Integrated Care for the Diabetic Patient: How to

Transcription

AOC
Supplement to
September 2016
Advanced Ocular Care
COPE CE Activity
Integrated Care for the
Diabetic Patient:
How to Diagnose and Manage
the At-Risk Patient Mark Dunbar, OD, moderator
A. Paul Chous, OD
Steven G. Ferrucci, OD
Jay M. Haynie, OD
Leo Semes, OD
Administrator
Release Date: September 1, 2016; Expiration Date: August 29, 2019
This course is COPE approved for 2.0 hours of CE credit for optometrists.
COPE Course ID: 50824-SD
COPE Event ID: 111927
This continuing education activity is supported through an unrestricted
educational grant from Regeneron Pharmaceuticals.
Sponsored by
Integrated Care for the Diabetic Patient
Release Date: September 1, 2016
Expiration Date: August 29, 2019
COPE Course ID: 50824-SD
COPE Event ID: 111927
FACULTY
Mark Dunbar, OD, moderator
A. Paul Chous, OD
Steven G. Ferrucci, OD
Jay M. Haynie, OD
Leo Semes, OD
LEARNING METHOD
This educational activity consists of a supplement and 20
study questions. To obtain credit, the participant should read
the learning objectives contained at the beginning of this activity, read the material, answer all questions in the post test, and
complete the activity evaluation form. This educational activity should take a maximum of 2.0 hours to complete.
CONTENT SOURCE
This continuing education activity captures content from
a CE-accredited webinar held on Tuesday, June 21, 2016.
ACTIVITY DESCRIPTION
It remains clear that although diabetes is a systemic
disorder, the manifestations of diabetic complications will
occur without optimal glycemic and blood pressure control. Optometrists can help continually reinforce that message by educating patients about the necessity for ongoing
and yearly dilated eye exams, and discussing the potential
treatments should vision loss become obvious.
TARGET AUDIENCE
The target audience for this CE Activity is optometrists.
LEARNING OBJECTIVES
After successfully completing this activity, optometrists will
have improved their ability to:
• Determine who is a high-risk patient for the onset of diabetic eye disease
• Discuss the importance of conducting yearly dilated
exams on diabetic patients
• Develop plans to initiate comanagement of the diabetic
2 SUPPLEMENT TO ADVANCED OCULAR CARE SEPTEMBER 2016
patient with both ophthalmologists and primary care
physicians/endocrinologists
• Implement strategies to educate patients on the ocular
manifestations of diabetes
ACCREDITATION DESIGNATION STATEMENT
This course is COPE approved for 2.0 hours of CE credit
for optometrists.
DISCLOSURES
Mark Dunbar, OD, has had a financial agreement or affiliation during the past year with the following commercial
interests in the form of Consultant/Advisory Board/Speaker’s
Bureau: Allergan; Carl Zeiss Meditec; and Regeneron
Pharmaceuticals.
A. Paul Chous, OD, has had a financial agreement or affiliation during the past year with the following commercial
Bureau: Bausch + Lomb; CooperVision; Freedom Meditech;
Regeneron Pharmaceuticals; and ZeaVision, LLC. Grant/
Research Support: ZeaVision, LLC
Steven G. Ferrucci, OD, has had a financial agreement or
affiliation during the past year with the following commercial
Bureau: Alcon; CenterVue; Macula Risk; and Maculogix.
Jay M. Haynie, OD, has had a financial agreement or affiliation during the past year with the following commercial
Bureau: ArticDx; Carl Zeiss Meditec; Reichert; Notal Vision,
Ltd.; and ThromboGenics NV.
Leo Semes, OD, has had a financial agreement or affiliation during the past year with the following commercial interests in the form of Consultant/Advisory Board/
Speaker’s Bureau: Alcon; Allergan; Optovue; and Regeneron
Pharmaceuticals. Stock/Shareholder: HPO
Cheryl Cavanaugh, MS, director of operations, Evolve
Medical Education LLC; Michelle Dalton, medical writer; and
Melanie Lawler, PhD, reviewer, have no relevant commercial
interests to disclose.
DISCLOSURE ATTESTATION
Each of the contributing physicians listed above has
attested to the following: (1) that the relationships/affiliations noted will not bias or otherwise influence his or her
involvement in this activity; (2) that practice recommendations given relevant to the companies with whom he or she
has relationships/affiliations will be supported by the best
available evidence or, absent evidence, will be consistent
with generally accepted medical practice; and (3) that all
reasonable clinical alternatives will be discussed when making practice recommendations.
DISCLAIMER
The views and opinions expressed in this educational
activity are those of the faculty and do not necessarily
represent the views of Evolve Medical Education LLC, The
University of Houston, Regeneron Pharmaceuticals, or
Advanced Ocular Care.
Go to evolvemeded.com/online-courses/co-managing-thediabetic-patient-supplement to view the online version of
the supplement and to evolvemeded.com/online-courses/comanaging-the-diabetic-patient-webinar to view the archived
webinar.
PRODUCT USAGE IN ACCORDANCE WITH
LABELING
Please refer to the official product information for each
product for discussion of approved indications, contraindications, and warnings.
GRANTOR STATEMENT
This COPE CE Activity is supported through an unrestricted educational grant from Regeneron Pharmaceuticals.
SEPTEMBER 2016 SUPPLEMENT TO ADVANCED OCULAR CARE 3
Integrated Care for the Diabetic Patient:
How to Diagnose and Manage the At-Risk Patient
Diabetes is increasing at epidemic proportions, and optometry as a profession has an opportunity to play an important role as part of the
health care team in educating patients about the ocular consequences of diabetes. Yet, there may be even greater potential for optometrists
to serve as educational resources for patients about diabetes in general and to encourage healthy lifestyle choices that have been proven
to have an impact on overall health. Many of the complications of diabetes can be avoided if patients have an understanding about their
disease, and if they diligently follow-up with their health providers. As optometrists, we are uniquely situated to encourage positive, proactive
behaviors that can literally help save lives and lower diabetes-associated morbidity. Every patient encounter with an optometrist represents
an opportunity to conduct an eye exam and, more generally, to educate about A1C levels and the merits of proper glucose control. Thus, the
eye care practitioner is safeguarding the vision of patients while attending to their general medical needs. In the roundtable discussion that
follows, a renowned panel of optometrists with a particular interest in diabetic eye disease share their insights on the epidemiology of diabetic
eye disease and opportunities for optometrists to become involved in the holistic care of their patients.
—Mark Dunbar, OD, moderator
Mark Dunbar, OD: Let us start by reviewing the epidemiology of
diabetes and diabetic eye disease. It has been estimated that about
400 million people worldwide are currently living with diabetes.1
According to the Centers for Disease Control and Prevention (CDC),
there are about 30 million individuals in the United States alone with
diabetes and a great many number of individuals living with the disease who have not yet been diagnosed2—and these figures do not
even account for those with prediabetes and those at high risk for
developing it.3 The CDC estimates the prevalence in the United States
to be about 9% to 10% of the population.2 By 2050, as many as 20%
to 33% of Americans will have diabetes.2 To put it mildly, these numbers are staggering.
