, where there is no official way to take care of the uninsured, we really see people falling through the cracks.”
Dr. Walker noted that the gratis work he and his partner do is rewarding, and he encourages other physicians who have similar problems in their communities not to be afraid to get involved.
Community Providers on the Front
Comprehensive ophthalmologists may increasingly be called upon to monitor and manage diabetic retinopathy, especially in underserved areas. “Diabetes is a growing problem and we certainly expect to see more diabetic individuals requiring appropriate eye care,” said George A. Williams, MD, chairman of ophthalmology at William Beaumont Hospital in Royal Oak, Mich. “Comprehensive ophthalmologists can play a very important role in the delivery of that care.”
The Academy has guidelines. Dr. Williams noted that the Academy’s Diabetic Retinopathy Preferred Practice Pattern states that ophthalmologists who undertake the care of these patients must be adequately trained, experienced and competent in the diagnosis and management of diabetic retinopathy. “I don’t think that means you have to be a fellowship-trained retina specialist to provide good diabetic eye care,” he said. “Clearly some patients will require specialty treatment, such as those with the more end-stage forms of the disease who will require complex vitreoretinal surgery. But for routine follow-up of patients who have yet to manifest diabetic retinopathy or who have relatively mild forms of the disease, comprehensive ophthalmologists who understand the foundation for treating diabetic retinopathy can provide appropriate and timely care for the vast majority of patients.”
This foundation for treatment is built from the results of multiple clinical trials over the years. According to Dr. Williams, these trial results are essential to understanding the advances being made in diabetic retinopathy, including changing laser technologies, new pharmacotherapies and new surgical techniques. He noted that he often sees patients with proliferative disease who had been treated previously with inadequate panretinal photocoagulation or macular photocoagulation.
Indications that a patient should be referred to a retina specialist include an inadequate response to conventional therapy, such as an individual with macular edema who is not responding to focal laser therapy or a patient who has had appropriate and timely panretinal photocoagulation but still goes on to develop vitreous hemorrhage.
Dr. Walker agreed. “If a comprehensive ophthalmologist is having trouble controlling macular edema, particularly if it involves the fovea, they need to start thinking about intravitreal therapy and addressing any subtle traction. If you delay intervention with these patients, the damage will become more and more permanent with time.”
Dr. Walker also pointed out that if a comprehensive ophthalmologist is using the clinical exam alone or relying on older-generation optical coherence tomography, he or she may miss the more subtle signs of traction that would be picked up by the newer generation OCTs.
Dr. Williams said, “The good news is that when we are able to treat individuals at the right time in their disease process, treatments such as laser photocoagulation for proliferative diabetic retinopathy are 90 percent successful. Diabetic macular edema, depending on where the disease process is, also can respond very well to macular photocoagulation.”
There’s more to your patient than two retinas. Finally, Dr. Walker believes that ophthalmologists should be more aggressive in educating patients about the importance of tight glycemic control. “I ask patients what their hemoglobin A1c is, and if they don’t know—or they don’t even know what the test is—that’s a good indication that their systemic control isn’t what it should be. Then I educate the patient about the importance of hemoglobin A1c, tell them to be sure to discuss this with their primary care physician and follow up with a note to their physician. If I am really worried, I will simply order the test myself to be sure that it is done.”
1 Huang, E. S. et al. Diabetes Care 2009;32(12):2225–2229.
A Primer on DR
Dr. Walker has written a book for community ophthalmologists who are managing diabetic patients. Diabetic Retinopathy for the Comprehensive Ophthalmologist is 280 pages, published by Deluma Medical Publishers in Fort Wayne and available in paperback. Dr. Walker has also generously made it downloadable for free at www.drcobook.com.