Article Date: 10/1/2008

be the Standard of Care?
eye exams

Should annual Eye exams be the Standard of Care?

The answer starts with our eyes and reaches beyond to myriad socio-economic issues.

BY GULROOP HANSRA, O.D.
Chicago, Ill.

Over the past 20 years, the profession of optometry has advanced rapidly with innovative diagnostic technology, more effective pharmaceuticals, and breakthrough materials in contact lenses. Scope of practice has been redefined in most states. In fact, Illinois recently passed a law allowing optometrists to prescribe oral medications. A huge win!

Yet one major cause for concern is that even with all these tremendous advancements, consumer behaviors and perceptions of eye care have not changed much over the past 20 years. As ambassadors for eye care, we have kept these advancements bottled up in this time capsule. Patients need to know that:

1. Eye disease and disorders can occur in patients whose vision does not change. Therefore a regularly scheduled, comprehensive eye examination is critical to maintaining healthy eyes and healthy vision.

2. The optometrist is qualified to administer the exam as well as treat many diseases and disorders of the eye.

One additional question looms: How often should the regularly scheduled eye exam occur? To answer this, I'll address not only the expertise of optometrists, but also patient perception, medical costs, financial burden and socio-economic benefits of eyecare.

Patient perception vs. reality

The American Optometric Association states that "as primary eye care providers, doctors of optometry examine, diagnose, treat and manage diseases and disorders of the visual system, the eyes and associated structures as well as diagnose related systemic conditions."1 Yet, ask your patients why they came in, and most likely you will hear one of the following replies: "My glasses are broken," "I am seeing blurry" or "I am out of contacts." How often do your patients state they are here for an "annual eye health and wellness exam?"

Most people simply do not understand what an eye exam is, or how eye health and systemic conditions affect the visual system. This perception is prevalent even among those that visit their dentist twice a year and receive a mammogram annually. Unfortunately, there exists an extreme lack of awareness of the importance of regular eye care and the impact it can have on one's vision, eye health, and general health. For the majority of patients, they view an eye exam as only a refraction, or a permission slip, to buy a new pair of glasses or contact lenses.

Lack of Awareness and the Economic Burden

One can make a strong case for setting a clear standard for annual eye exams (unless the doctor recommends otherwise) based on a medical and economic perspective that follows. If we truly believe in the above definition of optometrists, then it might be our moral responsibility as well.

Figure 1 lists the prevalence of just a few visual and systemic diseases that can affect the eye. As eye care professionals, we understand how the diseases in figure 1 can impact the visual system, the eye, and associated structures. Yet survey after survey demonstrates consumers, even those with the highest risk factors, simply do not understand the relationship of how systemic disease can affect their eyes. For example, the Centers for Disease Control and Prevention states "There is an alarming lack of concern in those aged 50 and over regarding preventative eye care."2 Almost 50% of people above the age of 50 have never had a dilated eye exam and 30% to 35% have not visited an eyecare professional during the past year!2 (According to the CDC, annual dilated eye exams are recommended for patients with diabetes and individuals aged 65 years and older.) According to a June 2005 Vision Council of America study, over 50% of people do not know the difference between a vision screening and an eye exam.3 There are other numerous other studies to support the argument that there is an extreme lack of awareness of the importance of eye care.

This lack of awareness comes with a heavy economic burden as well. The combined cost of direct and indirect medical expenses of vision loss amount to over $51 billion annually.4 Eye disease health care expenditures amount to almost $16 billion annually,5 more than that of breast cancer ($7.2 billion), lung cancer ($5.6 billion), and HIV ($9.4 billion).6 Vision disorders account for more than $8 billion dollars in lost productivity.7 Uncorrected vision can decrease employee performance by as much as 20%.8 Also, there are over 800,000 work-related eye injuries annually, 90% of which are preventable.9

Fig. 1. Prevalence of Selected Visual and Systemic Disorders that Can Affect the Eye
Vision correction- Estimated 140 million American:
• 25% of children have a vision problem
• 35% of children between the ages of 5 and 12 have never had an eye exam
• Vision screenings miss one-third of kids who have a vision proble
• 80% of what a child learns is through their vision

Diabetes- 54 million pre-diabetics
• 20 million diabetics and 1/3 unaware
• Leading cause of new onset blindness in working age population
• Alarming increase in diabetes among adolescents and young adults

Hypertension- 65 million Americans
• Only 34% have hypertension under good control

Cholesterol- 105 million Americans have high or borderline high cholesterol

What are the economic and medical benefits of regular eye care?