Leo Semes, OD: When we think about patients with diabetes,
its important to remember that the eye might be a sentinel for
microvascular complications occurring in other parts of the body.
We have the ability and training to detect those that occur in the
eye, but when we do, that should be a warning signal to the patient
to be aware that other vascular changes may be occurring. Sadly, I
perceive a general lack of awareness and perhaps some denial from
patients about the implications of diabetes on vision and, consequently, their health.
Steven G. Ferrucci, OD: That denial and lack of awareness may
extend to providers as well. The data that has been cited should raise
alarm bells, and yet, I am continually surprised when optometric colleagues tell me that they do not see patients with diabetes. But, when
10% of the population has diabetes, my question is, how can you be
in regular clinical practice and not see a patient with diabetes? And
so, I think there is education that can be provided for patients, but I
think providers would benefit as well.
Dr. Dunbar: That is an important point, especially with the advent
of treatment options that can help save patients’ vision. Back in the
era of laser photocoagulation and panretinal photocoagulation (PRP),
the goal was to try to stop or slow the progression of proliferative
disease. For patients with diabetic macular edema (DME), the goal
was to stabilize or maintain their current visual function. In the current era of therapeutics, we actually can see an improvement in visual
function. There is an increased awareness that earlier referral in the
course of diabetic retinopathy (DR) and, consequently, earlier intervention can potentially stop and stabilize the DR. The result is that
we are no longer talking about slowing vision loss, but actually being
able to improve the visual acuity. In theory, knowing that patients
can have better visual outcomes should drive screening efforts to
identify patients in need of referral; in practice, however, fewer than
50% of patients even get an annual eye exam.4 Yet, that also speaks to
an opportunity, because optometrists are perfectly situated to be at
the forefront for eye care. Whether practitioners seize on that opportunity will depend on whether they have a heightened awareness
of diabetes complications, an appreciation for the ramifications and
complications, and willingness to be better educators for patients.
A. Paul Chous, OD: I have a different perspective on this topic. I
developed type 1 diabetes when I was 5 years old and have been living
with diabetes for about 48 years. I was diagnosed with proliferative retinopathy during my last year of college and subsequently underwent
PRP. Having experienced this disease from the patient side, I really
became interested in working with patients in my practice who have
diabetes. And so, about 80% to 90% of my patients have diabetes.
Something that I have become acutely aware of is that there are
about 90 million Americans with prediabetes, the majority of whom
are going to develop type 2 diabetes without intervention,3 and the
best way to not go blind from diabetes is not to get diabetes in the
first place. By the time someone gets diagnosed with type 2 diabetes,
about 60% of the pancreatic cells that produce insulin are not functioning.5,6 Furthermore, the average patient has already had diabetes
a mean of 6.2 years by the time of diagnosis.7 These data suggest that
we are not doing a very good job at preventing diabetes, and we are
also not doing a very good job at identifying it early and preventing
vision loss. Importantly, there are implications to this beyond the eye,
as numerous studies show that patients who develop ocular complications of diabetes are at heightened risk for cardiovascular disease
and death.8
Dr. Dunbar: There has been some indication lately that the incidence of new cases may be declining. The CDC reported 1.4 million
in 2014, which is down from 1.7 million new cases in 2008.2 Is that the
reality in the community?
Dr. Chous: I have seen those numbers, but there may be important context. First, I am not sure that a net drop in 300,000 new
cases overall is that meaningful. I get the sense that I am seeing
more people with diabetes, and that could be from greater disease
awareness in my community. Second, although incidence is going
down, prevalence is continuing to climb, and the United States is
not alone. The rate of diabetes growth in the United States is actually dwarfed by growth in new cases in the Middle East and in East
Asia.1 The third thing I would point out is that consensus guidelines
suggest that targeted screening should really occur for individuals
older than 40 years, but the follow through on those recommendations is really inconsistent.9 I wonder if better screening would actually lead to higher reporting rates. Another factor to consider is the
dietary habits of the average American and how that may contribute
to future diabetes cases. Although obesity is often cited as a major
contributing factor, the effect of sugar consumption may have a more
direct consequence. Rates of diabetes go up astronomically as per
capita sugar consumption goes up.10 According to the International
Diabetes Federation, there is a 1.1% increased prevalence of type 2
diabetes for each additional 150 Kcal consumption of added sugars
(the equivalent of one additional can of Coca-Cola consumed by each
person.)9 In the United States, that translates to an additional 3.7 million additional cases of diabetes. So, while the surveillance numbers
suggest a dropping incidence, there is every chance that trend will
reverse, and do so very dramatically, if there is not better education
about the connection between added sugar, particularly high fructose corn syrup, and risk of metabolic consequences. There are more
than 300 studies linking high fructose corn syrup to increased rates of
metabolic syndrome and type 2 diabetes, and yet it continues to be
consumed in voluminous amounts in the average American diet. To
be honest, that does not make me optimistic that we will witness a
decreased diabetes incidence in the coming years, especially because
health disparities in different populations are a factor. For example,
diabetes rates continue to go up much more in communities of color
and, especially in people of lower socioeconomic status.11
Dr. Dunbar: Those population disparities are important, and
there may be other factors that impact our ability to change the paradigm on an individual level. Numerous studies have suggested that
tight glucose control coupled with exercise and diet can help avoid
complications of diabetes. As optometrists, we should certainly be
advocating to patients to monitor their A1C levels, to eat properly,
and to exercise frequently. However, there may be daily struggles in
the life of the diabetic patient that providers may not be aware of.
The average patient with diabetes has 24 health care encounters per
year,12 and he or she may be confronted with a lot of well-meaning
individuals all trying to convey important information. That kind of
information overload can be a detriment at times. I imagine there
may be many things that can serve as barriers to effective disease
management. Remember that with each doctor visit, it may mean
more time away from work, another copay, or relying on somebody
to provide transportation.
Dr. Chous: From the patient’s perspective, it is simply much easier
to function when your blood glucose levels are higher. Tight blood
glucose control, although medically beneficial for prevention of
long-term complications, can have a negative impact on quality of
life precisely because it is significantly more likely to result in acute
hypoglycemia, the consequences of which severely impact quality
of life. Low blood sugars make you tired and affect cognitive performance, making it difficult to perform at work. Hypoglycemia also
affects one’s ability to drive safely and engage in pleasurable activities, including sex. In some ways, it makes sense in the short term, to
let your blood glucose levels remain high. When we are speaking to
patients, especially those on insulin and sulfonylurea agents, I think
there is tremendous value in addressing this issue head on, to let
them know we sympathize, but that there are strategies for dealing with hypoglycemia, including use of the newest technologies
like continuous glucose monitoring devices, and manipulation of
medication dosage and timing. We need to emphasize the long view,
that we want them to be able to see and be viable in 20 years and
beyond. We have to really talk about trying to prevent diabetes or
reverse it early on. There are strategies for doing that, which can be
very life altering and effective.
