Article

In this ophthalmic practice, diabetes is an important focus

An undiagnosed diabetic in her office five years ago cemented a decision for Shilpa Rose, MD: She now would look for similar patients, among her patients, every day.

Like everyone in our specialty, I have treated diabetic patients ­– as an ophthalmologist – for years. But, in my 15th year of practice, 5 years ago specifically, I began looking for diabetic patients.
 
 One patient is responsible for this decision.  He was a young attorney, wanting to get back to his office after a quick visit. He was having trouble seeing with his glasses and all he wanted  was an updated prescription.  But he was an ill young man and didn’t know it.  Yes, he got his new refractive change.  But I couldn’t ignore his recent weight gain. So I started taking tests of the unophthalmic type.
 
His hyperlipidemia number was more impressive than his BMI; his elevated blood pressure was clinically noteworthy as well. His responses to my additional queries led me to order a hemoglobin A1c and prompt referral to an endocrinologist. Within days, he had a new diagnosis and a lifestyle change. As his advocate I was responsible for getting him the appropriate medical care.  I knew that if I had just written a new prescription that day and had not been focused on the whole patient, I would have missed a life-threatening diagnosis. Sure, it is easy to check off the Review of Systems, but delving into the details is crucial and can be life-changing for many patients.
 
November is Diabetes Awareness Month. It is a time when all health-care professionals should re-evaluate how they approach this disease and how patients’ lives can be improved. I find it ironic that as ophthalmologists we are in an excellent position to warn patients of the hazards of this disease: We have looked at diseased retinas and seen the neovasculature forming, the macular disintegrating. But we only treat these patients after their sight is in danger. Would it not make more sense for us to look for clues that are harbingers of diabetes, to either ward off its coming or to control it when it does?
 
Hence, the change in my exam game plan.
 
The data
In 2011-2014, 36.5% of adults in the United States were obese (BMI 30 kg/ms or higher), according to the CDC.1
Most people with type 2 diabetes ­­– and most diabetics have type 2 – are obese.2
In 2015, Menke et al. 3 published results from surveys (NHANES) conducted of U.S. adults regarding diabetes prevalence. The years were between 1988-1994 and 1999-2012: 2781 adults from 2011-2012 were used to estimate recent prevalence and an additional 23 634 adults from 1988-2010 were used to estimate trends.
 
 The authors used three criteria to establish a diabetes diagnosis: an A1c; fasting plasma glucose or two-hour plasma glucose. They found:
  • Unadjusted prevalence, diabetes and prediabetes, 14.3%
  • Unadjusted prevalence of total diabetes, 12.3% (among those with diabetes, ¼ were undiagnosed)
  • Diagnosed, 5.2%
  • Undiagnosed, 36.4%
 
The bottom line: The age-standardized prevalence of total diabetes increased from 9.8% in 1988-1994 to  12.4% in 2011-2012.
 
Chronically high blood glucose from diabetes is associated with diabetic retinopathy (DR). When high blood glucose levels are not managed, blood vessels leading to the light-sensitive tissue in the retina can be damaged. This diabetes-induced injury of the retinal microvessels leads to the vascular pathology of DR and ultimately vision loss. The American Diabetes Association says DR is the leading cause of blindness for 20 to 64 year olds. This equates to 12% of all new cases of blindness, over 3 million people annually. (To add another dimension: Diabetes and cancer likely share direct links, such as aging, obesity, diet and physical inactivity. 4

Why switching gears makes sense
So how can this population protect their vision?  Getting regular eye care is vital, as early detection and treatment can reduce the risk of blindness by 95%.5  Studies such as the Diabetes Control and Complications Trial (DCCT) have shown that controlling diabetes slows the onset and worsening of DR.  DCCT participants who kept their blood glucose level as close to normal as possible were significantly less likely than those without optimal glucose control to develop DR, as well as kidney and nerve diseases.  Other trials have shown that controlling elevated blood pressure and cholesterol can also reduce the risk of vision loss for the diabetic patient.6
 
Nutrition and lifestyle play an intricate role in diabetes and DR prevention and treatment. Exercise and overall better nutrition can lead to dramatic decreases in a patient’s hemoglobin A1c. 2 Yes, many patients hear this from their primary care physician, but they should also hear the same message from their ophthalmologist.  Patients need to know that their risk of developing retinopathy 9 and 17 years after their diabetes diagnosis is strongly associated to modifiable risk factors such as glycemic control, obesity and tobacco use.
 
