Lean Management Principles

Thinking About Efficiency in Clinical Operations

Goal: to help increase awareness and support patient education around retinal disease. This edition features tips to improve efficiency in clinical operations.



Three Ways to Make Your Practice More Lean


It is no secret that retina physicians are getting exponentially busier these days. New regulatory requirements, increased patient volume, and paperwork demands threaten to negatively impact practice efficiency, prolong patient wait times, and frustrate physicians, staff, and patients alike.

Adopting lean principles may be one way we can help alleviate these stressors. Lean, which has its origins in the Toyota Production System, describes an approach to process that focuses on creating value and eliminating wasted effort and resources.

The lean philosophy is not an all or nothing proposition, and it is not even necessary to overtly adopt it to realize its benefit. Indeed, although each of us places different emphasis on how ardently we follow lean principles, we ultimately agree on what are probably the most fundamental aspects of finding greater efficiency in clinical workflow:

Know Your Practice

BUILD CONSISTENCY. The patient-physician interaction is the most valued commodity in a health care setting; as a result, effort should be taken to build consistency around the physician while adopting practices that improve workplace efficiencies (see 5S Principles).1 Understanding if there are any extraneous and wasteful practices in the clinic is the first step in accomplishing this (see The Wisdom to Change).2

Commit to Continuous Improvement

MAKE SMALL ADJUSTMENTS OVER TIME. Lean philosophy incorporates a principle called kaizen, or a commitment to continuous, unending improvement. It is likely not possible to overhaul everything at once; in fact, small adjustments over time eventually add up to be greater than the sum of their parts.

Be Receptive to Feedback

CHANGE STARTS WITH YOU. Successfully implementing any change requires leadership from the top (including at the institutional level). Involve your staff, put patients first, and listen and adjust if things are not going according to plan.

Three Common Bottlenecks in Retina

Even though every physician’s style of practice will inevitably differ, there are some common bottlenecks in retina practice.

1. IMAGING

Relieving the time constraints associated with capturing imaging can take many forms:

  • Understand and prioritize the images you actually use for different patient types and make sure technicians or photographers are aware of them.
  • Consider an additional OCT machine. Dr. Eichenbaum’s practice purchased a new, basic model OCT machine used only for photography. The modest investment has freed up the other machine in his office that is equipped with more specialized imaging, like angiography.
  • Reduce physical distance. Dr. Han’s practice has reduced the physical distance patients have to move during a visit in two ways:
    1. Patients receive all services in multifunction rooms (technician screening, exam, and injection) and are moved to imaging and other value-add services as needed.
    2. Patients are placed directly in the exam room after check-in.

2. INJECTION PROTOCOLS

Establishing an injection clinic, where patients who are to receive or be evaluated for an injection are scheduled together, helps the staff get into a rhythm, which pays dividends for increasing throughput.

  • Plan ahead with presoaked pledgets. Dr. Eichenbaum’s practice has adopted the use of presoaked pledgets for numbing patients prior to injections rather than using gel.
  • Prefilled syringes. Recently, prefilled syringes have come on the market. In addition to potentially improved safety (they are filled in a standardized format under sterile conditions), the time saved by eliminating the need to draw up the correct dosage for injection adds up over the course of the day. Using prefilled syringes means one less thing for the staff to worry about, resulting in a more streamlined and efficient injection process.

3. PAPERWORK

Save critical time during the patient encounter by building macros into the electronic record system and becoming more fluid with its operation.

Use metrics. An unspoken, but critically important, aspect to successfully making changes in one’s operations is to ensure the results are being tracked. Patient visit time can be measured in most electronic record systems. Patient surveys can also be measured for common themes.

CONCLUSION

Lean management philosophy is a set of guiding principles rather than an instruction booklet on how to change. Indeed, lean is most successful when it is used as a lens through which one’s operations are viewed. Because there are no one-size-fits-all solutions, it may be more worthwhile to think about how we approach the process of discovering greater efficiency instead of simply adopting practices that worked for someone else.

