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