PATIENTS’ EDUCATION
Dr. Dunbar: We have established that there are many barriers to
educating patients, but one of the biggest we face is getting access to
patients early in the treatment course when we have the best chance
of being successful. What kind of education does everyone provide to
the patient with newly diagnosed diabetes or to those early in the disease course to encourage long-term follow-up? Do you have any tips
for framing the message to make it resonate?
Jay M. Haynie, OD: I stress two messages to patients who are
referred with newly diagnosed diabetes, and you have to put the message in terms they will understand and appreciate. I tell patients that
seeing them early in their disease is like planning for retirement. If you
want to have money for your golden years, you start when you are
25. In the same way, controlling your diabetes now is an investment
on the future of having a relatively healthy life. When it comes to the
A1C levels, I use an analogy of driving the speed limit: having a hemoglobin A1C value of 9.5 is like driving 95 miles an hour. You might get
away with it for a while, but you are risking something catastrophic
happening. It is far safer to drive the speed limit, and it is much safer
to have the A1C level at a lower level.
Dr. Ferrucci: Unfortunately, a lot of patients do not seek a medical opinion until there has already been a catastrophic event. Often
times, it is too late to have a meaningful benefit. This has been studied, and the main reasons people often cite is lack of money or insurance and that “I don’t need it.”13 Each of those is unfortunate, but
the latter of the two shows us once again that there is tremendous
opportunity for optometry. Our profession is the primary care provider (PCP) of eye care, and it is critically important that we educate
patients about the fact that we need to start seeing them when their
vision is still good so that we can avoid vision loss.
Dr. Dunbar: The concept of the optometrist as the PCP in eye
care is one that has been discussed for years. But how do we make
that practical? In terms of diabetes care, are there barriers to collaboration with the other members of the patient’s health care team?
Dr. Semes: There are barriers, to be sure, but there are also factors
working in optometry’s favor when it comes to collaborative care.
One of the new performance metrics for physicians caring for diabetic
patients is whether an annual eye exam has been performed. In fact,
the Centers for Medicare & Medicaid Services (CMS) has issued a
Potential General Practice/Family Practice Preferred Specialty Measure
Set that includes quality measures for dilated fundus exams among
diabetic patients.14 Slowly but surely we are seeing the referral pattern
follow that guidance. Another helpful tool is that professional organizations like the American Optometric Association have created formalized information sheets that are intended to encapsulate the exam
findings for sharing with other members of the health care team.
Dr. Haynie: One of the barriers I see regularly is that many in
internal medicine may not be aware of new classification systems for
diabetic eye disease. Thinking in terms of nonproliferative (NPDR) or
proliferative DR (PDR) is not really relevant anymore, and instead we
discuss DR in terms of mild nonproliferative, moderate, severe, or very
severe. Where that becomes critically important is in our ability to
intervene and affect visual outcomes, but also in the ability to encourage patients to gain control of A1C to slow the rate of progression of
retinopathy. One thing I do regularly is to share the fundus photography with the other health care providers to demonstrate the clinical
presentation in a recognizable format.
Dr. Dunbar: We have data suggesting a surge in new cases in the
not too distant future to the point that patients who need to be seen
by the eye care provider may not have access for all the reasons we
have already discussed. Are there opportunities through telemedicine
programs at the time when the patient sees their endocrinologist or
internal medicine doctor?
Dr. Semes: There will come a time when that kind of screening
occurs, with interpretation at a reading center. The technology for
sharing images and the speed of information transfer suggest we
are close.
Dr. Chous: There is undoubtedly a workforce shortage to provide
proper care to every patient with diabetes, so retinal imaging will
become more critical, especially in areas where access to a provider
is limited. However, information transfer between providers must be
a two-way street and something we need to stress to our colleagues
is the importance of writing a consultation report and getting the
patient’s permission to send that report back to the PCP or endocrinologist. This really should be done every time, even if the exam
findings are seemingly innocuous. That serves the patient, but it also
reinforces the connection between systemic diabetes management
and eye findings. Conversely, PCPs and endocrinologists should send
us a note concerning each patient’s individualized metabolic goals,
something that rarely happens in my experience.
Dr. Dunbar: What would you say to the practitioner who is “just
too busy” to prepare those reports? And what about the optometrist
who practices in a retail setting, does he or she have any opportunity
to participate in the care of diabetes patients?
Dr. Chous: There are differing levels of participation. At a minimum, patient handouts are a form of education, and they can be
valuable. The National Diabetes Education Program has a nice pocketsized pamphlet for patients and providers to record adherence to
dilated eye examinations, dental exams, etc. I also think every optometrist should be doing retinal imaging, regardless of his or her setting.
But I also believe an efficient system of communication for use with
other providers is not that challenging to design and implement.
Dr. Haynie: In our practice, we place a huge emphasis on correspondence, because we live and die by referrals as a tertiary care
practice. Efficiency is key: be short and to the point, because not only
are we busy, but so are the PCPs and endocrinologists. In the age of
electronic records and templates, it is rather simple to convey the
essential information: What is the level of severity? When are you seeing the patient again? How is their vision doing? What are the complications that you are trying to manage?
IMAGING AND THE STANDARD OF CARE
Dr. Dunbar: Something that is stressed repeatedly, but probably
not enough, is that every individual with diabetes needs an annual
dilated fundus examination. This is standard of care. But is that being
followed in practice?
Dr. Semes: We definitely teach that to our students. However,
those who practice more in a retail setting may not have a great deal
of experience in interpreting the fundus photograph. The training
is one thing, and whether that training and expertise is maintained
over a practice lifetime may be a different question. The kinds of
tools available from CMS, which I mentioned earlier, are helpful for
reinforcing this notion.
Dr. Chous: I agree, but I would add that there are options if time
and/or understanding of the disease is problematic. For example, the
entire eye examination does not need to occur in a single visit. It is
perfectly acceptable to bring the patient back for more specialized
care if he or she requires it. Another strategy is an intraprofessional
referral to another optometrist who is more comfortable with managing patients with diabetes and diabetic eye disease.
Dr. Dunbar: Where I practice in Florida, optometry state law
requires that patients have a dilated fundus exam during the initial
visit. We all recognize the importance of that, especially in the individual with diabetes. Yet, we have entered an era with unprecedented
imaging capabilities. Are there viable alternatives to the dilated fundus examination?
Dr. Ferrucci: I see the role of imaging as complementary to the
retinal examination. I occasionally see things on photographs I am
not able to detect on clinical exam, and so I think there will always
be a role for imaging. Very often, I gain valuable insights from
ultra-widefield imaging, but I do not think that it can replace a
dilated retinal examination. A dilated retinal exam is still the standard of care for diabetic patients. That may change in the future
with better technology, but at this point, I look at retinal imaging
as an adjunct.
Dr. Haynie: I think complementary is the key word, because
whenever possible we want to know where the retinopathy originates. A lot of patients develop ischemic retinal disease that may not
be captured on a retinal photograph of the posterior pole or during
the examination. It may appear as hemorrhages in the far periphery.
The dilated fundus exam provides the ability to look at live tissue,
and when those findings are correlated with photographs and ultrawidefield imaging, that is how patients get the best care.
