An Optometrist's Guide to a Growing, Yet Treatable, Disease
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An Optometrist’s Guide to a Growing, Yet Treatable, Disease W. Lloyd Clark, MD Paul Karpecki, OD Sponsored by 061516_regeneron.indd 1 6/2/16 4:55 PM PREVALENCE OF DIABETES: DME IN THE US An Optometrist’s Guide to a Growing, • In the United States, ap- proximately 21% of people Yet Treatable, Disease with diabetes, or 8 million individuals, have diabetic retinopathy (DR).6 Only about 5.8 million of these are diagnosed.6,18,19 oth the prevalence and incidence of diabetes have • Of these 8 million peo- increased considerably over the past decade and show ple, about 2.3 million have no signs of slowing down. Make no mistake, diabetes is diabetic macular edema (DME), 1.5 million are now considered to be an epidemic in the United States. diagnosed and 750,000 BIt affects 9.3% of the US population (29.1 million people) and have clinically signifi cant 1 is the seventh leading cause of death. An additional 86 million macular edema (CSME)6,19 adults in the United States have prediabetes based on their fast- • Of those with CSME, only ing glucose or HbA1c levels and are at risk to develop diabetes.2 about 400,000 are receiv- It is projected that by 2050, as many as one in three to fi ve ing treatment for DME.8 adults will have diabetes.3 ABOUT THE AUTHORS W. Lloyd Clark, MD, is an ophthalmologist and Paul Karpecki, OD, received his doctor of optome- managing member at Palmetto Retina Center, LLC, try degree from Indiana University and completed in Columbia, SC. He is also clinical as- a fellowship in medical cornea and re- sistant professor of ophthalmology at fractive surgery in Kansas City in affi li- University of South Carolina School of ation with the Pennsylvania College of Medicine. Optometry. He currently practices at Kentucky Eye Institute. Dr. Clark specializes in vitreoretinal diseases and surgery. His clinical inter- Dr. Karpecki was one of two optome- ests include pharmacologic management of retinal trists appointed to the Delphi International Society vascular disease, complex retinal detachment and at Wilmer Eye Institute at Johns Hopkins, which in- retinopathy of prematurity. In addition to main- cluded the top 25 dry eye experts in the world, and taining an active referral practice in medical and the National Eye Institute’s Dry Eye Committee, to surgical retina, he operates a broad-based clinical provide insights around the prevalence or incidence research program. Dr. Clark participates in nation- of dry eye in women. al and international multicenter trials sponsored by industry and the National Institutes of Health as A noted educator and author, he is the chief clinical well as investigator-sponsored trials. He has written editor of Review of Optometry. Dr. Karpecki is also investigator-initiated clinical trial protocols for Ge- past president of the Optometric Cornea, Cataract nentech-Roche and Regeneron Pharmaceuticals. and Refractive Society and serves on the board for He also sits on the Retinal Vein Occlusion Steering the charitable organization Optometry Giving Sight. Committee for Regeneron, the Protocol B Steering committee for NIH-sponsored Diabetic Retinopathy Clinical Research (DRCR) Network and the Scientif- ic Advisory Board for Santen Pharmaceuticals. Dr. Clark provides consulting services to all stakehold- ers in the fi eld of retinal diseases and therapy. 2 REVIEW OF OPTOMETRY • JUNE 15, 2016 061516_regeneron.indd 2 6/2/16 5:02 PM Americans are also getting diabetes at increasingly younger ages.1,2 One of the ma- jor drivers for this in- crease is obesity, which is a major risk factor for type 2 diabetes. Rates of obesity have increased from 20.1% in 2000 to 27.6% in 2012, and are a likely driver of the increase in diabetes rates.4 Patients must be made aware Whatever the cause, that diabetic macular edema can diabetes and its com- plications are an develop at any stage of diabetes enormous burden on and is often asymptomatic. the healthcare system. Patients with diabetes visit a doctor about 24 times each year, on average, to address structures of the eye and many aspects of the many complications related to this visual function.10 disease.5 Specifi c to ocular complications, Diabetic retinal disease, the most com- approximately 21% of patients with dia- mon microvascular complication of diabe- betes develop diabetic retinopathy (DR)6 tes, is a leading cause of vision loss among and, among those who do, 70% will have adults worldwide. It primarily manifests as diabetic macular edema (DME).7 Unfortu- diabetic retinopathy and/or diabetic macu- lar edema. It is essential that diabetic patients Patients with diabetes are receive screening for retinal disease so also at an increased risk of non-retinal ocular compli- that appropriate interventions can be cations, including:10 initiated before irreversible damage • Changes in visual func- occurs.10,11 tion, such as