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Champlain LHIN
“Healthy, caring communities supported
by health services of choice that
achieve results- today and for the
future”
Estimated that 55,563 people over age 18 live with diabetes
Impact of Diabetes
1 BC Data: Dr. Ballem. Nov 19 08 Presentation: Optimizing Opportunities: Improved Chronic Disease Prevention and Management in the North West LHIN.
2 Champlain LHIN. 3 Institute of Clinical and Evaluative Sciences. 2003. Diabetes in Ontario
People with Diabetes Account For:
56% of lower limb amputations1
59% of retinal surgeries1
43% of dialysis treatment2
32% of coronary bypass procedures1
23% of cataract surgeries2
27% of angioplasty cases2
Main cause of blindness among those aged 30-693
Retinopathy screening in the
Champlain LINH
• 1 in 3 people with diabetes in the Champlain LINH have
not received an eye exam in the past 2 years
• Early detection and treatment of retinopathy are
essential to prevent blindness in patients who have
diabetes
Case • 63 y.o. woman presents with symptoms of polyuria and
polydipsia.
• PMHx: Obesity and Hypertension
• Diagnosed with diabetes by FBS = 13.0 & HbA1c = 8.5%
• She is referred to a community diabetes education program for diabetes education and started on Metformin.
• You recognize the need for complication screening and want to arrange for retinopathy screening….
But you have a number of questions….
• Who can you send your patient to ensure
retinopathy screening in a timely way?
• What type of exam is required?
• Do all eye specialists provide the appropriate
type of screening?
• Does my patient have to pay for this service?
• How can I facilitate the communication between
eye specialists, myself, and the patient’s other
caregivers?
Diabetic Eye Disease:
Ensuring our patients are
adequately screened
Sherif El-Defrawy MD PhD FRCSC
Co-Chair, Eye Health Council of Ontario
Disclosure
• No financial interest in anything discussed
in this talk
Objectives
Through attending this session, participants will be able to:
• Describe the current concerns regarding screening for diabetes related eye disease
• Explain the recently released guidelines for retinopathy assessment related to referral and follow-up
• Discuss with patients the assessment process and the costs that are covered and not covered by OHIP
• Use the form designed to increase the communication between health care providers
The Collaboration
Why 3 Logos
Diabetes Regional Coordinating Centre
(DRCC)
Office of CME, Faculty of Medicine
Eye Health Council of Ontario (EHCO)
• What is the Council
• Recommendations later in the presentation
Eye Health Council of Ontario
(EHCO)
• A forum created by Ophthalmology and
Optometry to serve patients through a unified
voice for eye health care issues.
• Representation from the academic, political and
regulatory arms of the two professions and MOH
• Opportunity for all stakeholders to play a role
regularly
Optician/Optometrist/Ophthalmologist
• Opticians:
– Opticians are regulated health professionals
– High school diploma and 2 year college
program
– Dispense ophthalmic eye wear (eyeglasses,
contact lenses and low vision devices) to the
public based on a prescription from an
optometrist or physician
– 2400 in Ontario
Optician/Optometrist/Ophthalmologist
• Optometrists: – Optometrists are regulated health professionals
– 4-year University post graduate degree program
– Lectures and clinical training experience in visual
system, optics, and ocular diseases.
– Prescribe and sometimes dispense ophthalmic eyewear
– Can diagnose eye disease and manage certain eye
diseases
– Able to prescribe medication in Ontario
– 1800 in Ontario
Optician/Optometrist/Ophthalmologist
• Ophthalmologists: – Physicians
– 4-year MD followed by a 5 year residency in
ophthalmology and often a 1-2 year fellowship in a
subspecialty.
– Diagnose eye diseases and provide medical and
surgical treatment
– Many still provide routine examinations and
prescriptions for eyeglasses (although those numbers
are decreasing)
– 450 in Ontario
Diabetes And The Eye
• Hyperglycemia endothelial damage: – loss of barrier function and leakage from vessels
– capillary fallout
– non-perfusion
• Retinal hemorrhages, exudates, edema and ischemia
• Ischemia results in new,
incompetent blood vessel
formation
• Retinal and vitreous hemorrhages
• Retinal detachments.