Dr. Ferrucci: There was a study several years ago that showed that
only 50% of eyes were correctly classified for the presence and severity
of retinopathy through an undilated pupil.15 Granted, the technology
has gotten better now, but the issue is the same: You are going to
miss important findings if you do not dilate the patient.
Dr. Dunbar: Just to play devil’s advocate, is there a possibility that
the quality of the cameras we have access to is now better than the
quality of the practitioner who is looking? What about the patient
who may be photosensitive, in whom a good dilation may not be
possible, or perhaps there is a cataract or other media opacity? Would
a fundus photograph be better in that situation?
Dr. Ferrucci: I think you make an excellent point, but that is also
why you do both the dilated exam and imaging. I use a scanner
system in my practice that has a confocal light source to penetrate
through cataracts and other media opacities. It takes remarkable
images of the fundus. Yet, it has its limitations, as well, so I think you
have to do the retinal imaging in conjunction with an actual physical
examination.
Dr. Dunbar: Dr. Chous, what is the role of imaging or fundus
photography in your practice? How do you utilize it in the patients
with diabetes?
Dr. Chous: I perform imaging in every single patient I see. I dilate
every single patient with diabetes at least annually, and I also take
images. Why? Because there have been a number of occasions
where I have picked up things, especially small microaneurysms, that
I did not identify in the clinical exam. In that vein, I use multimodal
imaging, so I use optical coherence tomography (OCT) at baseline
for every patient with diabetes, regardless of whether I see DME
on exam, because on occasion I will find subclinical DME. Those
are exactly the patients that need to be followed more closely and
counseled on A1C control, blood pressure, smoking cessation, and
sleep apnea. Imaging also helps me to educate patients and nonophthalmic providers.
Dr. Dunbar: Dr. Haynie, how do you use imaging in your setting of
a tertiary care clinic?
Dr. Haynie: When it comes to evaluating patients with diabetes,
there is nothing better than a dilated examination. We probably do
less fundus photography for routine care of patients with diabetes,
because many of the patients that we see already have some level
of retinopathy. However, fundus photography still has an important
role, because with retinal photography you introduce the ability to
compare images over time and compare for change. We use OCT
very similarly to how Dr. Chous does it, to look for subclinical pathology that, in many cases, triggers a decision to initiate treatment.
Dr. Chous: Dr. Haynie, would you agree there is an educational
benefit for the patient to see his or her own eyes? I find that imaging is an opportunity to show a patient his or her own eye and a
picture of an abnormal eye, and then to say, this is what we are trying to prevent.
Dr. Haynie: No question. Digital imaging, OCTs, are the best educational resource for patients, because you can show them the comparison between the eyes. Hands down, the greatest benefit of retinal
photography is education of the patient.
Dr. Ferrucci: I disagree on the educational value of imaging. I am
just not convinced that patients really understand the message when
you show them an OCT or a photo.
Dr. Semes: I have to agree with Dr. Ferrucci to some extent. The
analogy I will use is a personal story. I had a meniscus tear in my knee
a few years ago. I got an MRI and the orthopedist showed them to
me on his light box and told me it looked grossly abnormal, but I did
not have the context to understand what he was explaining. In the
same way, I am not sure patients have the interest in understanding
the photos and OCT images we may be showing them. They just
want to know if they are going blind or not and whether there is a
treatment for a particular tissue alteration even if it is vision-threatening, for example.
Dr. Dunbar: Something that is often discussed in this context is
whether OCT should be performed routinely on all patients with
diabetes. The educational merits could be debated, but there may be
clinically valid reasons for OCT screening.
Dr. Chous: Studies suggest that 25% to 30% of DME is not detected by clinical examination but it is picked up with spectral domain
(SD) OCT.16 I think that is an argument for routine use of SD-OCT
in patients with diabetes. It is undeniably the most sensitive tool for
detecting DME.
Dr. Ferrucci: But what percentage of those 25% actually need
treatment? I am not sure that OCT will necessarily change the course
of treatment. The clinical examination is much more likely to change
the management plan.
Dr. Chous: From a treatment standpoint, you certainly have a
point. I would point out that studies also show that patients with
subclinical DME are about three times more likely to progress on to
foveal-involved DME.17 My rationale for OCT is that I want to identify
those cases so I can provide education and so I know whom I need to
see back in the clinic on a more frequent basis, even if he or she does
not need treatment immediately.
Dr. Haynie: I am an advocate of using the technology we have at
our disposal to identify patients before they develop symptoms. You
cannot counsel or treat what you do not see, so if you have patients
with subclinical edema, you may not treat it, but you can certainly
counsel, tighten up follow-up, and educate on getting the glucose
under control and their blood pressure down.
TIPS FOR THE CLINICAL EXAM
Dr. Dunbar: What do you look for during the clinical examination
of the patient with diabetes?
peripheral retina for any signs of NPDR, dot and blot hemorrhages,
intraretinal microvascular abnormality (IRMA), cotton wool spots,
and exudates. I pay particular attention to the optic nerve head,
because that is the most likely site of neovascularization, indicating
PDR. Neovascularization can sometimes be very subtle, but is critically
important to detect early.
Dr. Dunbar: Do you classify based on the Early Treatment Diabetic
Retinopathy Study (ETDRS) guidelines25 in terms of mild, moderate,
severe, nonproliferative disease? Or do you use preproliferative, proliferative, etc?
Dr. Ferrucci: It is pretty well established that the ETDRS scale is
more sensitive and will help predict when patients need to be seen
back in the clinic. As we think about sending patients to endocrinology or to retinal specialists, I think it behooves us to use the most
up-to-date nomenclature to show that we are actually up-to-date on
our exams as well.
Dr. Dunbar: Any other thoughts on the ocular examination?
Dr. Semes: I look carefully at the macula for anything that might
be vision threatening, especially in the context of a refractive shift or
a change in vision. Even if the refraction is 20/20, I will be concerned
if the patient reports vision that is even a little bit off, especially in the
absence of any media opacity. I should mention that while my exam
is focused on the macula, I am not ignoring the periphery. There is
emerging evidence that the peripheral retina may either be an early
site of foveal-involving disease, or that it may contain clues to particular disease characteristics of DME that affects the macula.26
Dr. Dunbar: Fluctuating blood glucose can be a cause of
changes in refractive error and the high incidence of cataracts and
glaucoma has been well described in this population. There is also
a great deal of dry eye incidence in patients with diabetes. What
about the diabetes component? What is important to note during
the ocular examination?
Dr. Chous: I look for things that threaten my patients’ vision
immediately. The things we have to be very concerned about include
vitreous hemorrhage, neovascularization of the disc, and centerinvolved macular edema. Microaneurisms and hemorrhages are
indications to see the patient back sooner than later, and I routinely
use the ETDRS 4-2-1 rule to determine if patients have severe NPDR
that accelerates my referral to a retinal specialist for anticipated future
treatment. I agree with Dr. Semes that we are learning more about
the importance of peripheral disease, including that patients with
predominantly peripheral lesions are dramatically more likely to progress to proliferative disease.26 Recent papers coming out of the Joslin
Diabetes Center showed there was nearly a five-fold increased risk of
PDR, and that these predominantly peripheral lesions are associated
with retinal nonperfusion, the most important etiology for proliferative disease.
