Looking Beyond the Eyes

We exist in an era of increasingly specialized medical care where most providers carve out a narrow niche. But to provide the most complete care, ophthalmologists should to try to broaden their attention beyond strictly eye issues and take the opportunity to address underlying systemic diseases as well. The prospect to do more is perhaps greatest in the area of diabetes care – if patients are unable to properly manage their diabetes, they will never be able to extricate themselves from the perpetual downward spiral of complications. In addition to the clear systemic benefits of tightened control, intense treatment of glycemia can slow retinopathy progression (1). Many diabetic patients spend more time with their ophthalmologists than any other healthcare provider, and all of that chair time gives us the chance to improve diabetes control. The problem? Indirect evidence suggests we may not be realizing the full potential of our time. Even though it may seem intuitive that diabetic patients subjected to potentially uncomfortable, repeated, and time-consuming interventions may be “scared straight” into doing a better job with managing their diabetes, it has been shown many times that patients undergoing intravitreal anti-VEGF injections do not undergo clinically meaningful improvement in systemic measures, such as blood pressure and hemoglobin A1c (2)(3)(4). Many patients may not understand that injections and lasers should ideally be thought of as a mechanism to “bridge the gap” until the benefits of the improved systemic control can take effect – something that may take years to achieve. It behooves ophthalmologists to try to take a more active role despite the ever-present obvious limitations in time, expertise, and resources.

But extrapolating from the non-ophthalmic literature, it’s clear that there are several incremental steps that ophthalmologists and their clinic staff can take to help tangibly improve diabetes control (5)(6)(7): 1. Most patients (and many physicians) fail to appreciate the strong correlation between ophthalmic findings and long term systemic risk to patients. The eye is truly the “canary in the coal mine.” In addition to discussing the well-established risk of vision loss from diabetic eye disease, providing patients the broader implications of their eye findings can highlight the seriousness of their condition – especially when they remain asymptomatic. For example, all-cause mortality is 133 percent higher in patients with diabetic retinopathy than diabetics without retinopathy (8). In patients with type 2 diabetes, all-cause mortality is 38 percent higher in those with non-proliferative diabetic retinopathy and 132 percent higher in those with proliferative diabetic retinopathy (8). Patients undergoing pars plana vitrectomy for tractional retinal detachments have a mean survival of 2.7 years. At 10 years, these patients have a 48.7 percent all-cause mortality rate – compared with 2 percent in diabetics with minimal to no retinopathy (9)! Telling a young patient who requires tractional retinal detachment repair that they only have a 50 percent chance of living 10 more years with an average life expectancy of approximately three years is a sure way to get their attention; however, the initial shock value of these figures often fades and patients slide back into bad habits unless there is a way to channel their new found motivation into meaningful change. And that is why the next point is critical.

2. Close coordination of care with primary care physicians is invaluable. A two-way street of communication allows primary care doctors to gain a better view of their patients’ diabetes control and can also allow ophthalmologists to better understand the changes taking place in a patient’s management. It would be helpful to know if a sudden improvement in blood sugar pre-dated a new diagnosis of diabetic macular edema. Additionally, ophthalmologists can provide the appropriate nudge that may help convince patients to adhere to their primary care doctor’s interventions – such as finally convincing a patient to start an overdue insulin regimen. It is not uncommon for patients to view their ophthalmologist as their primary source for healthcare. A surprising number of patients have not seen their primary care doctor for years, and commonly, patients first establish care with an ophthalmologist before finding a primary care doctor. Simply ensuring patients are returning to see their primary care doctors for continued systemic management can hold significant value. 3. Health education classes and support groups are a valuable resource. Such programs have been shown to improve diabetes outcomes – and many are either covered by insurance, provided in the community at little to no cost, or exist online. Several online programs have already been vetted and are certified by professional societies or physician groups. Being familiar with these opportunities provides an easy way to direct patients to potentially fulfilling resources with minimal effort on the part of the ophthalmologist.  4. Repetition and reinforcement are critical to modifying patient behavior.  Medication reconciliation can be used as a mechanism to remind patients of the importance of medication adherence. Encouraging and reminding patients to diet and exercise at each visit can eventually start to influence behavior. For example, patients who received telephone calls every 4–6 weeks to encourage medication adherence and lifestyle modification had improved diabetes control compared with those provided only print literature (6). Retina clinics regularly see patients at similar intervals and could use their staff to employ similarly simple interventions. On the surface, these steps may seem unrealistically burdensome for a busy ophthalmology practice; however, many tasks only take a few minutes and can be done by ancillary staff during intake or check out. Ultimately, these relatively small interventions may serve as a long-term investment in the general and ophthalmic wellbeing of our diabetic patients.