1. Han D, Murray T. Lean practices in the clinic. EyeTube.net. Available at:
https://eyetube.net/series/daily-coverage-ards-snowmass-2015/ijufe/.
2. Han D. Toward a lean intravitreal injection clinic. New Retina MD. 2015;6(1):25-27.

Patient Adherence Tips

Improving Patients’ Adherence With Treatment and Monitoring

Goal: to help increase awareness and support patient education around retinal disease. This edition features tips to boost patient adherence to recommended therapy.



Anti-VEGF therapy has significantly improved outcomes for patients with age-related macular degeneration (AMD), diabetic macular edema (DME), and diabetic retinopathy (DR), but achieving successful outcomes is not magic; it is pharmacology. These drugs have to be dosed at consistent intervals to be effective. DR and DME are indications that the patient was previously noncompliant with managing blood sugar levels. However, these patients face many obstacles: most are of working age, have families, and are otherwise leading very busy lives. Receiving treatment or undergoing monitoring once a month can become taxing, especially considering that patients with diabetes already go to the doctor an average of 25 times a year1—and that is before accounting for the time they spend at a retina clinic.

Three Ways to Foster Collaboration

1. Maintain consistent messaging.

Ensuring consistency in messaging across the referral network is crucial for getting patient buy-in to the treatment program. Confusion builds doubts which will make patients less likely to comply with follow-up.

2. State treatment protocol early.

Dr. Dierker describes his role in the patient’s journey as “detecting things that are treatable at the earliest possible stage and then working closely with the retina specialists in our community and in my practice to help them achieve a better outcome.” That includes informing patients they will require multiple injections over an extended period of time but leaving details about injection frequency to the discretion of the treating physician.

3. Take advantage of available technology.

Use of the ForeseeHome device (Notal Vision) has been shown to result in more patients having 20/40 or better VA when choroidal neovascularization was diagnosed (ie, at the time of conversion to wet AMD) compared to Amsler grid.2 Early initiation of anti-VEGF therapy is associated with more favorable VA outcomes.3 However, most patients start therapy when VA is worse than 20/80, when permanent structural damage may already have occurred.4 Providing viable options that help patients preserve vision is motivating, especially as this population of patients has demonstrated a willingness to use home-based technology to proactively manage their disease.5

Four Strategies to Maintain Patient Motivation

The first patient encounter is critical for setting reasonable expectations. To reinforce the importance of routine monitoring, Dr. Dierker uses a portion of the first patient encounter to convey that patients may not notice symptoms like vision loss until it is too late. As patients come back, frequent reminders reinforce the message. Once in the care of the retina specialist, Dr. Holekamp tells patients that treatment will likely require returning to the office once a month for a year—and if they wind up coming back less frequently, it is seen as a win. “We don’t manage disease, we manage expectations,” Dr. Holekamp said.

Some other strategies that we have employed in our practice include the following.

1. Highlight the effectiveness of treatment.

DME and advanced forms of DR are biomarkers for other complications of diabetes, including nephropathy and neuropathy. Those cannot be reversed with current therapy, but there is strong evidence that timely introduction of anti-VEGF therapy can yield regression in DR severity.6-8

2. Use imaging as an educational tool.

Review the differences between the patient’s imaging and an example of a normal, healthy eye. There may also be a role for showing examples of treatment successes to demonstrate improvements in anatomy.

3. MAKE IT PERSONAL.

Ask patients if they know anyone who has gone blind or lost vision from AMD or DME/DR. Knowing someone who has lost vision from the disease is a powerful motivating factor. Patients who have already lost VA in one eye also tend to be highly motivated.

4. discuss how treatment has advanced.

Anti-VEGF treatment has significantly improved the visual prognosis for patients with AMD and DME/DR. Patients who witnessed someone go blind from these diseases 20 years ago may not be aware of just how far the field has advanced.

Conclusion

A lot of the conversation around patients’ adherence to follow-up requirements is framed around the burden of current treatment regimens. However, no matter how high the burden is for receiving treatment for these diseases, the burden of blindness is always going to be greater. Patients get to choose their burden. For some, framing the discussion in such frank terms may help get the message across.

