Last year’s Plenary session, which focused on the World Health Organization’s groundbreaking World Report on Vision, was a wonderful glimpse into the global problems facing eye care. But it was missing something, according to Timothy McMahon, OD, FAAO: it didn’t give attendees something new to apply to their clinical care of patients.
This year’s kick-off Plenary session, “Today's Research, Tomorrow's Practice: A New Look at Some Old Medical Guidelines,” made up for that in spades, according to Dr. McMahon, who moderated the virtual two-hour live lecture yesterday morning. Renowned experts in diabetes, rheumatology and cardiology teamed up to share what’s at stake for patients at risk for systemic issues—and what optometrists can do to help.
Diabetes: A Lifestyle Crusade
First up was Louis Philipson, MD, PhD, the James Tyree professor of Diabetes Research and Care at the University of Chicago, who punctuated his lecture with clinical calls to action. Diabetes has several different definitions and many classifications, but we mostly focus on blood glucose levels, he said. Everyone really should be below 7% HbA1c at least 70% of the time, he emphasized, although each patient may require an individualized goal. Some patients over 70, for example, could have an 8% goal just 50% of the time. “Diabetes is hard, complex and unrelenting,” he said. “I tell my kids all the time, ‘diabetes sucks.’ I’m just as much a coach and a cheerleader as I am a physician for my patients.”
His first call to action was for better patient education about the long-term benefits of glycemic control. Early control can reduce the risk of complications such as heart and renal disease and retinopathy, even if A1c increases in later years, he noted.
|Dr. Philipson shows the audience the staggering numbers that have led experts to consider diabetes an epidemic.|
His next call to action emphasized the importance of education and follow-up for patients with gestational diabetes. “Diabetes in pregnancy is a really interesting subtype, because we think hormones interrupt the body’s ability to absorb insulin, even if enough is being produced,” he explained. These patients are at risk for developing or worsening retinopathy, and they need eye exams during each trimester of pregnancy and follow-up six to 12 months postpartum.
Proper follow-up was crucial to his next call to action too, because patients who exhibit any signs or symptoms of diabetes on clinical exam need follow-up care with their primary care physician and you, the eye doctor. Those with a family history of diabetes, are overweight, are a minority, older than 45 or have a history of gestational diabetes all have a higher risk and need appropriate screening.
Luckily, there’s a lot patients can do to reduce their risk of complications. “Lifestyle changes win, hands down,” Dr. Philipson said. In the American Diabetes Association’s Diabetes Prevention Program Study, lifestyle changes decreased disease incidence by 58% compared with 31% for those on metformin. “Lifestyle had a huge impact—it’s spectacular,” he emphasized, calling on optometrists to encourage patient to enroll in nutrition and physical activity programs that can effectively delay, or even prevent, the onset of Type II diabetes.
Next, he turned to some key in-office pearls, including how to identify patients at risk for a hypoglycemic event. ODs need to have a blood glucose meter in the office and should even consider having single-use lancet devices. If a patient does experience an episode, clinicians should be prepared with rapid-acting carbs at the ready.
So much of diabetes care is multidisciplinary, Dr. Philipson said, turning his attention to the bigger picture. “Everyone who sees that patient is part of the care team, whether it’s the primary care physician—or more often the nurse practitioner or physician’s assistant—the diabetes coach, nutritionist, you name it.” Optometrists have to communicate with the team and share exam findings with the primary care physician, even if retinopathy isn’t noted.
At the end of the day, clinicians have to take a step back and make sure they aren’t focusing on the wrong things. “I don’t call patients ‘diabetics’ anymore,” Dr. Philipson said, referring to a new approach to positive language during patient care. “You aren’t your disease and it doesn’t define who you are.” His final call to action was for optometrists to stay positive. Instead of discussing compliance or adherence, try talking about engagement, participation or medicine-taking instead. See just how much that changes the conversation.
Rheumatology in Your Chair
Lianne Gensler, MD, from the University of California, San Francisco, took over the screen next, jumping to rheumatologic diseases that affect the eye. “It’s a discussion we need to have because optometrists really are on the front lines of this,” she said, noting that ocular complications are often the first manifestations. Her discussion began with a clinical case many optometrists are likely familiar with: a patient presents with new-onset photophobia and eye pain. However, the diagnosis of acute anterior uveitis (AAU) is just the beginning, according to Dr. Gensler. The ocular condition could be due to spondylarthritis, sarcoidosis or Behçet’s disease—and the answer is likely in the patient’s history and bloodwork.
