Guest Editorial: New paradigm aims for improved rates of diabetic retinal exams

January 15, 2006

The burden of diabetes in 2002 was 132 billion. The prevalence of diabetes in all age groups may be increasing, reflecting the surging rates of obesity. In terms of vision impairment, diabetes is the leading cause of blindness in the working population that is preventable with timely application of photocoagulation.

Unfortunately, the majority of people with diabetes may not obtain annual dilated retinal examinations as recommended by the American Academy of Ophthalmology (AAO). Even in managed-care populations, annual retinal examination rates may not exceed 50%. In rural populations, the rates may be less.

A sobering fact is that even when patients with diabetes are examined by an ophthalmologist, the sensitivity for detecting retinopathy may be as low as 34% compared with ETDRS photography, according to one publication.1 It has been suggested that residency programs should address this issue. The answer to this conundrum may lie not in the office of residency program directors, but rather in the office of the chief technology officer.

Ophthalmologists may feel threatened with this burgeoning practice. Retinal evaluations performed in the office of a primary-care physician and remotely interpreted by a reading center via telemedicine may reduce patient visits in the office of an ophthalmologist. I propose that ophthalmologists should embrace this new paradigm.

First, patients with preventable vision impairment from diabetic retinopathy may be undertreated due to annual dilated retinal examination rates at a level approximating 50% or less. Second, assuming every patient with diabetes were to be scheduled for an annual examination with an ophthalmologist, I submit we could not handle the load.

According to workforce analyses, each ophthalmologist in my home state of South Carolina would have to work an additional 4 to 6 hours per week to examine every patient with diabetes on an annual basis. Taking into account that not every ophthalmologist performs retinal evaluations, this workforce assessment is probably underestimated.

The advancement in technology that allows retinal evaluations of patients with diabetes in the office of the primary-care physician is a good idea. Telemedicine bridges communication barriers between primary-care physicians and ophthalmologists because the primary-care physician directly orders the exam. This practice will increase referrals to an ophthalmologist. In addition, the primary-care physician is more able to adhere to clinical practice guidelines as advocated by the American Diabetes Association (ADA).

Further work is needed to clarify the role of telemedicine and other innovative disease management approaches to improve ocular health outcomes. We are currently conducting National Institutes of Health (NIH) funding research that evaluates a comprehensive disease management approach to diabetes self-management utilizing telemedicine that focuses on ADA clinical practice guidelines, which includes a retinal assessment.

Richard M. Davis, MD, is professor and chairman, department of ophthalmology, University of South Carolina School of Medicine, Columbia. He can be reached at 803/434-7056 or rdavis@gw.mp.sc.edu
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References

1. Lin DY, Blumenkranz MS, Brothers RJ, Grosvenor DM. The sensitivity and specificity of single-field nonmydriatic monochromatic digital fundus photography with remote image interpretation for diabetic retinopathy screening: a comparison with ophthalmoscopy and standardized mydriatic color photography. Am J Ophthalmol 2002;134:204-213.

2. Davis RM, Fowler S, Bellis K, Pockl J, Al Pakalnis V, Woldorf A. Telemedicine improves eye examination rates in individuals with diabetes: a model for eye-care delivery in underserved communities. Diabetes Care 2003;26:2476.