Primary eyecare physicians often see patients early in the diabetes journey. Patients may be newly diagnosed with diabetes and referred to us for a comprehensive eye exam (including dilated retinal evaluation), or they may already have diabetic retinopathy that we are monitoring. These patients may still be processing the implications of their diagnosis when we see them.
As members of their care team, we are responsible for their ocular health, but we are also in a position to emphasize and expand upon the reasons why they should commit to managing their disease as prescribed.
In this article, we discuss the obstacles to adherence and how we can help patients overcome them.
Obstacles to Self-care
A patient’s adherence to care and therapy has a profound effect not only on retinopathy but also on his or her overall well-being. Patients’ attitudes, beliefs, and knowledge about diabetes may adversely affect self-management.
Patients are instructed and encouraged to adhere to the medical treatment regimen for their diabetes and to address modifiable risk factors and concomitant conditions, such as hypertension, dyslipidemia, obesity, sleep apnea, and smoking. For many patients, the recommended lifestyle changes may seem daunting. Keeping them engaged and motivated at every visit is important.
We use positive reinforcement of productive behaviors — for example, if they lower their HbA1c by even 0.5% or reduce their weight by even 2 pounds — to help motivate patients. We use a sensitive, caring approach to discuss setbacks, explaining that poor adherence to their diabetes care program may result in suboptimal glycemic control, potentially leading to microvascular complications. We emphasize that severe vision loss from diabetes is often preventable with timely detection and treatment.
Ongoing Challenge: Missed Appointments
One of the most challenging aspects of caring for patients with diabetes is that many of them have a tendency to not keep their appointments. Missed medical appointments disrupt the continuity of care, thereby interfering with regular preventive screening and timely intervention.
Patients who frequently cancel appointments may do so because of lack of transportation, inadequate insurance, occupational obligations, family responsibilities, or limited English language skills.
Many factors predispose patients to avoiding medical appointments, such as young age, limited education, and low income, so we need to be mindful and take extra care to educate patients in these groups. In addition, patients may be skeptical about the effectiveness of their care or the efficacy of medications, or they may be concerned about the complexity of therapy, out-of-pocket costs, polypharmacy, or hypoglycemia.
National health survey data indicate that only about half of patients with diabetes undergo an annual dilated retinal exam.1 The statistics for patients with diabetic eye disease keeping appointments with their retina specialists are also troubling. A recent study found that patients with diabetic macular edema were about three times more likely to miss appointments than patients with wet AMD.2
EDUCATIONAL ASSETS FOR PATIENTS WITH DIABETES
Enhanced knowledge may lead to improved adherence, and patients can consult various trusted sources to educate themselves.
Eye on Diabetes was a program developed by an interprofessional provider team that uses a structured curriculum of interactive classes to enhance patients’ knowledge of diabetes and its ocular implications.1
The National Eye Institute (NEI) has developed numerous educational brochures and videos to help patients better understand diabetic eye disease (nei.nih.gov/diabetes ).
The NEI offers the following easy-to-remember acronym to help people with diabetes keep their health on TRACK:
- Take your medications as prescribed by your doctor
- Reach and maintain a healthy weight
- Add physical activity to your daily routine
- Control your ABCs — A1c, blood pressure, and cholesterol
- Kick the smoking habit
In addition, patients can reduce their risk of developing severe vision-related complications by having regular comprehensive eye examinations with dilated retinal evaluation.
- Wagner H, Pizzimenti JJ, Daniel K, Pandya N, Hardigan PC. Eye on diabetes: a multidisciplinary patient education intervention. Diabetes Educ. 2008;34(1):84-89.
Practical Use of Posterior Segment Imaging in Diabetic Retinopathy
BY JOSEPH J. PIZZIMENTI, OD, AND SHANNON LEON, OD
In patients with diabetes, certain factors should alert clinicians to look more intently, perhaps using more sophisticated methods to identify a particular finding or group of related signs. The case history and patient demographic information should drive this purposeful examination process.
When properly implemented, posterior segment imaging technologies, such as OCT, OCT angiography (OCTA), and widefield fundus imaging may enhance the clinician’s ability to identify and characterize signs of disease, even in eyes with compromised media. Imaging may be employed in cases where more information about the optic nerve, vitreoretinal interface, sensory retina, RPE, Bruch’s membrane, and the choroid is desired.