The role of essential fatty acids in the diet is fascinating and revolutionary. Peer-reviewed data are plentiful to support the nutritional need for omega-3s EPA/DHA – DHA is found in high concentrations in the body as a medical food to protect against DR development or to arrest progression in the already omega-3-deficient diabetic patient.  A study conducted by the National Institute of Health (NIH) supports nutritional intervention as treatment.  The researchers found that increasing omega-3s and decreasing omega-6 fatty acids in mice reduced the area of vessel loss that ultimately causes the growth of the abnormal vessels which may lead to blindness.  Omega-6 fatty acids further contribute to the growth of abnormal blood vessels in the retina. The study showed that the mice with higher amounts of omega-3s had a nearly 50% decrease in all phases of retinopathy. Several stages of retinal vascular degeneration have been shown to benefit from the introduction of omega-3s EPA/DHA into a treatment protocol. 7-9
 
In the chair
I have adopted a whole patient, slightly holistic approach. I now examine and educate my patients during every step of the visit.  While I am at the slit lamp, phoropter or even when using my indirect ophthalmoscope, I will ask each patient about risk factors for DR, ARMD, dry eyes and glaucoma. I even ask about joint pains and arthritis. I ask about lifestyle; careers; exercise. I am trying to figure out refractive needs, but I also want to know if the patient is on the computer all day so I can assess stress levels. I notice what the patient brings into the exam room, like a muffin. I prefer to get the patient’s history myself. I make sure to get drug history.
I cite definitive medical data and studies to support my recommendations. If the patient has diabetes, I ask if the patient has learned about the latest monitoring pump or newest medication. I ask each prediabetic or diabetic patient who manages his diabetes about who monitors his blood glucose levels.  I suggest enlisting the additional support of an endocrinologist and health coach/nutritionist early on.

Referrals
Referrals to my retina colleagues are made much sooner these days. I will introduce them to retina, sometimes even before signs of DR can be seen. I find that the fear of retinopathy improves diet compliance and stricter glycemic control; hearing about the possibility of losing a limb is also an incentive for them to mind their carb intake.  My retina colleagues are most appreciative and supportive of this.  They too find enjoyment in education and early screening.
 
This new, whole patient approach has allowed me to screen more efficiently for those at risk for diabetes. My prediabetic patient population has grown considerably. Some of it likely stems from patient referrals as well as from my speaking to primary care physicians, both in more formal settings, and informally, to discuss an individual patient. In the days of the internet and social media, patients are receptive to information, education and sharing what they have learned from their physicians.
I haven’t increased my chair time considerably.  It now comes so naturally and as part of the exam, that I know no other way. It allows me to know my patients better, build rapport, and develop a trusting relationship with them. All of this helps build relationships and a good medical and surgical practice.
I get no opposition from my patients. They are so appreciative. That attorney who started this whole switch? He treats me like his primary.
Patient education from a specialized health care professional should remain the mainstay of prevention and cure, especially when people search internet sites with little guidance or knowledge. In my mind, we should be at the forefront of education and detection of diabetes and diabetic retinopathy.
 
November is a good time to start asking questions.
 
References
  1. Adult obesity facts. Prevalence of Obesity Among Adults and Youth: United States, 2011–2014. NCHS data brief. No. 219. November 2015. Accessed Nov. 1, 2017.
  2. Eckel RH et al. Obesity and Type 2 Diabetes: What can be unified and what needs to be individualized? Diabetes Care.2011. Jun; 34(6): 1424-1430
  3. Menke A1Casagrande S1Geiss L2Cowie CC3    Prevalence of and Trends in Diabetes Among Adults in the United States, 1988-2012. JAMA. 2015 Sep 8;314(10):1021-9.
  4. Table 1. Summary and recommendations. Diabetes Care. 2010 Jul; 33(7): 1674–1685.
  5. NEI. Facts about diabetic eye disease. https://nei.nih.gov/health/diabetic/retinopathy
  6. Fong, DS et al. Retinopathy in Diabetes. ADA Diabetes Care 2004 Jan; 27(suppl 1): s84-s87. 
  7. Omega-3 Fatty Acids Protect Eyes Against Retinopathy, Study Finds. National Institutes of Health(NIH) Archived Report, June 24, 2007.
  8. N-3 Polyunsaturated Fatty Acids Prevent Diabetic Retinopathy by Inhibition of Retinal Vascular Damage and Enhanced Endothelial Progenitor Cell Reparative Function. PLoS. January 2013; (8): 1.
  9. Chew, EY, SanGiovanni, JP. The role of omega-3 long-chain polyunsaturated fatty acids in health and disease of the retina. Progress in Retinal and Eye Research 24 (2005) 87-138
 

Shilpa Rose is in private practice at Whitten Laser Eye in Washington, D.C.