I am the president of the NYOIPA, a NY IPA dedicated to providing quality medical eyecare. We are building an OD / OMD network to reduce the cost of healthcare in NY. We plan to do this by creating a primary care optometry that directs surgical care to OMDS to keep them busy at what they do best, tertiary care. At the same time we are using the scope and availability of our network to screen patients who are at high risk but rarely see their PCP, until disaster strikes. These are people between the ages of 18 and 40 who see us for blurred vision but rarely see a PCP because they believe they are “invulnerable.” Certainly diabetes is a common finding; however, I believe there are even bigger issues that need the coordinated attention of PCPs and OD’s to help protect our countrymen’s lives and the future economics our health care insurance industry.
One enormous coming personal healthcare disaster and financial behemoth, waiting in the wings is the expense of hospitalization and disability caused by vision loss, strokes, heart attacks. Most of these are caused by venous occlusions and hemorrhages. The great opportunity is that Optometry can diagnose the early signs and help protect our neighbors while keeping down the disastrous expense these events cause our insurance system.
What makes me think this is possible? I have been in practice over 40 years. In that time, just like you, I have seen patients with arterial nicking (from arteriolar sclerosis and hypertensive retinopathy) who, within a few years or diagnosis, end up with a venous occlusion (elsewhere in their body or in their eyes) causing blindness, a stroke, a heart attack or even sudden death. Fundus photography, when used as a screening tool, will frequently disclose this pathology (as well as diabetes).
If we believe in the value of our arsenal of cholesterol lowering drugs, BP meds and dietary modification should these patients not be offered preventive treatment? Can we afford to not see the preventive option? Should we wait till the picture is painted with more red blood? The cost of eyecare is small the cost in disability is huge! It would seem common sense to intervene now! Every OD worth their salt has the tools to do this in their office, now.
In my office retinal photography has been offered as a screening for over 10 years. It is now more common across America. Progressively thinking companies like VSP, are even offering it in some of their routine vision care plans!
What should this coordinated OD / PCP approach look like? Every OD
should strive to screen their incoming patients at regular intervals for micro-vascular pathology. The finding of nicking, should be well documented and the PCP should be alerted to this finding. Patients with this finding should likely be monitored at regular intervals for progression of this systemic pathology. Though there are no clear clinical standards yet in place, it would seem logical that an annual or biannual imaging and comparison should take place. Obese patients, hypertensive patients and diabetics should likely be seen yearly and reports of progression sent to their PCPs.
I would recommend that all ODs, noting these changes, give their patients a written dietary and lifestyle questionnaire to complete in an effort to look for a common profile that can help the PCP understand the pathology and us help manage the patient’s care. Though we have yet to formulate such a questionnaire, past verbal assessment frequently points to diets high in carbohydrates, fast food, regular soda drinkers and alcohol consumption. Stress appears to be a common factor too……however these are all speculative until better studies are available. Nevertheless, many popular healthcare newsletters clearly espouse this connection.
What should you do now? I recommend screening as many patients as possible with high resolution retinal photography. I believe that the research documents below clearly indicate a need for the early diagnosis of not just diabetes but equally as important (if not more) nicking of the veins (hypertensive / arteriolar sclerotic vascular changes). A small investment now in the minimal cost of retina imaging can prevent a huge expense later in disability and hospitalization. What should an optometrist expect from a referral to a PCP? At a minimum we might expect testing to look at treating high blood pressure, cholesterol issues, C reactive protein and high triglycerides. What is the outcome or value of this process? If the patient is diagnosed, and there is a treatment option progression may be halted. Even if the patient just modifies their diet and lifestyle to lose weight and be more healthy, morbidity is likely reduced. Until there is a very detailed process for monitoring vascular changes (which appears to be soon forthcoming) I suggest that reasonable clinical judgment is indicated in monitoring as discussed above.
What is the research evidence for this coordinated OD / PCP approach?
- An article in American Diabetes Care: Retinal Vascular Changes in Pre-Diabetes and Prehypertension New findings and their research and clinical implications. This review suggests that retinal image analysis offers a novel noninvasive measurement of early changes in the vasculature—not detectable on routine clinical examination—that may allow the identification of individuals at risk of diabetes and hypertension and their subsequent complications…….. read more.