1. Kiss S, Liu Y, Brown J, et al. Clinical utilization of anti-vascular endothelial growth-factor agents and patient monitoring in retinal vein occlusion and diabetic macular edema. Clin Ophthalmol. 2014;8:1611-1621.

2. Group AHSR, Chew EY, Clemons TE, et al. Randomized trial of a home monitoring system for early detection of choroidal neovascularization home monitoring of the Eye (HOME) study. Ophthalmology. 2014;121(2):535-544.

3. Rasmussen A, Brandi S, Fuchs J, et al. Visual outcomes in relation to time to treatment in neovascular age-related macular degeneration. Acta Ophthalmol. 2015;93(7):616-620.

4. Rao P, Lum F, Wood K, et al. Real-world vision in age-related macular degeneration patients treated with single anti-VEGF drug type for 1 year in the IRIS Registry. Ophthalmology. 2018;125(4):522-528.

5. Schwartz R, Loewenstein A. Early detection of age related macular degeneration: current status. Int J Retina Vitreous. 2015;1:20.

6. Nguyen QO, Brown DM, Marcus OM, et al. Ranibizumab for diabetic macular edema: results tom 2 phase Ill randomized trials: RI SE and RIDE. Ophthalmology. 2012;119:789-801.

7. Wykoff C. Ranibizumab induces regression of diabetic retinopathy (OR), prevents retinal nonperfusion in patients at high risk of conversion to proliferative OR. Presented at: ASRS; Aug. 9-14, 2016; San Francisco.

8. Gross JG, Glassman AR, Jampol LM, et al; Writing Committee for the Diabetic Retinopathy Clinical Research Network. Panretinal photocoagulation vs intravitreous ranibizumab for proliferative diabetic retinopathy: a randomized clinical trial. JAMA. 2015;314(20):2137-2146.

Imaging Basics in AMD

What to Look for in Patients With AMD

Goal: to increase awareness of the hallmark findings on imaging in eyes with age-related macular degeneration (AMD) and the role of the entire eye care team in advancing care.



Increasing evidence points to the fact that patients with neovascular AMD have a better long-term visual prognosis when treatment with anti-VEGF therapy is initiated soon after or just before development of choroidal neovascularization.1-4 Inherent to that paradigm is early diagnosis. In the following, we present two perspectives on how the entire eye care team can work together to better utilize available imaging technologies to help patients achieve their treatment goals.

Imaging is Crucial for Diagnosing and Following AMD

By Mark R. Barakat, MD

Our clinic regularly provides education about AMD to our local optometric network and other eye care providers, as well as to primary care providers and internists. Given the nature of AMD and how it is managed, a good portion of our education efforts involves discussing the role of imaging.

Hallmark Findings Icon

HALLMARK
IMAGING FINDINGS

When it comes to diagnosing and following AMD, we look for changes in imaging features, so obtaining baseline imaging, where feasible, is extremely helpful. OCT and fundus photography are currently used most often in practices. These two modalities form the core of managing AMD, supported by the clinical examination, with findings from all of the above directing the need for more specialized imaging.

OCT findings are crucial for making a diagnosis and for staging the disease (Figure). It is imperative to look for these three findings when examining an OCT:

1. Drusen, appearing as deformations or thickening in the hyperreflective band of the retinal pigment epithelium (RPE), particularly in the Bruch membrane, are perhaps the earliest recognizable sign of AMD. Hard drusen (small hyaline deposits with delimited margins) are considered lower risk than soft drusen (hypo- or hyperpigmented findings), which are precursors of AMD. Risk of progression varies according to the number, size, and confluence of the drusen.

2. Continual atrophy of the RPE causes thinning of the retina, which allows the OCT laser to penetrate to greater depth, thereby depicting a hyperreflective signal from the choroid. Retinal maps may be useful in confirming areas of thinning and to quantify volume loss, especially in tracking change in these values over time and in response to treatment.

3. Active neovascular membranes can be identified and characterized on OCT. They appear as hyperreflective areas on or adjacent to the RPE, almost always in association with retinal edema. Other hallmark findings associated with a neovascular membrane include RPE detachment (which may be associated with intraretinal migration of the RPE cells), neurosensorial detachment, intraretinal fluid (dense particles may be present), and subretinal hemorrhage. Importantly, not all cases of AMD progress to choroidal neovascularization.