Dr. Ferrucci: Before I see the patient, it is useful to know how
long the patient has had diabetes and to what extent the hemoglobin A1C is under control. Both of those are risk factors for retinopathy, with longer duration strongly positively correlated to risk
of retinopathy.18-20 The correlation with uncontrolled A1C levels is
also well established.21-24 Then, I want to perform a comprehensive
ocular exam with dilation, looking closely at the posterior pole and
Dr. Haynie: Ischemic diseases cause pupil reaction to be more
sluggish over time, and so I check the reactivity of the pupil. I spend
the majority of my exam looking at the retinal vasculature, because
that is where ischemic findings begin with venous beading, IRMA,
and, eventually, proliferation with neovascularization. The nasal
fundus tends to develop ischemic retinal changes in comparison
to superior, inferior, and temporal. I am not as concerned with the
Dr. Ferrucci: The first comment I would make is that while we are
obviously concerned with the retinal disease, there are often many
ocular comorbidities in patients with diabetes, whether it is refractive changes, risk for glaucoma, or even sluggish pupils. Patients with
diabetes have other ocular complications that we can look for in a
complete comprehensive exam.
classification clinically significant macular edema; rather, whether
or not it is center involved or threatens the fovea is much more
important. I want to know if there are hard exudates with an area of
retinal thickening within 500 µm of the fovea because that will factor heavily in a decision to start treatment. Without intervention in
such cases there is a chance of vision loss.
Dr. Dunbar: When should the referral to a retina specialist occur in
a patient with noncenter involved DME? Is that ever something that
can be monitored off treatment or is that a trigger for a referral?
Dr. Haynie: The management of DR is going to involve a relationship with a PCP and then a tertiary care provider or a retina specialist.
There may be value in introducing patients to the various providers
in the eventual team early in the course to build familiarity. When
considering whether to refer, a bigger question may be “what is the
biggest risk to the patient based on the proposed course of action?”
There may not be rationale to treating a patient with noncenter
involved DME who is 20/20 and nonsymptomatic with an anti-vascular endothelial growth factor (VEGF) agent, because the worst thing
that is going to happen is endophthalmitis. When it comes down to
a referral decision, I think the practitioner has to be very comfortable
with his or her comfort level in detecting complications. If there is any
discomfort, there is an obligation to find someone who is confident,
whether that is an intraprofessional referral or somebody else who
can follow the patient.
Dr. Dunbar: What about the patient with DR? Guidelines from
the American Optometric Association27 and the American Academy
of Ophthalmology28 are clear on what is needed for these patients
whether it is mild or moderate NPDR: annual examination, education about A1C levels, explaining the risk factors, and making sure the
endocrinologist or PCP is aware of the changes. For severe NPDR, we
should be aware of the greater risk for proliferative disease,23 hence
the need to see these patients every 3 to 4 months. I wonder what the
general comfort level is in the community, however.
Dr. Semes: I think there is probably a tendency to over refer for
fear of a patient losing vision. No one wants to be the last person to
see a patient who loses vision.
Dr. Dunbar: My belief is that there is a comfort level monitoring patients up to moderate NPDR, but as it gets more severe, that
is when a referral becomes more likely, and for good reason. As we
move forward there may be an emphasis among retinal specialists to
treat earlier with anti-VEGF.
Dr. Semes: Recognizing when someone goes from moderate to
severe to very severe is not easy, especially if patients get inconsistent
with their follow-up appointments. It is worth pointing out that
patients with diabetes have a lot of health care visits throughout the
year. When it comes to the eye examination, if he or she does not
perceive any visual symptoms, the appointment may be skipped.
That could be from exhaustion secondary to dealing with so many
providers for so many things, or it could be for any number of reasons. Yet the risk is the same: the progression will have occurred but
there was not an examination performed to detect it.
Dr. Haynie: I would agree with that. I also think there may be some
over referring to our practice, but that may not be the worst thing
for the patient. My personal advice to referring doctors in the community is to develop their own comfort level. That said, I encourage
my referral network to think about referring severe NPDR, the reason
being that our practice has started offering anti-VEGF treatment to
those patients under the premise that there is no reason to wait until
it progresses to proliferative disease before intervening. Anti-VEGF
drugs have completely changed the treatment paradigm and the
thinking now is to be much more aggressive to slow or prevent progression and save vision—and that may be all the reason we need to
suggest earlier referral.
Dr. Semes: Early treatment has really become fundamental to
improving outcomes. Peripheral ischemia on fluorescein angiography
is another potential trigger to start treatment.
Dr. Haynie: The pattern of earlier referral is actually evident in
other parts of the health care system. Endocrinologists are encouraged to refer to the podiatrist earlier in the disease. Why? Because the
podiatrist can take care of complications. Because the system works
best when all parties get involved early in the disease as opposed to
waiting until an irreversible catastrophic event has occurred. And so,
I fully respect my colleagues who send patients early just to meet the
members of the health care team who are going to take care of them
to gain a comfort level.
Dr. Dunbar: Dr. Chous, what is your protocol for observing
your patients?
Dr. Chous: With no findings or a minimal amount of NPDR, I want
to see the patient back annually. In terms of risk factors for developing severe disease, the duration of diabetes is critically important, as
well as the current hemoglobin A1C, the variability of A1C over time,
and average blood glucose level and blood pressure. The risk of severe
vision loss from diabetes is halved by lowering the systolic pressure
from 154 to 144.29 Another thing that is important is the history of
metabolic control since the time of diagnosis because of so-called
metabolic memory. Patients who gain good control early on are less
likely to develop sight-threatening disease, even if blood sugar control
worsens over time. There may be more subtle signs that can serve as
clues to other comorbidities that we can detect as well. For example,
if I observe that the patient has a large neck circumference and the
patient or spouse reports snoring, I always suggest a sleep study
because obstructive sleep apnea is associated with DME.30
Dr. Dunbar: When do you refer a patient with DR?
Dr. Chous: I agree with what was stated earlier, that there is inherent value in referring a patient who will likely need specialty care to
become familiar with the rest of the members of the health care team
who will be treating that patient later on. Here we are talking about
a referral to a retina specialist, but I think it is equally as important to
suggest an endocrinologist if the patient is currently only under the
care of a PCP and has chronic, suboptimal diabetes control. As we
talked about earlier, the optometrist can be an important connector
in the health care team and a source of valuable information about
good diabetes control and reduced risk of complications.
greatest opportunity is to help patients live long, meaningful lives
through a better understanding of their systemic disease. We can
encourage their active participation in the management process to
effect more favorable outcomes. As optometrists, our opportunity is
to impact the quality and the quantity of our patients’ lives. Perhaps
there is an argument to be made that we should replace the word
opportunity with obligation so as to really drive home the important
role we can play in the total health and well being of our patients. n
Dr. Dunbar: A1C can be a complicated topic to broach with
patients without the proper background. Are there resources or
tools optometrists can use to familiarize themselves and share
with patients?