A 67-year-old black male with a history of hypertension and Type 2 diabetes with proliferative diabetic retinopathy (PDR) presented after panretinal photocoagulation (PRP) of both eyes. He reported gradual central blurring in the right eye. His entering visual acuity of 20/60 did not improve with pinhole. His recent HbA1c level was 6.9%, and in-office blood pressure measured 122/81 mmHg.
In addition to bilateral PRP laser, dilated fundus examination showed hard exudates, microaneurysms, and retinal thickening involving the foveal center, all in the right eye. The center-involved macular edema was confirmed on an OCT Macular Cube scan (Figure 1). A suspicious area of vascularization was noted in the retinal periphery of the right eye. Cirrus 5000 OCT with Angioplex (Zeiss) confirmed the presence of neovascularization elsewhere (NVE) (Figure 2). The patient was referred to his retina specialist for treatment of the macular edema and additional laser for the NVE.
TREATMENT AND FOLLOW-UP
The patient’s right eye was treated with a series of intravitreal injections of ranibizumab (Lucentis, Genentech), as well as additional laser therapy for the NVE. We continued to monitor the patient post treatment. He practiced good adherence to his scheduled visits and maintained effective glycemic and blood pressure control.
Although the patient has since moved to another state, HIPAA-compliant communications with his current retina clinic revealed that the treatments achieved a stable visual acuity of 20/30 OD for the past year with no further areas of neovascularization.
KEY CLINICAL TAKEAWAYS
- OCT is a noninvasive means to confirm a suspicion of macular edema, as well as to characterize and quantify that edema.
- Imaging of normal and abnormal retinal vasculature with OCTA is helpful not only for establishing a diagnosis, but also for providing a better understanding of the pathophysiology of retinal vascular disease.
- Along with explaining the results of the dilated retinal examination, reviewing with the patient the results of fundus imaging and OCT/OCTA provides valuable education and motivation for continued adherence to care.
Kirsti Ramirez, OD, and Carolyn Majcher, OD, contributed to this case.
CONTINUOUS GLUCOSE MONITORING AND DIABETIC RETINOPATHY
Glycemic control is vital to diabetes management. Among the methods used to monitor blood glucose are in-office glycosylated hemoglobin (HbA1c) measurement, self-monitoring of blood glucose, and continuous glucose monitoring (CGM).
While HbA1c is the gold standard in diabetes management, it has limitations.1 For example, HbA1c is significantly influenced by systemic conditions that affect red blood cell life span, and it has been shown to vary by race and ethnicity.1-3 Further, because HbA1c is a mean measurement, it cannot accurately predict or reflect acute glycemic changes, which is of great importance in diabetes management.1,3
Recognizing these limitations, researchers and clinicians have become interested in combining measurement methods or utilizing alternative blood glucose monitoring methods such as CGM.
CGM provides real-time or intermittently viewed measurements of blood glucose levels.3 This method of monitoring is gaining ground in blood glucose management because of increased understanding of the importance of tight glycemic control in both preventing and managing complications. Landmark clinical studies have shown the benefit of increased glycemic control (apart from early transient reversible initial worsening) with respect to diabetic retinopathy (DR), and additional follow-up studies have highlighted the ability to maintain this reduced risk.4
CGM employs small sensors that are placed on the body to painlessly collect information about blood glucose levels. These levels are then transmitted to a monitor that displays them, typically at 1-, 5-, 10-, or 15-minute intervals.
While CGM is used mostly by patients with type 1 diabetes, there is interest in using it for type 2 diabetes as well, because of its ability to track maintenance and to generate information on quality of therapy.5 Even with these benefits, however, concerns regarding CGM remain, including cost, standardization, necessity, and implementation.
Among the measurements that CGM provides is time in range (TIR), the amount of time a patient spends within his or her target glucose range.2,3,5 TIR provides a better understanding of glycemic control as it gives greater information about daily acute fluctuations, which can then be used to improve control over time.5
A recently published study evaluated the relationship between TIR and diabetic retinopathy in 3,262 subjects with type 2 diabetes. The investigators found that diabetic retinopathy and its severity are inversely related to TIR, as subjects with more severe cases of retinopathy spent less time in range and, thus, had higher variation in glycemic control.2,5 Although some limitations were noted within the study, TIR shows potential as a measurement of glycemic control that can provide new, important information independent of HbA1c metrics.