Figure. Sample images depicting OCT changes that may be identified in a patient with AMD: atrophy (A), geographic atrophy (B), pigment epithelial detachment (C), sub- and intraretinal fluid (D), and subretinal fluid (E).

The function of any imaging in retinal practice is to support and not replace decision-making. Thus, image findings are used to confirm clinical impressions and to direct follow-up. For example, drusen and RPE changes detected on macular exam are highly suggestive of AMD, but hemorrhages may require angiography to narrow down the differential. Conversely, in many cases, fundus photography is superior to the clinical examination for identifying drusen and may be used to confirm physical findings. Likewise, fundus autofluorescence helps identify the edges of atrophy and its activity, which is easy to overlook on macular exam.

Hallmark Findings Icon

THERE IS NO SUCH THING
AS “TOO EARLY” TO REFER

One of the most frequent topics to come up in our interactions with referral sources is when to refer and how to prepare patients before coming to our clinic.

Take these four factors into consideration when determining rate of referral and patient preparation:

1. Anti-VEGF therapy is highly effective at helping maintain vision and stabilize the disease; however, the rate of individuals gaining three lines of vision is only about 30 to 40% with monthly treatment.5-7

2. Ultimately, that suggests that earlier treatment is better, and as an eye care community, we have done a tremendous job at early recognition to give us a chance to start an intervention when it can save vision.

3. The best-case scenario is that we may find stable disease that does not require treatment; but even in that case, the patient’s concern has been addressed.

4. Gauge how much information the patient can absorb at the time. There is an art to reading a patient and determining how many details to share. It may not be a good idea to overwhelm someone with safety and efficacy data on anti-VEGF therapy; at the same time, if patients hear about the potential for treatment before coming to our clinic, our education and counseling is much more effective.

5. At a minimum, we encourage referral sources to introduce AREDS vitamins and to recommend the use of the Amsler grid. The former will help slow progression, while the latter helps detect vision changes suggestive of progression—and both help us achieve the goal of early identification and treatment to help save vision.

The Role Of Optometry in Caring for Patients With AMD Continues to Expand

By Nadia Virani, OD

The increasing number of patients affected by AMD, coupled with the growing role of optometry as primary eye care providers, suggests a need for optometrists to become proficient in recognizing signs of the disease and knowing when to refer for specialty care. While not all optometrists will have interest in managing retinal diseases, at a minimum, we should know how to make the diagnosis, how to follow these patients over time, how to counsel patients appropriately, and when to direct patients to specialty care. See Diagnosis and Monitoring sidebar for helpful imaging examples of what to look for in patients with AMD.

Hallmark Findings Icon

Diagnosis and Monitoring

Imaging is additive to the physical examination and patient history in building an overall clinical impression regarding the health of the retina, whether change has occurred, and what the prognosis is for future progression (see Figures 1 through 5 for examples).

Figure 1. Heidelberg Engineering OCT of foveal drusen with subretinal fluid—requires intervention with retinal treatment.

Figure 2. Cirrus OCT of subfoveal drusen (left). Cirrus OCT showing subfoveal drusenoid pigment epithelial defect (right).

Figure 3. Cirrus OCT displaying macular thickness cube of the right and left maculae. The top images show subfoveal drusen. The bottom images show subfoveal drusenoid pigment epithelial defect.

Figure 4. Bilateral Heidelberg Engineering OCT findings. In the right eye (left image), subretinal fluid with mild foveal drusen requires retinal treatment. In the left eye (right image), the macula displays normal variation, with no treatment required.

Figure 5. Heidelberg Engineering OCT displaying punctate drusen.

Monitoring for vision changes between office visits is increasingly important, particularly in light of data showing better long-term outcomes when treatment is initiated when VA is 20/40 or greater.8 We make regular use of the Amsler grid, although more recently, a number of smartphone apps that have a similar function have been released.