1. WorldHealthOrganization. Global Report onDiabetes2016. http://apps.who.int/iris/bitstream/10665/204874/1/WHO_NMH_
NVI_16.3_eng.pdf. AccessedJuly15, 2016.
2. Centersfor DiseaseControl andPrevention. DiabetesReport Card2014. cdc.gov. http://www.cdc.gov/diabetes/pdfs/library/
diabetesreportcard2014.pdf. AccessedAugust 3, 2016.
3. Ligthart S, vanHerpt TT, LeeningMJ. Lifetimeriskof developingimpairedglucosemetabolismandeventual progressionfrom
prediabetestotype2diabetes: aprospectivecohort study. Lancet Diabetes Endocrinol. 2016Jan;4(1):44-51.
4. Centersfor DiseaseControl andPrevention. KeepanEyeonYour VisionHealth. cdc.gov. http://www.cdc.gov/features/healthyvision.
Last updated: May4, 2016. AccessedJuly15, 2016.
5. LarsenMO. Beta-cell functionandmassintype2diabetes. Dan Med Bull. 2009;56(3):153-164.
6. Meier JJ, BonadonnaRC. Roleof reducedβ-cell massversusimpairedβ-cell functioninthepathogenesisof type2diabetes. Diabetes
Care. 2013;36(Suppl2):S113-S119.
7. PortaM, CurlettoG, CipulloD. Estimatingthedelaybetweenonset anddiagnosisof type2diabetesfromthetimecourseof retinopathyprevalence. Diabetes Care. 2014;37(6):1668-1674.
8. JuutilainenA, LehtoS, RönnemaaT, et al. Retinopathypredictscardiovascular mortalityintype2diabeticmenandwomen. Diabetes
Care. 2007;30(2):292-299.
9. BeckmanTJ. Regular screeningintype2diabetes. Amnemonicapproachfor improvingcompliance, detectingcomplications.
Postgrad Med. 2004;115(4):19-20,23-27.
10. BasuS, YoffeP, HillsN, LustigRH. Therelationshipof sugar topopulation-level diabetesprevalence: aneconometricanalysisof
repeatedcross-sectional data. PLoS One. 2013;8(2):e57873.
11. LinkCL, McKinlayJB. Disparitiesintheprevalenceof diabetes: isit race/ethnicityor socioeconomicstatus? ResultsfromtheBoston
AreaCommunityHealth(BACH) Survey. Ethnicity & Disease. 2009;19(3):288-292.
12. KissS, LiuY, BrownJet al. Clinical utilizationof anti-vascular endothelial growth-factor agentsandpatient monitoringinretinal
veinocclusionanddiabeticmacular edema. Clin Ophthalmol. 2014;8:1611-1621.
13. ChouCF, SherrodCE, ZhangX, et al. Barrierstoeyecareamongpeopleaged40yearsandolder withdiagnoseddiabetes, 20062010. Diabetes Care. 2014;37(1):180-188. 14. Centersfor Medicare&MedicaidServices. Potential General Practice/FamilyPracticePreferredSpecialtyMeasureSet. cms.gov.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/Potential_General_Practice_
Family_Practice_Specialty_Measure_Set_07_01_2014_508.pdf. AccessedAugust 3, 2016.
15. KleinR, KleinBE, Neider MW, et al. Diabeticretinopathyasdetectedusingophthalmology, anonmydriaticcameraandastandard
funduscamera. Ophthalmology. 1985;92:485-491.
16. TrichonasG, Kaiser P. Optical coherencetomographyimagingof diabeticmacular oedema. Br J Ophthalmol. 2014;98:ii24-ii29.
17. DiabeticRetinopathyClinical ResearchNetworkWritingGroup. Observational studyof subclinical diabeticmacular edema. Eye
(London). 2012(6):833-840.
18. KleinR, KleinBE, MossSE, et al; TheWisconsinEpidemiologicStudyof DiabeticRetinopathyII. Prevalenceandriskof diabetic
retinopathywhenageat diagnosisislessthan30years. Arch Ophthalmol. 1984;102:520-526.
19. VarmaR, TorresM, PenaF, et al. Prevalenceof diabeticretinopathyinadult Latinos: TheLosAngelesLatinoEyeStudy. Ophthalmology. 2004;111:1298-1306.
20. KleinR, KleinBE, MossSE, et al; TheWisconsinEpidemiologicStudyof DiabeticRetinopathyIII. Prevalenceandriskof diabetic
retinopathywhenageat diagnosisismorethan30years. Arch Ophthalmol. 1984;102:527-532
21. UKProspectiveDiabetesStudy(UKPDS) Group. Intensiveblood-glucosecontrol withsulfonylureasor insulincomparedwith
conventional treatment andriskof complicationsinpatientswithtype2diabetes. Lancet. 1998;352:837-853.
22. UKProspectiveDiabetesStudyVIII. Studydesign, progress, andperformance. Diabetologia. 1991;34:877-890.
23. DavisMD, Fisher MR, GangnonRE, et al. Riskfactorsfor high-riskproliferativediabeticretinopathyandseverevisionloss: Early
Treatment DiabeticRetinopathyStudyreport number 18. Invest Ophthalmol Vis Sci. 1998;39:233-252.
24. KilpatrickES, RigbyAS, AtkinSL, Frier BM. Doesseverehypoglycemiainfluencemicrovascular complicationsintype1diabetes? An
analysisof theDiabetesControl andComplicationsTrial database. Diabet Med. 2012;29:1195-1198.
25. EarlyTreatment DiabeticRetinopathyStudyResearchGroup. Gradingdiabeticretinopathyfromstereoscopiccolor fundusphotographs—anextensionof themodifiedAirlieHouseclassification. ETDRSreport number 10. Ophthalmology. 1991;98:786–806.
26. SilvaPS, CavalleranoJD, HaddadNMN, et al. Peripheral Lesionsidentifiedonultrawidefieldimagingpredict increasedriskof
diabeticretinopathyprogressionover 4 Years. Ophthalmology. 2015;22:949-956.
27. AmericanOptometricAssociation. Evidence-basedclinical practiceguidelines: eyecareof thepatient withdiabetesmellitus. http://
aoa.uberflip.com/i/374890-evidence-based-clinical-practice-guideline-diabetes-mellitus. PublishedFebruary7, 2014. AccessedAugust
9, 2016.
28. AmericanAcademyof OphthalmologyRetina/VitreousPanel. PreferredPracticePatternGuidelines: DiabeticRetinopathy. http://
www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp-updated-2016. PublishedFebruary2014. AccessedAugust 3, 2016.
29. UKProspectiveDiabetesStudyGroup. Tight bloodpressurecontrol andriskof macrovascular andmicrovascular complicationsin
type2diabetes: UKPDS38. Br Med J. 1998;317(7160):703-713.
30. MasonRH, West SD, KiireCA, et al. Highprevalenceof sleepdisorderedbreathinginpatientswithdiabeticmacular edema. Retina.
