Over the past decade, telehealth programs have become more integrated among medical subspecialities; however, due to the nature of eye care evaluations, the practice has remained far less common in optometry and ophthalmology.
Over the past 18 months, many doctors, including eye care providers (ECPs), found themselves exploring a variety of telehealth options in an effort to maintain continuity of care in the face of pandemic-related challenges. At University of California Davis Health, we were fortunate to have a head start.
We began laying the foundation for a telehealth program several years ago in an effort to provide image-based screenings for diabetic patients in both our primary care (PC) and endocrinology clinics. Retinal specialist Glenn Yiu, MD, founded the UC Davis Teleretinal Screening Program, and we have worked closely together as we continue to expand the program. By facilitating earlier detection of pathology and streamlining referrals, the program has resulted in better, more efficient care for this patient population. It has also expanded the role of optometry and increased collaboration among optometry, ophthalmology and primary/subspecialty medicine.
UC Davis developed the telehealth program to better mitigate health care disparities, particularly in the diabetic population. Unfortunately, the number of diabetic patients who are not currently established with an ECP remains significant; particularly among minority populations who are more at risk for developing visual complications due to diabetes. To address this concerning gap, we began offering eye care screenings in PC and endocrinology offices to help detect and expedite eye care referrals for the patients who need them most.
As with most new ventures, we had to learn by doing. We utilized a variety of imaging platforms in the PC and endocrinology clinics and found that the Optos ultra-widefield (UWF) technology provided the widest field of view in the least amount time, resulting in more opportunity to detect pathology. These devices offer noncontact, nonmydriatic imaging, capturing 80% of the retina in less than 0.50 second and require minimal training to operate. They are ideal for our busy PC practices even though they are operated by staff with little or no previous retinal imaging experience.
Our UWF technology has proven particularly beneficial for screening diabetic patients, who often have changes in the far peripheral retina even before they have visual complaints or detectable changes in the central retina visible in a typical 30-degree to 45-degree fundus camera image. Our PC and endocrinology colleagues now have the opportunity to offer their patients eye screening as part of their standard appointment and explain that if pathology is identified, they will be referred to the appropriate eye care provider.
As an optometrist and telehealth grading specialist, I evaluate the images, document and report findings, and make specific referral recommendations.
Our current protocol recommends patients with no evidence of diabetic retinopathy (DR) or those with early diabetic changes, such as mild nonproliferative diabetic retinopathy (NPDR), to continue annual retinal screening with their established PCP or endocrinologist. Those with moderate-severe NPDR are referred to an optometry or general ophthalmology clinic within 1 to 3 months to establish care. In the case of proliferative DR, referrals go directly to our retina specialists within 1 month or sooner. Of course, urgent cases are expedited as appropriate (such as suspicion of diabetic macular edema).
I have found my medicine colleagues to be collegial and receptive to my analysis and recommendations. As one of several optometrists at UC Davis, I frequently examine these diabetic patients referred to our optometry clinic. In these cases, I am diligent to document my exam findings in order to best monitor for signs of progression. Once the exam is completed, I prepare a report for the referring provider with my recommendations to ensure continuity of care.
In addition to reinforcing the critical importance of eye exams for diabetic patients, the screening program has helped our organization improve and expedite patient care. Diabetics are often surprised to hear that deleterious changes within the retinal vasculature can precede significant changes in lab results. Information from the eye screening exam has proven valuable to our primary and subspecialty medicine colleagues as they work to fine tune prescriptions and modify treatment plans. In some cases, the retinal exam has even helped our physician colleagues identify and address previously undetected systemic issues.
From the practice management side, screening patients and reading the images are billable procedures that facilitate better, more accurate referrals. Because PC physicians and endocrinologists understand the seriousness of diabetic eye disease, they often refer patients with any suspected pathology directly to the ophthalmology department. However, general ophthalmologists and retina specialists primarily focus on providing surgical and medical interventions. By managing the screening evaluations, optometry has proven to play a vital role in ensuring accurate eye care referrals. This process helps us manage our specialists’ time more efficiently rather than creating backlogs that can lead to over-crowding and frustration. This is particularly important for an institution like ours that serves as a referral center for the local optometric and ophthalmic community.
The screening model also creates more opportunity for optometrists to demonstrate our specialized training to non-eye care medical specialties. In addition to managing and monitoring many of these patients, optometrists are uniquely positioned to more appropriately refer patients when they require intervention and treatment for their diabetic retinal disease.
The downstream benefits that come from optometrists playing an active role in the systemic care of patients with diabetes and other conditions are evident in our results. The Optos ultra-widefield retinal imaging technology is used in nearly 20,000 eye care clinics, and the new, point-of-care Optos Telehealth Solution is active in hundreds of primary care locations. I hope this will inform and encourage others to adopt collaborative telemedicine programs.
Jonathon M. Ross, OD, MS, FAAO, is a senior optometrist, Department of Ophthalmology and Vision Science, at the University of California, Davis. He can be reached at jonross@ucdavis.edu.
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