A talk on Monday discussed the shifting landscape of diabetic retinopathy (DR) care and how optometrists can secure their place in helping manage DR patients.
During a pivotal time when many primary care doctors are increasing their ability to screen for DR, “optometrists need to keep up, not catch up, with diabetes and diabetic retinopathy,” said Leonid Skorin, Jr., OD, DO, MS, FAAO, FAOCO, in the session titled “The Diabetes Pandemic: How Do We Fit In?”. Dr Skorkin is a consultant to the Mayo Clinic Health System in Minnesota and assistant professor of ophthalmology at the Mayo Clinic College of Medicine.
|Moderate nonproliferative diabetic retinopathy will show an increase in intraretinal hemorrhages and microaneurysms, as seen here.|
AI System to Detect DR
One factor transforming DR care today is the approval of new screening technology. Deep learning, a subset of artificial intelligence (AI), involves the training of devices such as imaging technology to identify conditions or diseases such as diabetes. Eye care now has this capability, with the 2018 FDA-approval of the IDx-DR AI-based system (Digital Diagnostics) to detect greater than a mild level of DR in adults who have diabetes, and provide a screening decision without the need for physician/clinician input. Created in collaboration with the IBM Watson AI computer and in alignment with clinical standards, the software program uses an AI algorithm to analyze images of the eye taken with the Topcon NW400 non-mydriatic retinal camera.
In the clinical trial leading to its approval, researchers revealed the system exceeded all pre-specified superiority endpoints: with sensitivity of 87.2%, specificity of 90.7% and an imageability rate of 96.1%.
“This technology has been found to be of equal performance to a panel of expert retinal ophthalmologists,” Dr. Skorin said.
The system is mainly being used in primary care offices, and medical technicians are being trained to use it over several hours, Dr. Skorin said. The clinician can get a readout while the patient is still in the office and rapidly determine whether the patient should be referred on or return in a year for another DR screening, he added. A new CPT code is scheduled to start in January 2021 so providers will be able to start billing for the screening.
Evolving DR Patient Care
Why Are Diabetes and DR Important?
United States statistics:
• 30 million people have diabetes, of which 90% experience Type 2
• 7.2 million are undiagnosed
• 84.1 million have pre-diabetes
• 1.4 million are legally blind from diabetes
• One diabetes patient loses visual function every 15 minutes
In the future, many primary care offices, which often make referrals to optometrists and ophthalmologist to do annual DR screenings, may have their own DR screening capabilities: “So, optometry may be impacted in profession-altering ways,” Dr. Skorin pointed out.
He suggested that optometry should step up its involvement in helping to manage DR patients in addition to screening them for DR. Optometrists can have a powerful impact on patients’ health with a basic understanding of and simple observations related to pre-diabetes, Dr. Skorin suggested.
As a case in point: In one study (Tseng E, et al., 2017) evaluating 140 primary care providers (family medicine doctors, internal medicine doctors, pediatricians, nurse practitioners and physician assistants) on their knowledge of pre-diabetes, only 6% identified the 11 risk factors of pre-diabetes, and 30% were unfamiliar with American Diabetes Association (ADA) guidelines.
Better Understanding Diabetes & Its Risk Factors
Along with outlining the 11 ADA risk factors of pre-diabetes, Dr. Skorin offered a list of factors starting with the letter “C” that indicate why ODs are well-positioned to work with diabetic patients: ODs are the first “contact” to the medical system, they “coordinate” referrals, “collaborate” with other healthcare providers, provide “continuity” of care over time, “communicate” well with patients, provide “comprehensive” evaluations to identify comorbidities and monitor patient “compliance” with therapy regimens.
He gave an example of the impact ODs can have on DR care. Over a weekend when Dr. Skorin was working on-call for his hospital, he received a call from the emergency department about a male in his 30s. Earlier that morning, the man woke up and noticed that his distance vision was blurry in both eyes. The emergency department doctor had checked the man’s visual acuity by having him look at a distant eye chart, evaluated his pupils, tried to do a slit lamp exam and examined the back of the eye with a direct ophthalmoscope through undilated pupils. However, he couldn’t find an explanation for the bilateral simultaneous blurred vision, so he called Dr. Skorin to discuss the situation.
Risk Factors of Pre-diabetes
• Age 45 and older
• Body mass index 25kg/m2 or greater
• Heart disease
• Family history of diabetes, first-degree relative
• Sedentary lifestyle
• Black, Asian or Latino
• History of gestational diabetes
• FBS: 100-125mg/dl
• HbA1c: 5.7-6.4%
Dr. Skorin asked the doctor to use a pinhole occluder to re-test the patient in each eye, and the man’s visual acuity significantly improved on the eye chart. Dr. Skorin also had the doctor check the patient’s near vision with a near point card, and asked about patient medications since some drugs can cause a myopic shift, although the patient wasn’t on medication. Despite the fact that the patient wasn’t currently diagnosed with diabetes, Dr. Skorin suggested a blood sugar test be done on the patient. The doctor called back and said the patient’s blood sugar was almost 400 mg/dL.
“Here’s a diabetic who’s making first contact, not with me directly, but I’m helping make the diagnosis,” Dr. Skorin said.
Barriers to DR Success
Barriers to optimal DR care lie at essentially every level of care: patients, clinicians and the health care delivery system itself all experience deficits and deterrents to success, Dr. Skorin explained. In addition, clinical inertia is a problem in the diabetes world. This includes the failure of healthcare providers to initiate or intensify therapy when indicated, make treatment decisions that follow evidence-based guidelines, establish appropriate treatment targets and de-intensify treatment when appropriate. Research (Strain WD, et al., 2014) reveals that clinical inertia is responsible for 200,000 avoidable diabetes-related complications per year in the US.
Importantly, Dr. Skorin said, studies show that diabetes control slows the onset and worsening of DR, and that optimal glucose control yields less DR, and less nephropathy and neuropathy.
“Optometrists need to start playing a greater role in assisting patients’ glycemic control, watching their body mass index, helping them reduce behavioral and cardiovascular risk factors beyond just addressing the diabetic retinopathy and diabetic macular edema, and often glaucoma and cataracts that may accompany them,” Dr. Skorin said. “But adding also other microvasculopathies that are found in diabetics such as neuropathies and nephropathies [is important as well].”