The same study also considered the concept of glycemic variability, which is categorized as the fluctuations in blood glucose during a 24-hour period, and the differences in blood glucose fluctuations during the same time periods on different days.2,4,5 Research on the role of glycemic variability in improving glycemic control is ongoing, with studies also evaluating its potential association with micro- and macrovascular complications.6
One major issue in the use of glycemic variability is standardized measurements, as currently there are several ways to evaluate glycemic variability.6 Further research and standardization are needed for more practical use of this metric. However, the combination of glycemic variability, TIR, and HbA1c would provide a more complete picture of glycemic control apart from HbA1c alone. By assessing time in target glucose range using a continuous glucose monitor, providers may now have a measurable risk for development and severity of DR.
- Wright LA, Hirsch IB. Metrics beyond hemoglobin A1c in diabetes management: time in range, hypoglycemia, and other parameters. Diabetes Technol Ther. 2017;19(s2):S16-S26.
- Lu J, Ma X, Zhou J, et al. Association of time in range, as assessed by continuous glucose monitoring, with diabetic retinopathy in type 2 diabetes. Diabetes Care. 2018;41(11):2370-2376.
- Danne T, Nimri R, Battelino T, et al. International consensus on use of continuous glucose monitoring. Diabetes Care. 2017;40(12):1631-1640.
- Chatziralli IP. The role of glycemic control and variability in diabetic retinopathy. Diabetes Ther. 2018;9(1):431-434.
- Time in range according to CGM associated with diabetic retinopathy. Endocrinology Advisor. 2018;Sept 26. Available at: https://www.endocrinologyadvisor.com/home/topics/diabetes/type-2-diabetes/time-in-range-according-to-cgm-associated-with-diabetic-retinopathy/ . Accessed April 4, 2019.
- Suh S, Kim JH. Glycemic variability: how do we measure it and why is it important? Diabetes Metab J. 2015;39(4):273-282.
Making Appointments a Priority
We explain to patients that we want to see them at least once per year — and we pre-schedule their next visits — because diabetes can affect virtually every ocular tissue. If we wait until they have new symptoms before we see them again, significant damage may already have occurred. We emphasize that most early ocular complications associated with diabetes are treatable and not immediately sight-threatening. Asking patients to briefly summarize our discussion ensures that they understand and appreciate its importance.
Long-term, sustained reductions in poor attendance rates remain difficult to achieve. Common tactics include reminders and educational videos, as well as print and online material from the American Diabetes Association (diabetes.org ), the American Optometric Association (aoa.org ), and other sources. (See “Educational Assets for Patients With Diabetes”).
We show patients images of their affected retina alongside an image of a retina without retinopathy for comparison. Reviewing with them the results of their structural OCT and OCT angiograms also serves to educate and empower patients to take control of their care and keep appointments.
As primary eye care physicians, we must coordinate care with the other key players on a patient’s diabetes care team, which may include a retina specialist, an endocrinologist, a nephrologist, and a primary care provider. Of course, we must always remember that the central member of that team is the patient!
Individual providers on the diabetes care team should remember that we are not alone. Referring patients for sessions with a certified diabetes educator (CDE) has been shown to improve adherence and is usually covered by insurance.3 A CDE is the ideal professional to counsel patients in detail about how to implement specific lifestyle changes to improve their HbA1c and other measures of glycemic status and overall health. (For more information, see “Continuous Glucose Monitoring and Diabetic Retinopathy”.)
Good self-care and regular follow-up with an interprofessional team of providers are fundamental to optimal diabetes management.
Education Empowers Patients
We can positively influence patients’ perceptions of their disease by effectively communicating information about self-care, medications and therapies, and long-term prognosis. We believe it’s important to share details in small amounts at a time, particularly immediately following a diabetes or diabetic retinopathy diagnosis, and at an appropriate level that is culturally and linguistically relevant to that individual. In the end, we must strive to be our patients’ most enthusiastic cheerleaders and advocates. ■
- Murchison AP, Hark L, Pizzi LT, et al. Non-adherence to eye care in people with diabetes. BMJ Open Diabetes Res Care. 2017;5:e000333.
- Jansen ME, Krambeer CJ, Kermany DS, et al.; Compliance Study Group. Appointment compliance in patients with diabetic macular edema and exudative macular degeneration. Ophthalmic Surg Lasers Imaging Retina. 2018;49(3):186-190.
- Zgibor JC, Maloney MA, Malmi M Jr, et al. Effectiveness of certified diabetes educators following pre-approved protocols to redesign diabetes care delivery in primary care: Results of the REMEDIES 4D trial. Contemp Clin Trials. 2018;64:201-209.