Hallmark Findings Icon

Optometrists Are a
Vital Source of Education

Because optometrists have a number of interactions with AMD patients, they have an important role in providing education.

In our clinic, there are a few key messages we want to impart to patients with AMD:

1. What is AMD? AMD is essentially a buildup of proteins and lipids under the retina that may threaten central vision.

2. Will you require treatment? About 85% of patients have dry AMD,9 and only a certain percentage of those patients progress to advanced stages that threaten vision and require treatment.

3. How can you delay or prevent disease progression? There are things patients can do to lower the risk of progression, including consuming leafy greens, avoiding tobacco use, and being diligent about UV protection.

4. Take the whole body into consideration. Systemic health also matters. Blood pressure, cholesterol levels, and blood sugar levels can affect progression.

5. Exceptional advances have been made in treating AMD, if that becomes necessary; we introduce the topic in the clinic, but don’t get into specifics of treatment, because the treating clinician will make the ultimate determination whether treatment is required and how it will be performed.

6. Low vision services are an option to help patients cope with loss of acuity and function.

The internet can be a wonderful tool for patient research, but in our experience, patients get more relevant information when the eye care team sets the stage. Saying something to the effect of, “here is what you are going to read about, and it may be scary sounding, but that is what we are trying to prevent,” puts the patient at ease and lets him or her be more deliberate about the kind of information they are consuming.

CONCLUSIONS

Affecting early treatment in AMD is a matter of teamwork: directing patients to specialty care requires prompt recognition of early signs of the disease. More often than not, the diagnosis is made by a primary eye care specialist. Our patients are truly fortunate to be living in a time where treatment has advanced, where ongoing research offers the promise of new and potentially better therapeutic interventions, and where the increasingly collaborative model of eye care delivery has helped foster greater working relationships between specialties.

1. Wong TY, Chakravarthy U, Klein R, et al. The natural history and prognosis of neovascular age-related macular degeneration: a systematic review of the literature and meta-analysis. Ophthalmology. 2008;115(1):116-126.

2. Ying GS, Huang J, Maguire MG, et al. Baseline predictors for one-year visual outcomes with ranibizumab or bevacizumab for neovascular age-related macular degeneration. Ophthalmology. 2013;120(1):122-129.

3.  Maguire MG, Martin DF, Ying GS, et al. Five-year outcomes with anti-vascular endothelial growth factor treatment of neovascular age-related macular degeneration: the comparison of age-related macular degeneration treatments trials. Ophthalmology. 2016;123(8):1751-1761.

4. Rasmussen A, Brandi S, Fuchs J, et al. Visual outcomes in relation to time to treatment in neovascular age-related macular degeneration. Acta Ophthalmol. 2015;93(7):616-620.

5. Rosenfeld PJ, Brown DM, Heier JS, et al; MARINA Study Group. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. 2006;355(14):1419-1431.

6. Brown DM, Kaiser PK, Michels M, et al ANCHOR Study Group. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med. 2006 Oct 5;355(14):1432-1444.

7. Heier JS, Brown DM, Chong V, et al, VIEW 1 and VIEW 2 Study Groups. Intravitreal aflibercept (VEGF trap-eye) in wet age-related macular degeneration. Ophthalmology. 2012;119(12):2537-2348.

8. Lee AY, Lee CS, Butt T, et al. UK AMD EMR Users Group Report V: benefits of initiating ranibizumab therapy for neovascular AMD in eyes with vision better than 6/12. The British journal of ophthalmology. 2015;99(8):1045-1050.

9. Jager RD, Mieler WF, Miller JW. Age-related macular degeneration. N Engl J Med. 2008;358(24):2606-2617.

Tips for Early Disease Identification

Uncovering treatment-warranting diabetic eye disease

Goal: to increase awareness of the tools for early diabetic eye disease detection and the role of the entire eye care team in advancing care.



Although clinicians can be guided by a wealth of clinical evidence regarding their role in treating patients with diabetic eye disease, a multitude of factors will ultimately dictate when and how to treat—and even whom to have a conversation with regarding the options. If there is one thing that is nearly universal in diabetic eye disease, though, it is the fact that early detection and diagnosis affords an opportunity for the retina specialist and optometrist to offer options to selected patients at a timepoint that is highly likely to preserve long-term vision and even potentially yield regression of the disease.

