Using Telemedicine to Expand Diabetic Retinopathy Screening

Although guidelines advise annual screenings, nearly half of patients with diabetes skip essential eye exams, driving increased use of teleretinal programs to detect unnoticed eye damage early. According to Jose A. Martinez, MD, president and retina specialist at Austin Retina Associates, teleretinal screening programs—especially in primary care settings—are emerging as effective tools to reach unscreened patients and connect them with specialists early in the disease process.

This transcript has been lightly edited for clarity.

Transcript

Can you give an overview of the current diabetic retinopathy screening guidelines?

The guidelines are [that] anyone with type 2 diabetes diagnosed as an adult should be screened annually; someone that's diagnosed as a child with type 1, usually they start screening about 5 years after diagnosis, some say 10, but these patients all need to be seen annually. Studies show that up to 50% of diabetic patients do not get annual screenings, which is tragic because with our current therapies, we can prevent vision loss from diabetic retinopathy in 95% of patients with proper care. There's no reason for most patients to lose sight from diabetic eye disease; it's a matter of screening them early.

The challenge is [that] the best time to treat patients is usually before they have any symptoms. Consequently, if you're a diabetic and you're seeing great, it's natural to assume, "My eyes are probably healthy, because I see perfectly well," and they're not aware of the silent damage occurring in their eyes. So, that's the biggest challenge. Because 50% of patients are not being screened properly, obviously public education is super important, educating the public on the importance of diabetic screening, and those are programs that have been in place for quite a while that don't seem to make a huge difference.

Something that's come online recently that we've been involved in over the last probably 10 years now is teleretinal screening or diabetic screening using telemedicine. We have deployed at this point about 20 fundus cameras in primary care settings in the central Texas area that screen patients in the primary care doctor's office. As I understand it, they essentially send the patients for a lab draw to get their labs done. That is a routine thing they do as they're taking care of their diabetic patients, and in that same laboratory setting, they have a fundus camera that's connected to a web-based platform that allows us to screen the images captured in the primary care doctor's office. If they have significant diabetic eye disease, they're immediately scheduled to see a retina specialist. And at that point, they're integrated into the retina specialist’s office and we can better educate them on their need for treatment if they need it or on the reality of diabetic eye disease, [and] that the best time to treat is before they have symptoms, so really educate the patient on the importance, often making that patient-doctor connection. That educational component in our office does move the patient to be more compliant with screening exams, and at that point, they've been integrated in our office.

The nice thing about these teleretinal programs that have been accepted by the American Academy of Ophthalmology as legitimate ways to screen patients is it gets the patients with disease into the retina specialists that can manage diabetic eye disease in their offices and those without disease not in their office. It's actually a very good screening program in patients that had not been getting annual exams. Those 50% of patients that do get annual exams typically do not need to get screened in their primary care doctors' offices because they already have a relationship with an eye care specialist. It's not those patients we're targeting in these teleretinal diabetic screening programs vs those patients that have not been screened, the primary care doctor does not have any report from or referral from an ophthalmologist or optometrist stating that they have no diabetic eye disease.

It's a very effective way that we have found in our area in central Texas to screen patients. That's super, super important, because I mentioned we have these anti-VEGF [anti–vascular endothelial growth factor] treatments, we have this laser that we've used for years that we often treat these patients with both, at least in my clinic, both anti-VEGF, and I still do use laser in patients with proliferative diabetic retinopathy—they really reduce their treatment burden. I tend to treat with panretinal laser in a less aggressive way than I had in the past because of the adjunct with anti-VEGF, but each patient is different depending on how they present, whether they're compliant, what else is going on their life will determine how I manage them. It's very patient specific.