2012;32(9):1791-1798.
31. RetinaRisk. Research. http://retinarisk.com/research. AccessedAugust 9, 2016.
32. vBarnoskyAR, HoddyKK, UntermanTG, VaradyKA. Intermittent fastingvsdailycalorierestrictionfor type2diabetesprevention: a
reviewof humanfindings. Transl Res. 2014;164(4):302-311.
33. Klonoff DC. Thebeneficial effectsof apaleolithicdiet ontype2diabetesandother riskfactorsfor cardiovascular disease. J Diabetes
Sci Tech. 2009;3(6):1229-1232.
Dr. Chous: Yes, there are several tools optometrists can become
familiar with to help patients with not only their A1C levels but their
overall quality of life. I am a big fan of a sight-threatening DR risk calculator developed in Iceland and validated in European cohorts31—it
allows you to demonstrate to patients immediately their individualized risk reduction by lowering both A1C and blood pressure. The
website DiabetesInControl.com is a great resource for health care professionals to familiarize themselves with the latest diabetes research.
As I mentioned earlier, continuous glucose monitoring systems
allow the physician and the patient to identify blood glucose problem areas. Patients who wear an insulin pump, who are on insulin
therapy, or who use continuous glucose monitoring systems are less
likely to develop eye disease. They also have lower mortality rates. I
also think it could be valuable to become familiar with the types of
medications patients may be or could be on relative to the hemoglobin A1C control. The newer medications, although expensive, not
only lower blood glucose they also assist with weight loss and appear
to reduce cardiovascular risk. Some severely obese patients may also
benefit from bariatric procedures, and virtually every obese patient
with diabetes will benefit from caloric restriction, especially refined
carbohydrates. There is also emerging evidence that type 2 diabetes
can be reversed early on with intermittent, alternate daily fasting.32
Both the Mediterranean and Paleolithic diets have been shown to
have beneficial effects for individuals with diabetes, to help reduce
dependence on insulin therapy and to lower dependence on blood
pressure medications.33 I think the one thing we can really stress to
our colleagues is that efforts to get patients to gain control of their
diabetes are not just about helping them save vision, it is about helping them save their lives and to lower their risk of a whole series of
potential complications.
CONCLUSION
Dr. Dunbar: Thank you all for your valuable insight. I think this last
point really drives home many of the points we have discussed. We
use the word opportunity a lot to discuss the care of patients with
diabetes. If we recognize the signs of progression early, we may be able
to refer for treatment at a time that is advantageous for saving sight.
If we can encourage patients to gain control of their A1C levels, then
there is an even better chance we help them avoid microvascular
complications, only some of which occur in the eye. Yet, perhaps our
Image Atlas of DR and DME
By Mark Dunbar, OD
The appearance of diabetic retinopathy (DR) and diabetic macular
edema (DME) can be highly variable on the clinical examination and on
imaging studies. Most experts agree that imaging is not independently
A
sufficient for diagnosing or monitoring diabetic eye disease, and that it
serves a complementary role to the clinical examination. Thus, pattern
recognition becomes critically important for making a diagnosis, and
B
Figure 1. Early stage, mild NPDR can have subtle findings on fundus photography (A), but FA shows microaneurysms more definitively than the
clinical exam (B).
Figure 2. Moderate NPDR is more conclusive on fundus photographs.
even more so for discerning change over time.
Early stage, mild nonproliferative DR (NPDR) can have subtle findings
on fundus photography (Figure 1A), although fluorescein angiography
(FA) shows microaneurysms more definitively than the clinical exam
(Figure 1B). The risk for developing proliferative DR (PDR) at 1 year at
this stage is about 5%.1
Moderate NPDR (Figure 2) is more conclusive on fundus photographs, although not as easily identifiable as severe NPDR, which can
be identified following the classic 4-2-1 rule, meaning presence of hemorrhages and macular edema in four quadrants, or significant venous
beading in two, or intraretinal microvascular abnormalities (IRMA) in
one quadrant (Figure 3). The risk for developing PDR in 1 year jumps
from 12% in moderate NPDR, to 52% in severe NPDR, and 72% in very
severe NPDR.1 Optical coherence tomography angiography (OCT-A) is
helpful for identifying capillary dropout, which is in turn useful for identifying ischemic manifestations of the disease process (Figure 4).
Figure 3. Severe NPDR can be identified following the classic 4-2-1
rule.
Figure 4. OCT-A can be helpful for identifying ischemia and possible
capillary dropout.
A
C
B
Figure 5. PDR becomes more obvious to appreciate clinically and on imaging, especially as patterns of neovascularization and preretinal
hemorrhage (A), capillary dropout (B), and florid neovascularization (C) become evident.
A
B
Figure 6. Patterns of macular edema in DME can be appreciated on fundus photography (A) and OCT (B).
Courtesyof JohnKitchens, MD
Figure 7. If imaging is only performed in the central macular, some increase in CRT may be missed. The thickness map on the right shows retinal
thickening superior and inferior to the central macula.
Figure 8. A 5-line raster scan of the macula can be valuable to detect DME.
A
B
C
E
F
G
PDR becomes more obvious to appreciate clinically and on imaging
studies, especially when trying to identify subtle areas of neovascularization, preretinal hemorrhage (Figure 5A), capillary dropout (Figure 5B),
and florid neovascularization (Figure 5C) become evident.
Patterns of macular edema in DME can appear as focal, multifocal,
as a circinate ring of exudate (especially with leakage in center of the
ring), or as diffuse leakage. Such patterns can be appreciated on clinical
examination through a dilated fundus examination, but also on fundus
photography (Figure 6A) and OCT (Figure 6B).
OCT creates high-resolution cross-sectional images of the retina.2
In patients with DR, it can be used to aid in the diagnosis of DME.
It is especially good at at detecting subtle areas of retinal thickening that can be missed on clinical exam.3 OCT has its greatest utility
when multiple scans are used in conjunction. If, for example, imaging
is only performed in the central macular, some increase in central retinal thickness (CRT) may be missed (Figure 7). Thus, in addition to a
D
Figure 9. A patient with severely
ischemic peripheral retina findings
(A). FA images are captured at 11
(B), 14 (C), 17 (D), 23 (E), 32 (F), and
120 (G) seconds, respectively.
three-dimensional rendering of the macula, a 5-line raster scan of the
macula can be valuable (Figure 8).
More recent advances in imaging, such as ultra-widefield imaging, provide additional information that may alter the clinical course.
Ultra-widefield offers a 200° view of the retina, providing insight on
areas that may not be easily imaged with mydriatic or nonmydriatic
fundus photography or OCT. A dramatic example is seen in Figure 9 in
a patient with severely ischemic peripheral retina findings. In particular,
FA on widefield showed clear nonperfusion that is not apparent on
the static photograph. n
1. DavisMD, Fisher MR, GangnonRE, et al. Riskfactorsfor high-riskproliferativediabeticretinopathyandseverevisionloss: Early
Treatment DiabeticRetinopathyStudyreport number 18. Invest Ophthalmol Vis Sci. 1998;39:233-252.