- Retinal Microvascular Abnormalities Predict Progression of Brain Microvascular Disease: These data are consistent with previous reports that retinal microvascular signs predict white matter disease and lacunar infarcts. In treating WMP as a continuous measure and combining it with lacunar infarcts, we see associations between brain microvascular disease and retinal signs that, though expected based on common pathophysiology, were not seen before. The cumulative brain microvascular disease score that we developed could be a useful research tool in further studies seeking to elaborate on risk factors and outcomes associated with lacunar infarcts and white matter disease.………read more.
- BRAIN a journal of neurology. Retinal microvascular abnormalities and subclinical magnetic resonance imaging brain infarct: In this population-based cohort of middle-aged persons without clinical stroke, retinal microvascular abnormalities measured at baseline were prospectively associated with long-term risk of subclinical cerebrovascular disease on MRI, independent of conventional risk factors. The presence of retinopathy signs was associated with more than 2-fold higher odds of cerebral infarct and 3-fold higher odds of lacunar infarct. The presence of retinal arteriovenous nicking was associated with more than 2-fold higher odds of not only brain infarcts but also with incidence and progression of WMLs. Associations were similar in people with and without diabetes and hypertension.… read more.
- Retinal and cerebral microvascular signs and diabetes: the age, gene/environment susceptibility-Reykjavik study. Retinal microvascular abnormalities and brain microbleeds may occur together in older adults. People with both diabetes and signs of retinal microvascular lesions (AV nicking and microaneurysms/hemorrhages) are more likely to have multiple microbleeds in the brain. Microvascular disease in diabetes extends to the brain….. read more.
- Retinal microvascularisation abnormalities and cardiovascular risk Retinal vascular abnormalities appear to be predictive of an increased coronary, and more widely, cardiovascular morbidity and mortality predominantly in individuals under the age of 75…. read more.
- Retinal Vascular Signs: A Window to the Heart? How should current information and retinal imaging be translated into clinical usage? A recent review has recommended an updated classification system of these retinal signs, which, because of their close association with hypertension, are often referred to as hypertensive retinopathy. This new classification system divides hypertensive retinopathy into 4 levels: none; mild, which refers to the presence of generalized and focal arteriolar narrowing, and arteriovenous nipping; moderate, which refers to the presence of lesions such as microaneurysms and hemorrhages, hard and soft exudates (cotton wool spots) and severe, referring to optic disc edema. The authors recommend physicians undertake more vigilant monitoring of cardiovascular risk profiles in patients with mild retinopathy and adopt a more aggressive approach to risk reduction in patients with moderate retinopathy, while optic disc swelling requires urgent intervention to lower BP. The presence of these signs could be elicited either through ophthalmoscopy or photography after pupil dilatation. Patients of ophthalmologists and optometrists often have such photographs taken digitally, which are better records than ophthalmoscopic examination and enable monitoring of longitudinal changes in these retinal signs as well as in vascular health. ….. read more.
- Retinal signs and stroke: revisiting the link between the eye and brain. New data, from population-based studies, suggests that many retinal signs, in particular hypertensive retinopathy signs (eg, focal retinal arteriolar narrowing, arterio-venous nicking), may be markers of stroke risk and mortality, independent of other stroke risk factors. Diabetic retinopathy signs (eg, microaneurysms, hard exudates) are similarly associated with incident stroke and stroke mortality. … read more.
The Potential Dangers Of Obama Care – Health Care Reform As Currently Evolving: Managed Care has its new EMR / Data Exchange mechanism for evaluating clinical care and choosing the least costly path via “Service Review Committees”. This may help with misuse and overuse but it will not lead us down the path to the huge savings that America needs and good health care demands.
“Health Care Reform” is designed by businessmen for businessmen to make them money. It is designed to make profits for the companies that manage the doctors and hospitals by restricting access to services.
We need an additional structure to introduce long term change that results in huge savings and huge health benefits long term. Not short term profits that the current “reform” is designed for. The current designs for “managed care” will like make money for its corporate structures for short periods and destroy health care long term. Just as Wall Street takes investors to profits by quarterly evaluations but lead corporations to stagnation and failure through too much cost cutting and lack of R&D as they dance to the drum beat of quarterly profit reports. Corporations addicted to Wall Street financing cut corners, minimize services and fail to plan for the long future. This is a part of why America is sliding backwards economically. Do this to health care and people will pay with their lives as well as their dollars long term!