Imaging over in-person exams? Telehealth study misses point

A recent telehealth review that claims new imaging for diabetic retinopathy could "cut unnecessary referrals" for in-person eye exams is short-sighted to the range of benefits afforded by such personalized care.

Published online in the March Ophthalmology—and reviewed in Medscape—the study found ultrawide field (UWF) imaging reduced the overall number of ungradable ocular images by 81% as compared to the current standard for tele-imaging, nonmydriatic multifield fundus photography (NMFP), in a national telehealth program. The study also concluded that UWF imaging increased the identification of diabetic retinopathy nearly twofold, "thus demonstrating significant benefits of this imaging method for large (diabetic retinopathy) teleophthalmology programs."

The Indian Health Service conducted the research with 42% of the study population residing in remote areas, such as the Arctic Circle or Grand Canyon, where access to medical specialists was limited.

In a follow-up review from Medscape Medical News, the web service noted the study's significance: "reducing the ungradable image rate is important because ungradable images often result in referral for comprehensive eye exams, which many patients may not need."

A. Paul Chous, O.D., optometric representative to the National Diabetes Education Program of the National Institutes of Health, contends that while UWF imaging is valuable, especially in underserved areas, the study fails to recognize the myriad benefits of an in-person, comprehensive eye exam for patients with diabetes.

"There are aspects of an eye exam, independent of identifying someone with vision-threatening eye disease, that are beneficial specifically to patients with diabetes," Dr. Chous says. "People with diabetes are at risk for a host of other ocular disorders and often benefit from patient education provided by eye care providers.

Dr. Chous adds: "There's no substitute for an in-person examination where a doctor can take a case history, query patients about their blood glucose control, and provide routine, dilated exams to detect not only retinopathy, but also cataract formation, glaucoma, ocular surface disease and more. Additionally, we can educate patients about the asymptomatic nature of much diabetes-related eye disease and discuss preventative strategies in an open-ended way that allows patients to ask questions and collaboratively 'buy in' to their management plan."

Advantage patients: The benefits of in-person care

There are definite advantages to face-to-face encounters between patients and their doctors—factors that cannot be replicated through an impersonal telehealth screening or consult. One such advantage: Patient education and retention.

A 2008 study, titled, "Eye on Diabetes: A Multidisciplinary Patient Education Intervention," found that patients with diabetes participating in a multidisciplinary (optometry, pharmacy and endocrinology) educational curriculum intervention demonstrated an increase in knowledge about diabetic eye disease over time. Prior to the educational intervention, patient knowledge revealed a number of misconceptions about the disease with notable findings including:

• 88% correctly recognized that people with diabetes should have regular, dilated eye exams
• 75% incorrectly reported that diabetic eye disease exhibits early warning signs

Following the trial, intervention participants were twice as likely to score higher on a posttest, while there was no difference in test scores for patients not participating in the intervention.

"There's clearly an educative effect for patients to have contact with all members of their health team, including eye doctors, not only to continue encouraging them to get care, but also to hear about new findings," Dr. Chous says. "That opportunity is lost without a face-to-face encounter."

Diabetes resources for AOA members

More than 29 million Americans have diabetes, and 1 in 4 don't know they have it. Doctors of optometry are a crucial component of patients' multidisciplinary care team, often the first to detect the tell-tale signs of this disease. Take advantage of diabetes resources available to AOA members, including:

• The AOA's evidence-based clinical practice guideline, Eye Care of the Patient with Diabetes Mellitus, and the quick-reference guide.
• The Diabetic Retinopathy Chairside Tool, created by the AOA Health Promotions Committee with support from Optos, available at AOA Marketplace.