Editor’s note: The information provided in this article relates to general optometric practices. All testing and follow-up appointments should follow the guidelines of the patient’s insurance plan, when that is being utilized.
“Optometrists are often the first to suspect and recommend testing for diabetes, based on clinical findings during [comprehensive] eye exams,” says Francisco Burgos, O.D., A.B.C.M.O., Katzen Eye Group, Lutherville, Md. This is important because more than 30.3 million people, or 9.4% of the U.S. population, had diabetes as of 2015, The American Diabetes Association reports. Furthermore, more than 84.1 million U.S. adults are pre-diabetic, and more than 90% of them don’t even know they have it, according to the CDC.
As such, optometrists should have in place practices to serve these patients to the best of their abilities, specifically, developing relationships with primary care providers, adding value via providing patient education, tracking clinical signs and, finally, coding appropriately.
“It’s imperative that they [optometrists] have working relationships with primary care providers, internists and endocrinologists,” says Dr. Burgos. “This is because the eye is the only place in the body where diabetic changes can be seen without invasive procedures.”
A simple way to create such relationships is to send a summary letter to a patient’s primary care provider after an exam, he suggests. In addition, Dr. Burgos recommends optometrists look up primary care providers, internists and endocrinologists in their local areas and send letters introducing their practices and describing their services, diagnostic equipment and abilities to diagnose and manage diabetic eye disease, he says. Also, making a simple phone call to communicate and share pertinent findings of a mutual patient enhances the connection between O.D.s and primary care providers, possibly, generating future referrals.
Nathan Rock, O.D., F.A.A.O., consultative optometrist, Wang Vision Institute, Nashville, says he establishes physician relationships through his existing diabetic patient base. “When I see a patient with diabetes for a dilated exam, I always send a letter to their primary care provider,” he says. “This has become easier with electronic health record systems, which can quickly generate customizable template letters. Once a patient’s primary care physician is in the EHR system, it becomes easier to send the next follow-up letter to them. Practices appreciate receiving the communications and start proactively referring other patients.”
Aaron Lech, O.D., F.A.A.O., managing partner, ClearVue Eye Care, Roseville, Calif., says he drew a radius that matched his patient database and zip codes in an effort to gain referrals. Then, he compiled a list of primary care physicians, endocrinologists and nephrologists and visited and introduced himself to them. At that time, he requested a lunch date to discuss recent advances in caring for these patients.
Vision Source provides Peter H. Kehoe, O.D., F.A.A.O., F.N.A.P., president, Kehoe Eye Care, PC, Galesburg, Ill., with a program to purchase baskets to deliver every quarter to local physician and mid-level practitioner offices to introduce his practice. It includes a little food, but primarily information on his practice’s technology and services.
Other ways optometrists can establish physician relationships include being involved in local civic organizations and participating in local health screenings and patient support groups, says Mohammad Rafieetary, O.D., F.A.A.O., A.B.O., consultative optometric physician, Charles Retina Institute, Germantown, Tenn.
Prevalence of Diabetic Retinopathy
→ ESTIMATED INSTANCES OF DIABETIC RETINOPATHY FOR U.S. PATIENTS, ACCORDING TO THE JOURNAL OF INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH
Stephanie Pisano, O.D., F.A.A.O., clinical assistant professor, The Ohio State University Wexner Medical Center, Department of Ophthalmology and Visual Science, Columbus, Ohio, says she thoroughly explains to patients what she is looking for and why during the exam. For example, she shows patients photos of a normal fundus vs. the various stages of diabetic retinopathy on a small tablet.
“Oftentimes, patients use the level of their vision as a measuring stick for how well their retinal disease is doing,” Dr. Rafieetary says. “Consequently, they may forgo follow-up care until they have symptoms and, possibly, irreversible disease. Tell patients that just because they can still see, it doesn’t guarantee that vision loss won’t occur. But with proper care of their systemic condition(s) and eye care, their long-term outcome is extremely improved.”
During an appointment, an optometrist should thoroughly educate patients who have diabetes about modifiable risk factors, such as obesity, tobacco use, dietary habits, obstructive sleep apnea, systemic hypertension and lipid disorders, that contribute to the and progression of DR, Dr. Rafieetary says.
They should also discuss the possible consequences of DR: “I tell patients that it’s the leading cause of blindness, which is preventable by proper follow-up and management,” he says.