Making Progress in Early Detection of Diabetic Eye Disease

The definition of “treatment-warranting early stage disease” is evolving.

By Charles C. Wykoff, MD, PhD

There are two key messages we try to get across in our various interactions with referral sources: diabetes is very common, and, overall, patients are not receiving the appropriate level of eye screening across our communities. The role of screening is to identify disease that is at a treatable threshold before it is symptomatic for the patient; diabetic retinopathy (DR) can be asymptomatic and yet still have crossed over into a threshold that deserves treatment (Figures 1 and 2). All patients with diabetes should have at least an annual ophthalmic screening evaluation.

Fundus photography is invaluable for supplementing a comprehensive dilated fundus examination. Photographs provide objective imaging to use for patients’ education and for reference during subsequent follow-up visits.

• If financing is removed from consideration, OCT imaging is also valuable as a supplemental tool for screening to pick up diabetic macular edema (DME). In certain situations (the patient is symptomatic or if vision is not correctable to a normal level) OCT imaging may be more valuable than fundus photography. For the majority of cases (asymptomatic with normal vision, first imaging), a color fundus photograph has greater value.

Figure 1. Color fundus photographs in a 60-year-old woman with type 2 diabetes mellitus presenting with no visual symptoms. The image findings are consistent with a diagnosis of moderate nonproliferative DR (NPDR).

Figure 2. Wide-field angiography captured in the eyes of the same patient as shown in Figure 1. In this case, the use of multimodal imaging helped identify PDR.

THRESHOLD FOR REFERRAL

How closely patients are followed and when they are referred for specialty care depends on the referral source and the patient. There really is no such thing as “too early for referral.” That said, I find I can make the greatest impact when I start to see patients before they advance to severe NPDR or worse, with the understanding that DME and DR severity do not necessarily correlate. Presence of macular edema is definitely an indication for a prompt referral.

Certain broad clinical characteristics that might suggest a need to follow that patient more closely include:

• Monocular status
• Poorly controlled systemic cardiovascular risk factors
• Family history of blindness

The threshold for discussing treatment has evolved over the past few years because there is now data to support the use of treatment in selected patients with severe NPDR without DME. The recent PANORAMA study1 confirmed much of what we suspected about using anti-VEGF agents in this setting, but it also gives retina specialists a dataset with which to have individualized conversations with patients to help them make the decision that is right for them.

In that context, referral sources can facilitate the later conversation by emphasizing two points:

1. There are treatment options available that can be used at earlier disease stages.
2. Making a decision to start treatment is individualized, and patients can follow-up with someone to discuss the risks and benefits.

Future Directions

The promise of artificial intelligence algorithms is substantial, and I believe they will improve our ability to deliver care based on individual patient risk stratification. Additionally, newer imaging modalities such as OCT angiography (OCTA) will add to our ability to prognosticate and follow patients with diabetic eye disease. We are starting to learn how to use OCTA to quantify retinal nonperfusion longitudinally, which I anticipate will allow us to better identify patients with early stages of DR who may benefit from earlier interventional therapies.

How I Use Imaging in My Practice

Using imaging is highly individualized.

• Generally, I like to obtain an OCT and use my clinical exam to guide the use of additional imaging as necessary. For example, normal OCT and a few microaneurysms would likely mean no additional imaging, but scattered dot blot hemorrhages might lead me to obtain a wide-field photograph.
• I typically consider a fluorescein angiogram for anything beyond moderate retinopathy and prefer to obtain a wide-field angiogram before initiating interventional treatments. Proliferative disease, a marker for a high-risk eye, may be masked by anti-VEGF injections.
• I have access to OCTA in most of my clinics, and the images are impressive. At this point, however, it is not essential to the management of DR in my practice. It does confer the ability to quantify areas of retinal nonperfusion longitudinally in a way not possible with liquid-based angiography.

