Setting Treatment Regimen and Outcome Expectations
How to manage expectations for treating patients with diabetic eye disease.
Goal: to support patient education around retinal disease.
When working with patients with diabetic retinopathy (DR) or diabetic macular edema (DME), setting expectations for treatment regimens and outcomes is key. Optometrists often set the initial tone, as patients commonly encounter them during routine care; retina specialists build on those relationship as they administer therapy to patients.
Preparing Patients With Diabetic Eye Disease for Referral
By Mark T. Dunbar, OD
There are three essential elements to preparing patients with DR or DME for treatment: education, prognosis, and treatment explanation. The form these steps take are informed by clinical judgement, which is in turn informed by the optometrist’s long-term relationship with the patient.
Educating the patient about diabetes in general and ocular implications in particular is the first place to start. Analogies are helpful. I often compare ocular vascular structures to pipes and explain that leakage from those pipes as caused by diabetes is resulting in toxicity. Imaging reports can be helpful at this step, too. OCT scans and fundus images help patients conceptualize their disease’s biology and its effects on anatomy.
Judgement Call: You know your patient better than anybody at this point of their ocular history. Is your patient inquisitive or educated in the sciences? Then be prepared for a deep-dive biology lesson. Is your patient less interested in particulars? Then keep it simple enough that this new information is digestible while making sure they understand the gravity of their disease.
Striking a balance between conveying a serious tone while also offering a voice for hope yields patients who are likely to pursue treatment. I tell them that the risk of avoiding treatment is disease progression, but underscore that treatment by a retina specialist will likely result in restoration of vision or prevention of visual loss. Be sure to tell the patient that routine follow-up will be required so that the retina specialist can closely track their progress and adjust treatment as needed.
Judgement Call: If your patient has a history of compliance, there is no reason to scare them. Also, remember that they are hearing a lot of new information at once. The retina specialist might repeat the information you deliver in this encounter, but that information isn’t redundant. Rather, the optometric conversation serves as the foundation, and the retina specialist conversation serves as the emphasis.
3. TREATMENT EXPLANATIONS
Explain that modern medicine offers clinicians plenty of options for treating diabetic eye disease and that treatment strategies are constantly improving. By describing retinal therapies as common, quick, and painless, you keep therapy accessible and unintimidating.
Judgement Call: Is your patient the type of person who, upon finding out that treatment requires a needle in their eye, would decline treatment? If so, then consider avoiding details about treatment procedures so that they can process the idea of treatment and then become more comfortable with the procedure over time.
Setting Expectations for Treatment Outcomes
By Rishi P. Singh, MD
In conversations with patients with DR or DME, I find that there are three major points I need to hit when setting outcomes expectations: a message of hope, an emphasis on the need for routine evaluation, and a confirmation of buy-in from the patient.
1. MESSAGE OF HOPE
Many patients fear full vision loss when they present to my clinic with DR or DME. I inform them that progress in medicine in the past few decades has greatly reduced the likelihood that they will lose their vision, and that laser, steroid, and anti-VEGF technologies are commonly used in our field. Reassuring the patient that treatment is likely to be efficacious starts the treatment cycle on a positive note.
2. ROUTINE EVALUATION
I build on a conversation that the optometrist started with the patient by stressing the importance of continual follow-up. I explain to the patient that our overall goal is to prevent vision-threatening complications such as vitreous hemorrhage or neovascular glaucoma, as those conditions will force working-age patients to miss large periods of work and could exacerbate vision loss. I explain that the treatments that we have work well and that they may even reverse some of the effects of their disease, but that they need to report back for follow-up appointments as instructed.
3. PATIENT BUY-IN
Explaining to patients that follow-up is needed is one thing; committing patients to becoming an agent in their own disease management is another.
For patients with early-stage disease, conversations about buy-in are shorter, as I generally outline the risks of lost follow-up and the benefits of annual checkups. For patients with more advanced disease, conversations are more nuanced. I explain that risk of developing vision loss is high and that follow-up appointments will be more frequent. Securing buy-in from these patients is the difference between controlling their disease and risking vision loss.
I talk to all patients about controlling A1C, and I make sure to celebrate patients’ success when they achieve metabolic control or when they return for an annual checkup. The power of encouragement is real, and it may help patients develop new habits that may affect treatment outcomes.
- Expectations are key. When a patient with diabetic eye disease is initially approached about treatment, it falls on the clinician who sees the patient to set realistic and honest expectations.
- Properly educating patients that the treatment cycle requires routine follow-up may be the difference between setting the standard for compliance or allowing some patients to fall off the treatment wagon.