OSLI Retina

October 2019

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608 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina ■ C L I N I C A L S C I E N C E ■ Examination Practices and Referral of Patients With Diabetic Retinopathy by Optometrists in Routine Clinical Care Andrew X. Chen; Jessica Hsueh; Michael M. Han; Thais F. Conti, MD; Felipe F. Conti, MD; Wes K. Immler, OD; Amy S. Babiuch, MD; Rishi P. Singh, MD BACKGROUND AND OBJECTIVE: To analyze the ex- amination practices and referral of patients with diabetic retinopathy (DR) by optometrists in rou- tine clinical care. PATIENTS AND METHODS: Diabetic patient records from 2012 to 2018 were retrospectively reviewed for documentation of dilated fundus exam (DFE), imaging, follow-up appointments, and referrals. Concordance between clinical exam and coding was also analyzed. RESULTS: For 97.8% of encounters, DFE was per- formed, the patient was referred for DFE, or DFE was scheduled for follow-up. When DFE was per- formed at the initial visit, this resulted in referral of 19.8% of patients to an ophthalmologist. Imaging was obtained occasionally, with fundus photos in 2.6% and optical coherence tomography in 14.5% of encounters. Concordance of DR grading between exam and coding was 78.8%. Recommended fol- low-up times were incorrect based on DR severity level in 13.8% of encounters. CONCLUSION: Although DFE was performed reliably by optometrists, utilization of imaging, DR grading and coding, and appropriate follow-up pe- riods could be improved. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:608-612.] INTRODUCTION As of 2017, 23.1 million people in the United States had been diagnosed with diabetes, and it is es- timated that 7.2 million people were undiagnosed. 1 With the increasing societal burden of diabetes, op- tometrists can expect an increase in the number of di- abetic patients and diabetic retinopathy (DR) in their practice. DR is the most common cause of vision im- pairment and blindness among working-age adults in the United States. 2 It also has a known natural history and an asymptomatic phase, which makes it a suit- able disease for screening. Over time, uncontrolled blood sugars lead to increased vascular permeability and retinal ischemia, with resultant proliferative dia- betic retinopathy (PDR) and macular edema, known causes of significant visual impairment. If at-risk dia- betic patients can be identified, effective treatments can be delivered, and vision loss can be prevented. Optometrists serve as first-line providers for ocu- lar health and, therefore, in the detection and man- agement of DR. According to the American Optomet- ric Association, "In 2016 alone, doctors of optometry identified diabetes-related manifestations in more than 320,000 patients who were unaware they had diabetes." As optometrists play an integral part in preventative care, it is imperative that they are aware of diabetic status, perform a comprehensive dilated fundus exam (DFE), and recommend appropriate fol- low up and referral. 3 According to the International Council of Oph- thalmology (ICO), diabetic patients should receive comprehensive DFEs every 1 to 2 years, or more fre- quently if DR is present. 4 Efforts have been made to From Case Western Reserve University School of Medicine, Cleveland, Ohio (AXC, JH, MMH, RPS); Cole Eye Institute, Cleveland Clinic Foundation, Cleve- land, Ohio (TFC, FFC, ASB, RPS); and the Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio (TFC, FFC, WKI, ASB, RPS). Originally submitted August 9, 2018. Revision received January 9, 2019. Accepted for publication March 11, 2019. Supported by a continuing medical education grant from Genentech. Dr. Babiuch has received personal fees from Allergan, MCME Global, and Vindico outside the submitted work. Dr. Singh has received grants and personal fees from Genentech during the conduct of this study, as well as grants and personal fees from Regeneron and Novartis/Alcon and personal fees from Optos, Bausch + Lomb, and Zeiss outside the submitted work. The remaining authors report no relevant financial disclosures. Dr. Singh did not participate in the editorial review of this manuscript. Address correspondence to Rishi P. Singh, MD, 9500 Euclid Avenue, Desk i32, Cleveland, OH 44195; email: SINGHR@ccf.org. doi: 10.3928/23258160-20191009-02

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