Treatment of Diabetic Retinopathy
Vitrectomy
Intravitreal injection Laser
The Eye Examination
• Vision assessment
The Eye Examination
• Pupillary and motility assessment
• Visual field and color vision
The Eye Examination
• Slit lamp examination
– Anterior segment exam
– Intraocular pressure
• Glaucoma
• Magnified stereoscopic
exam of the optic
nerve head and
macula
The Eye Examination
• Indirect ophthalmoscopy
– Examination of the
peripheral retina
The Eye Examination
• Optical coherence tomography (OCT)
EHCO Recommendations For
Primary Health Care Providers
• Ask at every visit about last visit to an
optometrist or ophthalmologist
• Refer all newly diagnosed patients with type II
diabetes to an optometrist (or ophthalmologist)
for retinal assessment.
• Patients with type I diabetes should be assessed
within 5 years of diagnosis.
Options For Referral For Retinal
Assessment • Facts about numbers in the region:
– Optometrists – 87
– Ophthalmologists - 56
• For yearly retinal assessment, there should be no cost to patient when they
go to either an optometrist or ophthalmologist, unless patient chooses
optional aspects of the exam
• When referring patients for a retinal assessment, ask the optometry
or ophthalmology office:
…..Will you do a major eye exam for patients who are diabetic at no
cost to patients?
Ophthalmologists and optometrists should provide a yearly
update to primary health care provider
EHCO Recommendations For
Primary Health Care Providers
• Pediatric patients with Type 1 Diabetes:
– Refer for a comprehensive eye examination once the
child has reached the age of 10, or has had diabetes
for 3 years.
– An ophthalmologist should perform this initial
examination.
• At age of 13, in the absence of retinopathy, the
patient should be followed by an optometrist (or
ophthalmologist) on an annual basis.
EHCO Recommendations For
Primary Health Care Providers • Pregnant women with diabetes:
– Before attempting to become pregnant, women with
Type 1 or Type 2 Diabetes should undergo an
ophthalmic evaluation by an optometrist or
ophthalmologist.
– Repeat assessments should be performed during the
first trimester, as needed during pregnancy, and
again within the first year postpartum. This guideline
does not apply to women who develop gestational
diabetes, because such individuals are not at
increased risk for diabetic retinopathy.
–
To Make Things Easier
• Use the Diabetic Checklist to keep track of patient status
• Remind patients about their diabetic passport
• See list of Optometrists in your area
http://www.optom.on.ca/find_an_optometrist • Use Eye Health referral/consult template for
referrals to optometrists and ophthalmologists
• Or…revise your present form with the recommended critical components. (note be sure to
insert a request for a report following assessment or treatment)
Diabetes Passport
My Diabetes Passport
enables the client to record
when they had their last retinal
eye exam.
What happens if the assessment
detects problem?
Vitrectomy
Intravitreal injection Laser
What does it cost patients to have
retinal assessment?
For yearly retinal assessment,
there should be no cost to patient
when they go to either an
optometrist or ophthalmologist,
unless patient chooses optional
aspects of the exam
What are potential additional costs?
Optometrists or ophthalmologists may offer
additional services to patients that are not
covered by OHIP. These include: • a photo record of the retinal assessment
• Optometrists may charge a fee if the patient is between
20-64 and the primary reason for the visit is a refraction
(new glasses)
The cost for these services vary and patients should clarify
the specific details with their eye care provider
Reasons why there may be confusion
• OHIP covered major eye examinations for everyone up until 2004
• For patients 20-64, there is a fee for an eye examination if the patient has no eye disease (routine assessment and glasses prescription)
• College of Optometry recommends services during a major eye exam that are not considered essential by OHIP and are not covered
• If, during a routine eye exam there is evidence of undiagnosed diabetes : – the eye exam will still not be covered for optometry until the
patient has been diagnosed by a physician
– It will be covered for ophthalmology
Closing - summary
• Ask at every visit about last visit to an
optometrist or ophthalmologist
• Refer all newly diagnosed patients to an
optometrist (or ophthalmologist) for retinal
assessment.
• Use referral form for all referrals with name and
fax clearly visible with request for results.
• Ensure patients’ follow-up care is overseen by
their eye health provider