Harnessing Telehealth to Prevent Diabetic Blindness

For people with diabetes, going to an eye doctor for a diabetic retinopathy screening is yet another burden in managing their chronic disease. New technology allows them to get screened where they seek routine health care.

High blood-sugar levels can damage the blood vessels in the retina, as shown above, and lead to vision loss.

When patients with diabetes visit Esperanza Health Center in Chicago, nurse practitioners are now able to use a specialized handheld digital camera to snap detailed images of their retinas for annual eye screenings.

The images — captured without dilating the pupils with eye drops — are transmitted to eye specialists, who generally deliver a diagnostic report within 90 minutes. The reports show whether high blood-sugar levels are damaging the small blood vessels in the retina, the tissue that lines the back of the eye. The Centers for Disease Control and Prevention lists it as the leading cause of new cases of blindness among working-age adults.

Using telehealth technology for these exams is more than a matter of convenience. Early detection and treatment of diabetic eye disease may protect against vision loss in most cases.

But fewer than 60 percent of adults with diagnosed diabetes get their recommended annual screening for retinopathy, and the rates are lower in underserved communities and among some racial and ethnic minorities.

People with diabetes face many challenges managing their disease and may see going to yet another doctor for an eye test as another burden. Plus, in its early stages, the retinopathy rarely causes symptoms that compel people to get their eyes checked, even though their eyes are already being damaged.

Yet another challenge is that many people don’t know they are diabetic. The CDC estimates that 7.2 million Americans (23.8 percent of total population with diabetes) have disease but have not been diagnosed.

These realities have inspired new efforts to deliver eye screenings in places where people with diabetes visit regularly, such as community health centers, pharmacies and labs.

“It means less time away from their jobs or families, and it saves them the time and costs associated going to a specialist for the testing,” says Dr. Andrew Van Wieren, medical director of Esperanza Health Centers.

It also means the patients with the most serious cases can quickly be referred to specialists.

Barriers to retinopathy screening

The rising rate of diabetes is making vision loss more prevalent among younger Americans, says Jeff Todd, chief operating officer at Prevent Blindness. It’s not uncommon for people with diabetes to be diagnosed with eye disease in their 30s and 40s.

“They live with the condition for a significantly longer time, that’s why early detection is so important,” Todd says. Using a triage model to identify people in a community health center and move them quickly toward treatment provides opportunities to get care at the earliest stage possible. “That slows down the progression of vision loss.”

With regular checkups, most people with diabetes have nothing more than minor eye disorders, according to the American Diabetes Association. Treatments – which start with controlling blood sugar and blood pressure and may include medication and surgery – usually work well if they are started soon enough and include adequate follow-up care.

Reaching out

As part of broader efforts to manage and prevent diabetes by coordinating care in local communities, Blue Cross and Blue Shield Plans in Illinois and Texas are working with clinics like Esperanza to improve screening rates for diabetic retinopathy.

In a pilot initiative, the health plans are working with six clinics in the Chicago area and two in Austin, Texas, to provide complimentary screenings for any patient who needs one, regardless of whether the patient is enrolled in a Blue Cross and Blue Shield health plan. BCBS will track how many of their members are screened at the clinics and how many are referred to specialists.

When they see blood in the eye, that wakes them up.

The participating clinics are federally qualified health centers, meaning they receive government funding to provide comprehensive primary and preventive care to underserved areas or populations.

“In the past, there were a lot of barriers to members with diabetes getting the services they need,” which could put their eyesight at risk, says Esther Morales, a divisional vice president of quality management programs with the Blue Cross and Blue Shield Plans in Illinois, Montana, New Mexico, Oklahoma and Texas.

Patients with diabetes often explain that they didn’t get their annual dilated eye exam because they lacked transportation or couldn’t get an appointment, says Julie-Ann Collins, a family nurse practitioner who was recently trained to conduct the retinal screenings at Friend Family Health Center in Chicago. “If we can get them right after their visit with us, that would eliminate a lot of their issues,” Collins says.

Positive signs

Similar initiatives have yielded promising results.

In one pilot in the Los Angeles County Department of Health Services, annual rates of screening for diabetic retinopathy increased by 16 percent and wait times for screening were reduced by 89 percent. The program eliminated the need for more than 14,000 visits to eye specialists.

Another effort by Community Health Center Inc., in Connecticut, increased diabetic retinopathy screening, detection and referrals through a software program to speed communication between primary health care providers and specialists at Yale Eye Center. In the first year, more than 550 adults were screened and 145 cases of diabetic retinopathy were detected.

In addition to identifying people who may need to see a specialist, the images can be powerful tools in motivating people with diabetes to manage their health.

By the time symptoms emerge, patients may be far along the path to serious vision damage, says Dr. Rajeev S. Ramchandran, an ophthalmologist who specializes in retinal diseases at the University of Rochester.

“When they see blood in the eye, that wakes them up. They can see it for themselves,” Ramchandran says. “It gives them a strong reason to work on better controlling their diabetes.”

— MHCSW writer Heather Punke contributed to this article

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