Making Progress in Early Detection of Diabetic Eye Disease

The definition of “treatment-warranting early stage disease” is evolving.

By Margie Recalde, OD, FAAO

Screening for diabetes is a component of the comprehensive eye exam we encourage all patients to repeat annually. As an additional step, and certainly if there is history of diabetes, high blood pressure, glaucoma, or other high-risk factors, we recommend patients get an OCT and an Optomap (Optos) image. Of note, the latter most likely requires an out-of-pocket expenditure for the patient, but they help increase the sensitivity of detecting early stage disease.

The American Optometric Association manual for diabetic eye care is a great resource for the fundamentals of what the exam should entail.2 The focus on questioning patients about their ABCs is a concise reminder of notable systemic risk factors:

• A = A1C blood hemoglobin level
• B = Blood pressure
• C = Cholesterol
• s = Smoking status

HOW OFTEN TO FOLLOW-UP

The standard guideline on how often to follow patients diagnosed with diabetic eye disease or suspicion for DR or DME is every 12 months.2 I tend to err on the side of caution and ask patients to return in 6 to 8 months. In eyes with moderate DR without macular edema the timeline might change to 4 to 6 months. If I am considering bringing the patient back at any greater frequency, or if there is severe NPDR or PDR, that is a patient being referred for consultation with a retina specialist. Macular edema, at any point, triggers a referral.

Often times, optometrists think of themselves as the person to follow-up on ocular manifestations of diabetic eye disease, although it may also work the other way around. I have been surprised by how often I have zoomed down on an Optomap image to detect bleeding at the retina in a patient with no known history of diabetes. In that situation, I can refer the patient to a primary care physician for further testing. In caring for patients with diabetes there are, in fact, multiple pathways the optometrist can help guide patients along, working closely with partners in systemic medicine as well as in eye care.

Concise, Telling Statistics Tend to Stick

Much of the interaction with patients with diabetes is focused on counseling about systemic risk factors. After letting patients know there are treatment options available, encouraging them to be partners in their own health can be fundamentally important. In our experience, generic advice, like “lose weight” and “exercise,” is ineffectual. The same information could be presented another way:

• It takes about 150 minutes of moderate physical activity a week to maintain weight and 250 to lose weight.3
• Losing 7% of your body weight, which may be as little as 5 to 7 pounds, reduces the risk of diabetes progression by 58% in 4 years.4

conclusion

Caring for patients with diabetes is ideally a long-term relationship. We are not yet at the point of having curative interventions, but we have made remarkable progress toward identifying treatments likely to significantly slow progression and potentially yield regression in large proportions of high-risk eyes. The next step in this evolving treatment paradigm is improved recognition of disease at a stage when treatment is likely to have its greatest impact, as well as improved prognostication for individual patients to identify those most likely to benefit from earlier intervention.

1. Wykoff C. Intravitreal aflibercept for moderately severe to severe nonproliferative diabetic retinopathy (NPDR): the phase 3 PANORAMA study. Presented at the ASRS Annual Meeting, July 20-25, 2018; Vancouver, BC.

2. American Optometric Association. Evidence-based Clinical Practice Guideline Eye Care of the Patient with Diabetes Mellitus, Second Edition (CPG3). Published Online. Available at: https://www.aoa.org/optometrists/tools-and-resources/clinical-care-publications/clinical-practice-guidelines. Accessed November 11, 2019.

3. Office of Disease Prevention and Health Promotion. How much daily exercise is best for weight loss? Available at: https://health.gov/news/blog/2012/10/how-much-daily-exercise-is-best-for-weight-loss/. Accessed November 11, 2019.

4. Diabetes Prevention Program Research Group. Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study. Lancet Diabetes Endocrinol. 2015;3(11):866-875.

Contact Info

Bryn Mawr Communications LLC
1008 Upper Gulph Road, Suite 200
Wayne, PA 19087

Phone: 484-581-1800
Fax: 484-581-1818

Scott Krzywonos
Editor-in-Chief
484-581-1880
skrzywonos@bmctoday.com

Janet Burk
Publisher
214-394-3551
jburk@bmctoday.com

About Retina Today

Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.