Unfortunately, the World Bank states that the cost of vision loss and blindness is much higher than previously recognized. The good news is, they list "sight-saving therapies as being among the most highly cost-effective interventions."11 According to the research done by Jonathon Javitt, people with blindness and vision loss are significantly more costly to Medicare. In fact it is almost twice the cost of a typical Medicare beneficiary.10 His research also indicates eye care can play a significant role in helping manage diabetes. He states, "enrolling a single person with IDDM (Type 1 diabetes) in proper eye care yields a net annual savings of approximately $10,000 in federal budgetary expenditures."11 A study cited by VCA in their 2007 Vision in Business Report supports this position. They write "employers gain as much as $7 for every $1 they spend on vision coverage."7

As eye care professionals, we understand how early treatment improves clinical outcomes for patient's with glaucoma, diabetes, and age-related macular degeneration (AMD). It seems week after week we read about how early AMD is linked to higher (double) risk of stroke.12 Other research demonstrates that early detection and treatment for AMD reduces the personal, social, and economic burden of the disease.13

As one can see, eye care practitioners need to play a larger role in the disease management and wellness realm of health care. In addition, the annual examination provides optometrists with perhaps the best tool to ensure health health and vision, which in turn, increases worker productivity and saves society potentially billions of dollars.

Annual Exam Standard

In summary, there are economic, medical, and moral benefits for setting a clear standard for patients to return annually. We must consider:

1. It is our duty to address the lack of public awareness of eye care and the link to systemic conditions.

2. We have a moral responsibility to ensure children are receiving proper eye care to help them to set them up for successful academic and professional careers.

3. We can dramatically improve the quality of life of our patients, particularly the elderly through disease prevention, early detection, and better disease management.

4. With early detection, we reduce the economic burden on Medicare while boosting worker productivity.

5. An eye exam is a low cost/high benefit, non-invasive way for the public to enter into the healthcare system.

A new gold standard

If we are truly optometrists that take care of vision, and help manage eye health and systemic conditions, we must look upon ourselves differently. Disease management and wellness will play an increasingly important role as baby boomers continue to age.

Industry leaders, organized optometry, and colleges of optometry must help consumers move forward with the times as well. It's time to set a clear standard for when to return and improve the delivery of eye care to consumers. OM

1. American Academy of Optometry. "Why Choose Optometry?" http://www.aoa.org/x5130. xml

2. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, Dec. 15, 2006

3. Prevent Blindness America, "Our Vision is Our Children's Vision," www.preventblindness.net/ovcv

4. The Alliance for Aging Research, National Alliance for Eye and Vision Research "The Silver Book: Vision Loss." www.silverbook.org/visionloss

5. Centers for Disease Control, "Communication Plan Excerpt: A Diabetic Eye Disease Program For People with Diabetes." www.cdc.gov

6. Brown, ML., J. Lipscomb, and C. snyder. 200. "The Burden of illness of Cancer: Economic Cost and Quality of Life." Annual Review of Public Health 22:9–3.23

7. The Vision Council, "Vision in Business 2007." www.checkyearly.com

8. Daum, K.M. Optometry, January 2004; vol 75: pp 33-47.

9. Centers for Disease Control. "Healthy People 2010 Vision. Fact Sheet: Eye Safety at Work is Everyone's Business." www.cdc.gov/features/dsworkPlaceEye/

10. Javitt J, Venkataswamy G, Sommer A. The economic andsocial aspect of restoring sight. In: Henkind P, editor: ACTA: 24th International Congress of Ophthalmology. New York, JB. Lippincott, 1983:1308–1312.

11. Javitt JC: Preventing blindness in Americans: the need for eye health education. Surv Ophthalmol 40(1): 41-44, 1995

12. Tien Yin Wong, MD, MPH, PhD, et al. "Age-Related Macular Degeneration and Risk for Stroke" Annals of Internal Medicine, 18 July 2006, Vol.145 Iss. 2, 98-106

13. Gonzales, C. "Early treatment of macular degeneration with macugen may help patients preserve their vision." Retina, October 2005, 815-27.

Dr. Hansra is Director of Eye Care Luxottica Retail. Readers may contact him at Send e-mail to ghansra@luxotticaretail.com.


Optometric Management, Issue: October 2008