Mark Dunbar, O.D., F.A.A.O., director of optometry, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami says, “Optometrists should echo the sentiments of primary care physicians and endocrinologists.” This means asking the patient how often she checks her blood sugar, what her hemoglobin A1c is and what her diet is like, in addition to educating her on what a healthy diet consists of, such as lean meats and fish. Also, this means discussing the benefits of regular exercise and the importance of having an annual eye exam, even if the patient doesn’t have DR. “Patients may need to hear these things a number of times from various doctors, before their importance resonates with them,” he says.
John Warren O.D., president, Warren Eye Care, Racine, Wisc., says he has found that it’s much better to motivate and encourage patients than to use scare tactics, until motivation and encouragement have failed. “A bit of empathy goes a long way toward patient engagement,” he says.
If exam findings raise suspicion of other comorbidities, such as carotid artery disease in the presence of asymmetrical retinopathy, the optometrist should further explore by investigating the patient’s history or making the appropriate recommendations, such as a carotid ultrasound or angiography or referral for further evaluation, Dr. Rafieetary says. Optometrists should also emphasize the importance and need for follow-up eye care.
TRACKING CLINICAL SIGNS
Dr. Pisano advises starting anteriorly and moving posteriorly when examining patients who have diabetes.
“After refracting a patient, carefully look at their non-dilated iris for any abnormal vessel growth or neovascularization of the iris,” she says. Moving back, examine the lens for any opacities, the vitreous for any presence of hemorrhages and, finally, the retina. For particularly complicated findings, I examine one eye, have the patient sit back while I thoroughly document it and then move to the other eye.”
“I do this because most patients I examine have complex findings,” Dr. Pisano says. “This helps facilitate accurate and thorough documentation of exam findings of each eye. I don’t have a scribe or use verbal dictation, so I have found this technique helps if I am charting after the patient has left the office.”
Dr. Kehoe says tracking refractive changes, especially big shifts, is key in tracking diseases, such as DR and macular edema. He says he relies heavily on ultra-widefield images to direct dilated fundus exams. “A single capture ultra-widefield image and fundus auto-fluorescence images help to detect the subtlest of retinopathy, including [in] the far periphery, which really matters,” he says.
If retinopathy is detected, Dr. Kehoe says he will continue to monitor the disease with periodic updated ultra-widefield images, as well as OCT to monitor structural changes and full-field electroretinogram to monitor functional changes in the retina.
Dr. Rock finds fundus photography to be particularly helpful now that intravitreal injections are approved for use in patients with DR whether they have macula edema or not.
Dr. Warren says he checks the appearance of the fundus via several imaging technologies, including ultra-widefield imaging. When retinopathy is present, he says he also obtains scanning laser ophthalmoscopy images to determine whether there is any retinal or macular edema present, which may or may not be visible with other observation or imaging techniques. Edema also can be quantified and followed for progression or regression over time.
“If retinopathy is present, then OCT helps measure the impact on retinal thickness and helps detect retinal or macular edema earlier than any other means,” Dr. Warren says.
Additionally, Dr. Warren says he performs a screening OCT on all annual comprehensive eye health exams, whether the patient is diabetic or not.
“Oftentimes, early and subtle macular edema is present and detectable first with OCT screening well before it can be visualized with any other imaging technique,” he says.
He adds that he orders a comprehensive macular OCT with interpretation and report for patients who have known retinopathy — a more comprehensive OCT exam to better evaluate the macula.
As far as the anterior segment: “I look carefully at the aberrometry of patients with diabetes,” he says. “They’re more likely to have more aggressive and earlier cataract formation.”
Many times, patients benefit from multiple imaging studies.
The most common diagnostic code Dr. Rock’s office uses is E11.9 for a Type 2 diabetic patient without retinopathy. The codes in the family of E11.3 specify Type 2 diabetic patients with retinopathy, and the codes grade the specific level of retinopathy and the presence or absence of macular edema.
“Fortunately, good EHR coding software makes this selection list available, which can then be transmitted to billing staff,” Dr. Rock says. Other procedure codes commonly used for diabetic patients are 92134 for OCT of the macula and 92250 for fundus photography.
Managing patients who have diabetes, a growing population, can be a great way to provide exceptional patient care, while building a practice. Optometrists can see patients who have mild and moderate non-proliferative DR once or twice a year (when medically necessary and within guidelines of patient insurance) and use technology to determine when referral to a retinal specialist is necessary. OM