American Diabetes Association Recommends Telemedicine for Retinal Screening

For the past 25 years, the American Diabetes Association has developed evidence-based guidelines and standards of medical care that are a valuable source of information for the many different healthcare professionals who care for people with diabetes.

The Standards of Medical Care in Diabetes – 2019 provides easily searchable recommendations for all aspects of comprehensive diabetes care, including prevention of, screening for, and treatment of diabetic retinopathy (DR). DR continues to be the most common cause of new cases of blindness among adults. The number of people with diabetes diagnosed with DR increased by 89% (from 4.06 million to 7.69 million) between 2000 and 2010, and the Vision Health Initiative by the Centers for Disease Control predicts that by 2050, 16 million people with diabetes will have DR. These figures have staggering implications for quality of life, productivity, and healthcare costs.

Screening to detect DR is essential given that treatment can reduce severe vision loss by up to 94% and the fact that patients with proliferative diabetic retinopathy or macular edema may have no symptoms. The ADA recommends that adults with type 1 diabetes have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes, while patients with type 2 diabetes have an initial dilated and comprehensive eye examination at the time of the diabetes diagnosis. Subsequent screening intervals depend on glycemic control and whether there is evidence of retinopathy. “If there is no evidence of retinopathy for one or more annual eye exam and glycemia is well controlled, then exams every 1–2 years may be considered. If any level of diabetic retinopathy is present, subsequent dilated retinal examinations should be repeated at least annually by an ophthalmologist or optometrist. If retinopathy is progressing or sight-threatening, then examinations will be required more frequently.” The ADA further recommends that “telemedicine programs that use validated retinal photography with remote reading by an ophthalmologist or optometrist and timely referral for a comprehensive eye examination when indicated can be an appropriate screening strategy for diabetic retinopathy.”

Despite a clear health imperative for regular screening, it is estimated that more than half of patients with diabetes do not, in fact, receive this screening. Fathy and colleagues in their comprehensive review of DR screening in the US reported that risk factors for non-screening included low health literacy, lack of access to care, physician adherence to guidelines, unique factors in various minority populations, and living in rural regions, among others. Gibson undertook a study to estimate what percentage of adults with diabetes have regular contact with primary care physicians to determine who could potentially be screened for DR in the primary care setting. Using a survey sample of 3229 adult participants with diabetes from the 2016 National Health Interview Survey, she measured the percentage who visited a primary care physician and the percentage who missed having a dilated eye examination in the past year. The vast majority (82.2%) of participants who had not received a dilated eye examination had, however, seen a primary care physician.

Innovative solutions are needed to dramatically increase screening rates in order to prevent vision loss in the millions of people with living diabetes. Gibson’s findings highlight the potential to provide DR screening within primary care settings because most adults with diabetes regularly see a primary care doctor. Retina Labs iVision teleophthalmology platform offers a comprehensive, workflow-based solution for DR screening in this setting. iVision provides all the capabilities necessary to manage a teleretinal screening program including image acquisition, clinical diagnosis and reporting. iVision allows primary care providers, health systems and payers to improve screening compliance rates, drive quality outcome measures and to lower costs associated with the treatment of diabetic retinopathy.

Bottom Line: Teleretinal diabetic retinopathy screening is a proven and cost-effective approach to improve access to retinal exams in primary care settings.

References:

• American Diabetes Association. 11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes—2019. Diabetes Care 2019 Jan; 42(Supplement 1): S124-S138.
• Fathy C, Patel S, Sternberg P Jr, Kohanim S. Disparities in Adherence to Screening Guidelines for Diabetic Retinopathy in the United States: A Comprehensive Review and Guide for Future Directions. Semin Ophthalmol. 2016;31(4):364-77.
• Gibson DM. Estimates of the Percentage of US Adults With Diabetes Who Could Be Screened for Diabetic Retinopathy in Primary Care Settings. JAMA Ophthalmol. Published online January 31, 2019. doi:10.1001/jamaophthalmol.2018.690