loss of visual acuity, refractive error changes, changes in color nately, by 2020 approximately 9.6 million vision, accommodative dysfunction and Americans will have diabetic retinopathy.8 visual fi eld changes For this reason, our responsibility as eye • Eye movement anomalies secondary to care providers to carefully monitor diabet- diabetic neuropathy ic and prediabetic patients is crucial. • Sluggish pupillary refl exes • Microaneurysms in the bulbar conjunc- OCULAR COMPLICATIONS tiva and an increased risk of conjunctival OF DIABETES bacterial infections Up to 45% of people with diabetes ex- • Tear fi lm abnormalities leading to an perience vision loss.9 Diabetes impacts all increased incidence of dry eye 3 REVIEW OF OPTOMETRY • JUNE 15, 2016 061516_regeneron.indd 3 6/2/16 4:49 PM DIABETES: An Optometrist’s Guide to a Growing, Yet Treatable, Disease • Corneal abnormalities, such as slower may present with microaneurysms, intra- wound healing, reduced corneal sensitivity, retinal hemorrhage, vitreous hemorrhage, abrasions and contact lens–related micro- exudates, macular ischemia, neovascular- bial keratitis ization and tractional retinal detachment. • Iris abnormalities, such as depigmen- Seventy percent of patients with the most tation, neovascularization of the iris and severe form of diabetic retinopathy will neovascular glaucoma experience progression to diabetic macular • Cataracts, including reversible lenticular edema.7 opacities • Vitreous degeneration and posterior vit- UNDERSTANDING reous detachment (PVD), which may play BARRIERS TO CARE a role in PDR It is essential that diabetic patients • Optic disc and nerve abnormalities, such receive screening for retinal disease so that as diabetic papillopathy and ischemic optic appropriate interventions can be initiat- neuropathy ed before irreversible damage occurs.10,11 However, nearly one in four patients with dia- betes age 40 years and older is not complying with the recommended yearly eye exam.13 There are several reasons why patients don’t receive annual eye exams. According to a 2014 study on barriers to eye care in diabetes patients, the Color fundus photography can aid in most commonly cited documenting and evaluating more reasons for not getting exams are “no need” severe cases of DME while helping (39.7%) and cost or lack to track disease progression and of insurance (32.3%).13 treatment response. Other reasons are: not having an eye doctor, not being able to make an appointment with a • Primary open angle glaucoma doctor and not having transportation to an Diabetic retinopathy disease severity appointment. varies greatly, ranging from no disease and People ≥65 years of age were more likely no signs or symptoms, to nonproliferative to report “no need” as their main reason diabetic retinopathy (which can be mild, for being noncompliant, whereas those moderate or severe), to proliferative dia- 40 to 64 years of age and women overall betic retinopathy and possible severe vision were more likely to report “cost or lack of loss due to neovascularization.11 Macular insurance” as their main reason. edema may occur at any stage of DR.12 As Given that “no need” was the most diabetic retinopathy progresses, patients commonly cited reason for not seeking eye 4 REVIEW OF OPTOMETRY • JUNE 15, 2016 061516_regeneron.indd 4 6/2/16 4:51 PM Why Patients Don’t Receive Other Annual Eye Exams As reported by patients 21.5 diagnosed with diabetes who No eye No are not receiving annual eye doctor, no need* exams. transportation, 6.4 39.7 or could not get • Patients with visual appointment impairments are more likely to cite “cost or lack of insurance” 32.3 as a reason for not receiving an eye exam and less likely to report “no need” Cost/lack of insurance *Consisted of “have not thought Chou CF, et al. Diabetes Care. 2014;37:180-8. of it” and “no reason to go” care, diabetes eye health education pro- diabetes has on vision can help reduce the grams or interventions that increase the numbers who believe there is no need for awareness of the need for eye care among an exam. people with diabetes may be effective Furthermore, targeting simple interven- strategies toward helping to protect against tions (such as reminders) to patients with a vision loss. lower income, those 40 to 64 years old, pa- tients without health insurance and those HOW TO GET PATIENTS who have been diagnosed with diabetes INTO THE OFFICE for a longer amount of time can encourage Education is vital in the effort to con- patients to seek annual dilated eye exams. nect with the 23.5% of patients who are noncompliant with their eye exams and get WHEN TO REFER1,2 them into the offi ce.13 To begin, we need to An annual dilated eye examination and increase awareness be- tween healthcare profes- sionals and adults with IMMEDIATE High-risk REFERRALS: diabetes 65 years and DME (within PDR (within • Traction 2-4 weeks) retinal older of the importance 24-48 hours) detachment of annual eye exams.