Eyeworld

123 EW RETINA March 2017 by Maxine Lipner EyeWorld Senior Contributing Writer Meanwhile, investigators in another study examined how telemedicine may be a factor. Maria A. Wood- ward, MD, assistant professor of ophthalmology, University of Michigan, Ann Arbor, together with colleagues such as lead investigator Nita G. Valikodath and Thellea K. Leveque, MD, examined the role of telemedicine. In the study, published in the June 2016 issue of Telemedicine Journal and e-Health, investigators considered how the ability to have the screening done more locally, such as the primary care setting, would be welcomed by patients. 4 "Telemedicine gives us the abil- ity to see patients where they're al- ready seeking care for their diabetes in primary care offices locally versus having to make an extra appoint- ment to see an eyecare provider," Dr. Woodward said. "They can get the services of telemedicine in the pri- mary care setting and therefore have more universal services in one place and not have to take the extra cost and trip." The telemedicine tech- nique itself has been shown to be as accurate as a gold standard exam by an ophthalmologist, she continued. With telemedicine, a photo- graph can be taken during a visit to the general practitioner's office and then transmitted to an ophthalmol- ogist, optometrist, eyecare provider, or another person who has been trained to interpret these photos, Dr. Woodward explained. "We wanted to understand how our patients perceived telemedi- cine and what their attitudes were towards it, as well as their willing- ness to engage with it once they understood it," she said. While the patient population was unfamiliar with telemedicine, investigators determined that hypothetically, the majority were willing to undergo such a screening for possible diabetic retinopathy, once the approach was described to them. However, there were certain factors that played into how willing they would be to participate in this approach. "If they perceived that the telemedicine exam would be conve- nient to them, that was a really im- portant factor in determining how willing they would be to participate in telemedicine," Dr. Woodward said, adding that likewise if they had cost. Meanwhile, healthcare provid- ers who were also given the survey, did not anticipate cost as a barrier because there was no direct out-of- pocket expense for diabetic retinop- athy screening where the study was conducted, he continued. However, this didn't take into account other costs, such as time the patient had to take off work to undergo the screening, Dr. Ipp explained. Some barriers concerned basic understanding of the need for the screening. "We found that people who could not describe why retinal screening was necessary were much less likely to be screened," he said. "It points to the need for patient education and using whatever methods are available and appro- priate to enhance education in the primary-care setting so patients will actually get their retinal screenings done, because that looks like it may actually lead to a productive out- come." The population surveyed was about 70% Hispanic and close to 30% African American, which en- abled investigators to make further insights. "We had an opportunity within the same low socioeconomic group to look at who was likely to show up for screening," Dr. Ipp said, adding that even though patients reported the same 75% rate of being told that they should get screened, African-Americans in the study were about half as likely as Hispanics to undergo screening. 3 Telemedicine for screening foods high in fat, carbohydrates, and fructose sugar. Vision loss prevention Because diabetic retinopathy is usually asymptomatic until it's severe, the only way to identify it and intervene early enough without vision loss is with the aid of peri- odic retinal screening, according to Eli Ipp, MD, professor at the David Geffen School of Medicine, UCLA. Concerned that not enough people were being screened, Dr. Ipp and col- leagues launched a study to consider potential screening barriers. 2 Having already instituted telemedical retinal screening at the institution, inves- tigators wanted to determine what other factors were important. "We wanted to figure out what the barri- ers were besides just the availability of teleretinal screening," Dr. Ipp said. "So we took a sample of 101 patients who walked into clinics and had diabetes and asked them a bunch of questions to try to get at the barriers." Investigators in the study pub- lished in the October 2016 issue of Preventing Chronic Disease discovered a large gap between those who knew they should be screened and those who actually showed up. "We found that 75% said 'Yes, my doctor told me I should get screened.' but only 55% actually got the retinal screen- ing," Dr. Ipp said, adding that the highest frequency of barriers that reportedly kept patients from receiv- ing screening were being in a state of depression and concerns about Considering barriers to preventing vision loss S creening for diabetic reti- nopathy is a must, yet too often patients forgo this. From barriers to screening to telemedicine as a route to try to improve this, as well as hot spots for diabetic retinopathy around the globe, we hone in on the latest management strategies. In a study published in the November 2016 issue of Diabetes Care, investigators led by Janet L. Leasher, OD, Nova Southeastern University, Fort Lauderdale, Florida, reported that since 1990 there has been a 27% rise in blindness due to diabetic retinopathy. 1 Meanwhile, for those with moderate to severe diabetic retinopathy, there was a 64% rise in related vision loss during this same period. When investigators looked glob- ally, they determined that regions such as South Asia, the Middle East, North Africa, and West Sub-Sa- haran Africa were the areas with the highest number of those with diabetic retinopathy-related visual impairment. Hot spots with the most people who were blind from diabetic retinopathy included East Asia, Tropical Latin America, and South Sub-Saharan Africa. Steve Charles, MD, clinical pro- fessor of ophthalmology, Hamilton Eye Institute, University of Tennes- see, and founder of the Charles Reti- na Institute, Memphis, stressed that such alarming rates are the result of diet, cultural preferences, and tradi- tion. "If you ride a bike everywhere, and you run, and you eat rice and vegetables, this problem is not going to happen," Dr. Charles said, adding, however, if you're eating foods much higher in carbohydrates and fat, this condition all but becomes a given. He cites the work of Elliott P. Joslin, MD, the founder of the Joslin Diabetes Center, Boston, who studied the Pima Indians of Arizona in the 1920s. "Dr. Joslin said: 'This is amazing. Here is a rather pure culture without any intermarriage outside of the culture, and they don't have any diabetes at all,'" Dr. Charles said, adding that the incidence now in this same popula- tion has risen to an alarming 70%, all as a result of a change in diet to Dialing in on diabetic retinopathy continued on page 124 " Telemedicine gives us the ability to see patients where they're already seeking care for their diabetes in primary care offices locally versus having to make an extra appointment to see an eyecare provider. " —Maria A. Woodward, MD

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