2. Prall FR, OlsonJL, Barnett CJ, MandavaN. Fluoresceinangiography, indocyaninegreenangiography, andoptical coherence
tomography. In: Yanoff M, Duker JS, eds. Ophthalmology. 1991;98(suppl):823-833.
3. AmericanAcademyof OphthalmologyRetina/VitreousPanel. PreferredPracticePatternGuidelines: DiabeticRetinopathy. http://
www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp-updated-2016. PublishedFebruary2014. AccessedAugust 3, 2016.
INSTRUCTIONS FOR CE CREDIT
Cope Course ID: 50824-SD
COPE approved for 2.0 credits
Expiration Date: August 29, 2019
CE credit is available electronically via evolvemeded.com
To receive credit, you must complete the post test and activity evaluation and mail or fax to Evolve Medical Education; PO Box 358; Pine Brook, NJ 07058 –
Fax: (610) 771-4443. To answer these questions online and receive real-time results, please visit www.evolvemeded.com and click “Online Courses.” If you are
experiencing problems with the online test, please email us at [email protected]. Certificates are issued electronically, please provide your email
address below.
Please type or print clearly, or we will be unable to issue your certificate.
Name _________________________________________________________________ OE Tracker Number ________________________________
Phone (required) ________________________________________ Email (required) _____________________________________________________
City ______________________________________________________________ State __________________________________________________
INTEGRATED CARE FOR THE DIABETIC PATIENT: HOW TO DIAGNOSE AND MANAGE THE AT-RISK PATIENT
CE QUESTIONS
1. At diagnosis of type 2 diabetes, about how long has the typical
patient already had the disorder based on the prevalence of DR
at that time?
a. 6 months
b. 2 years
c. 4 years
d. 5 years
e. 6 years
2. Risk factors for developing severe DR and/or DME include which
of the following?
a. long diabetes duration
b. higher glycosylated hemoglobin (A1C)
c. Lack of early, tight blood sugar control
d. Systolic blood pressure > 154 mm Hg
e. All of the above are risk factors
3. What percentage of diabetic patients have an annual dilated
fundus evaluation?
a. 10%
b. 15%
c. 25%
d. 50%
e. 75%
4. An early indicator of DR is often thought to be the appearance
of hemorrhages and microaneurysms. What recent evidence has
been suggested as an alternative indicator?
a. Peripheral vascular alterations
b. Center-involving macular edema
c. CSME
d. Refractive shift
e. Symptoms of peripheral neuropathy
5. Involvement by other health care providers in the care of the
diabetic patient has been supported by guidelines from which of
the following agencies?
a. American Academy of Family Practice
b. American Society of Endocrinologists
c. American Academy of Optometry
d. Centers for Medicare and Medicaid Services
e. American-European Diabetic Care Association
6. Diabetes is estimated to affect approximately:
a. 300,000 Americans
b. 3.0 million Americans
c. 30 million Americans
d. 300 million Americans
7. The CDC estimates that the current prevalence of diabetes in
the United States to be approximately:
a. 1% of the population
b. 10% of the population
c. 50% of the population
d. Greater than 50% of the population
8. Which of the following is a risk factor for retinopathy?
a. The duration of the diabetes
b. The overall A1C level
c. Previous eye disease
d. Both a and b
9. Which of the following have also been associated with diabetes?
a. Refractive changes
b. Increased risk of glaucoma
c. Sluggish pupils
d. All of the above
10. W
hich technology has helped make the diagnosis of DME
much easier?
a. Fundus autofluoresence
b. Hruby lens
c. OCT
d. Fluorescein angiography
11. W
hich technology has helped identify peripheral ischemia in
patients with DR?
a. Widefield fluorescein angiography
b. Fundus autofluoresence
c. OCT
d. Optos retinal imaging
12. W
hat do the preferred practice pattern guidelines of both
AOA and AAO recommend for follow-up of patients with
severe NPDR?
a. 2 weeks
b. 1 month
c. 4 months
d. 6 months
13. A
t what stage can DME be seen?
a. Mild nonproliferative diabetic retinopathy
b. Moderate nonproliferative diabetic retinopathy
c. Severe nonproliferative diabetic retinopathy
d. It can be seen in any stage of diabetic retinopathy
14. W
hat is the most common cause of vision loss in patients
with DR?
a. Macular edema
b. Vitreous hemorrhage
c. Tractional retinal detachment
d. Ischemia
15. W
hat is the average number of doctor visits a patient with
diabetes has per year?
a. 6
b. 12
c. 18
d. 24
16. W
hat is a desired hemoglobin A1C level for a diabetic
patient?
a. < 3
b. 3-5
c. < 7
d. 8-9
17. P CPs are recommended to stress the ABCs of diabetes. What
does the B stand for?
a. Bronchial health
b. Bowel movements
c. Blood glucose level
d. Bad breath
18. W
hat is the estimated prevalence of DME in the US
population?
a. 500,000
b. 1 million
c. 2.3 million
d. Over 10 million
19. W
hat is the role of VEGF in the pathophysiology of DME?
a. Increases vascular permeability
b. Causes capillary dropout and ischemia
c. Decreases neovascularization
d. Increases perfusion to the optic nerve
20. In a patient with severe NPDR, what is the risk of going on to
develop PDR within the next year?
a. 12%
b. 52%
c. 75%
d. virtually 100%
ACTIVITY EVALUATION
Did the program meet the following educational objectives? Determine who is a high-risk patient for the onset of diabetic eye disease
Discuss the importance of conducting yearly dilated exams on diabetic patients
Develop plans to initiate comanagement of the diabetic patient with both ophthalmologists and primary care physicians/endocrinologists
Implement strategies to educate patients on the ocular manifestations of diabetes Agree _____ _____ _____ Neutral _____ _____ _____ Disagree
_____
_____
_____
_____ _____ _____
_____________________________________________________________________________________________________________________
Your responses to the questions below will help us evaluate this CE activity. They will provide us with evidence that improvements were made in
patient care as a result of this activity.
Do you feel the program was educationally sound and commercially balanced? ___ Yes ___ No
Comments regarding commercial bias:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Rate your knowledge/skill level prior to participating in this course: 5 = High, 1 = Low __________
Rate your knowledge/skill level after participating in this course: 5 = High, 1 = Low ____________
Would you recommend this program to a colleague? ___Yes ___No
Do you feel the information presented will improve/change your patient care? ____ Yes ____ No
Please identify how you will improve/change:
____ Change the management and/or treatment of patients. Please specify
_____________________________________________________________________________________________________________________
____ Create/revise protocols, policies, and/or procedures. Please specify
_____________________________________________________________________________________________________________________
Please identify any barriers to change.
____ Cost
____ Lack of consensus or professional guidelines
____ Lack of administrative support
____ Lack of experience
____ Lack of time to assess/counsel patients
____ Lack of opportunity (patients)
____ Reimbursement/insurance issues
____ Lack of resources (equipment)
____ Patient compliance issues
____ Other. Please specify _____________________
____ No barriers

Integrated Care for the Diabetic Patient: How to

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