A checkup on checking blood pressure

Patients are likely to sooner visit their doctor of optometry in any given year than their primary care physician, according to a UnitedHealthcare white paper. That means doctors of optometry can make a real difference for patients. Elizabeth Steele, O.D., associate dean for clinical affairs at the University of Alabama at Birmingham (UAB) School of Optometry, who lectures widely on hypertensive guidelines, offers tips.

1. Make blood pressure checks routine.

According to the Centers for Disease Control and Prevention, 1 in 3 American adults have hypertension.

"Since evidence supports that millions are undiagnosed, and intervention can prevent future cardiovascular disease, blood pressure measurements are relevant regardless of whether or not the patient appears to be at risk," Dr. Steele says.

2. Train staff on what to look for.

Automated devices make checking blood pressure a quick and easy portion of preliminary testing, and paraoptometric staff can be trained in proper technique.

"There is a wrong way and a right way to get readings, and technique can impact accuracy," Dr. Steele says. "Staff and optometry students at UAB are trained, for instance, to rest the patients' arms at heart level and to have them keep their legs uncrossed, so that no exertion is present for the patient. And if the reading is outside normal limits, blood pressure can be measured using a manual sphygmomanometer and stethoscope, as automated cuffs can be less accurate for high readings."

Interpreting blood pressure measurements is equally important to technique. There are nationally recognized thresholds for different stages of hypertension, which can be used in an optometric practice as more of a referral guide. Staff should be provided with a set of guidelines to use to make smart triaging decisions after taking measurements.

3. Determine the level of urgency.

Dr. Steele says there are two kinds of changes doctors of optometry will see re­flected in the eye: chronic and acute. Chronic changes will manifest in the retina as leaking from the blood vessels or signs of ischemia (e.g., intraretinal hemorrhages, cotton wool spots).

Acute changes in the eye, though, along with blood pressure beyond the critical point, require a quick and confident judgment by the doctor and staff. In these cases, the exam contents should be more focused on examining the optic nerve and macula to determine level of urgency.

Optic disc or macular edema are signs of end-organ damage and indicate a hypertensive crisis, she says. This is consistent with a rapid, out-of-control elevation of blood pressure that can be life-threatening. "They would need to go to the emergency room immediately, necessitating an immediate referral to an ER," she says.

4. Communicate.

Whether your hypertensive patients have retinopathy, elevated blood pressure or even normal findings, communication is key in the care of patients. That includes keeping patients' primary care physicians apprised of the care provided by you, says Dr. Steele, who sends notes for their records. "It's a good habit to close the loop, and I think it's a potential practice builder for doctors of optometry—it opens their eyes to the kind of care doctors of optometry can provide," she says.