Upwards of 50% of AAU cases are HLA-B27-associated, she noted, and sending patients out for this lab could help narrow the differential considerably. Anywhere from 15% to 50% of patients with spondylarthritis will present with HLA-B27-associated AAU, and that number jumps to more than 70% for those with axial spondylarthritis in particular.
|Dr. Gensler highlights the many ocular findings that could be secondary to rheumatoid arthritis.|
Patient history is also crucial to a diagnosis, Dr. Gensler says. Spondylarthritis, for example, often presents with pain specific to the back and sacroiliac joints. She presented the case of a 26-year-old man with HLA-B27-associated AAU with a past medical history of chronic back pain. With those two criterial alone, there’s a more than 75% chance that his AAU is due to spondylarthritis. “If you send me this patient, I will find the arthritis he never knew he had,” she joked. “If you have an acute anterior uveitis patient, please consider sending them to rheumatology because we would love to see them,” Dr. Gensler added—even if it’s the patient’s first manifestation of AAU.
She then pivoted to rheumatoid arthritis (RA), which shares very little with spondylarthritis when it comes to signs and symptoms. “Rheumatology is like the produce section of a grocery store,” she explained. “You might still be in the same section, but the only thing that’s really similar between a carrot and an orange is their color. Likewise, rheumatologic conditions are very different from one another.”
Dry eye, scleritis, episcleritis and peripheral ulcerative keratitis are all likely ocular manifestations for RA, and joint pain is more specific to the hands and wrists, rather than the back. Also, nearly twice as many women are diagnosed with RA compared with men.
Dr. Gensler spent her final few minutes discussing an oldie but goodie in the optometry world: hydroxychloroquine retinal toxicity. “In rheumatology, we joke that this drug is so safe it should be in the water, and all it really needs is proper eye exams,” she said. While it’s a negotiable treatment for some, it’s critical for those with Lupus, she added. “Treatment can get really tricky for a patient with Lupus who starts showing signs of retinopathy,” she noted.
Part of the reason the drug is so safe is that most of the risk is dose-dependent, and that’s something clinicians can control. Newer guidelines use real body weight, not ideal weight, to calculate safe dosing, and now the real-world risk of retinopathy after five years on hydroxychloroquine is around 7.5%, she said.
“The key here is that every patient starting hydroxychloroquine should have a baseline exam and then proper follow up,” she said. “I’ve often had optometrists give me a call to ask that I reduce a patient’s dosage. Less so now with the new guidelines, but that’s important communication to reduce a patient’s risk.”
The Biggest Threat
The final speaker of the session, Mark Glazer, MD, a cardiologist at Vanderbilt in Nashville, pulled no punches when discussing cardiovascular health. “Cardiovascular disease has been the number one killer in America since 1900, with the exception of one year,” he explained. That one year, ironically, was 1918, the year of the Spanish flu. Not only that, the assumption that it only affects men is a myth, he added. A startling 48% of those over the age of 20 had cardiovascular disease between 2013 and 2016, and researchers speculate 805,000 patients will experience a myocardial infarction this year—170,000 of which will be asymptomatic. “I just find this staggering,” Dr. Glazer said.
He then showed attendees exactly what is happening during a myocardial infarction, punctuated by a recent case of a 64-year-old woman saved by emergency heart surgery to place a stent and re-establish blood flow in the heart. “Nothing is more satisfying for a cardiologist than interrupting a heart attack with this technique and saving a life.”
|Dr. Glazer explains what happens during a myocardial infarction—and how a stent can save the day.|
So, what can optometrists do to protect themselves and their patients from this deadly condition? Not unlike diabetes, the answer lies in lifestyle changes. Mortality rates rose steadily from 1900 until the 1980s, when a better understanding of risk factors led to improved patient education and a focus on healthier living. Dr. Glazer stressed the importance of follow “Life’s Simple 7,” promoted by the American Heart Association (AHA):
- Manage your blood pressure
- Control cholesterol
- Reduce blood sugar
- Get active
- Eat better
- Lose weight
- Stop smoking
These are more important than ever before, he said, noting that the mortality rates due to cardiovascular disease are on the rise again, after a steady decline in the 80s, 90s and early 2000s. Dr. Glazer ended his session with as much of a bang as he started, sharing a music video his department produced to support the AHA’s annual Heart Walk.