LC 09-2011-Broader Blindness Prevention
- 1. Jorge Cuadros OD PhD Tara Seymour
- 2. Significance of Broader Blindness Prevention in Our Clinics Diabetic retinopathy is the main cause of blindness in working age adults, but not in all adults. More people will become blind from macular degeneration and glaucoma. The majority of blindness could be prevented with early intervention. Many sight-threatening conditions have been detected and referred through EyePACS
- 3. EyePACS Referrals 8.21% of all EyePACS consults resulted in referral for sight-threatening diabetic retinopathy 7.83% of all EyePACS consults resulted in referral for other sight-threatening conditions Glaucoma Cataract Maculopathy Papillopathy (optic nerve) Pigmented lesions Retinal degeneration
- 4. How Does Your Clinic Handle Eye Referrals? No time frame given – all eye referrals generally treated the same Urgent referrals (within 2 days) made with sudden decreased vision or ocular pain; all other referrals generally treated the same Clinic is able to differentiate conditions requiring within 1 month from conditions requiring referral within 2 days
- 5. What Is The Average Waiting Time For Eye Care Referrals From Your Clinic? Less than one week One week to less than one month One month to less than three months Three months to less than six months Six months or more I don’t know how long my patients wait to see an eye care provider.
- 6. The Challenge of Referral for Other Conditions The retinal consult does not take the place of a full eye exam. Sensitivity and specificity of referral based on electronic consults have not been validated for other conditions Disagreement about when to treat, when to refer Excessive variability in consultant recommendations Less effective treatment Excessive over-referral
- 7. Scientific Committee Recommendations: Purpose: Identify patients with sight- threatening conditions. Develop protocol for acquiring necessary information and images for consistent and easily adapted detection system. Retinal image interpretation protocol for identifying significant lesions in: Optic nerves Retinas Maculas
- 8. Optic Nerve Lesions Signs of glaucoma: Asymmetric cupping: greater than 0.2 dd cupping difference between the two eyes Enlarged cup: optic nerve cupping equal to or greater than 0.7 Rim notch or thinning: notch in or thinning of optic nerve tissue extending to edge of the optic nerve or disproportionate thinning of rim tissue in inferior or superior sections of optic nerve Optic nerve/Splinter hemorrhage: flame shaped hemorrhage near or at the rim or in the substance of the cup Nerve fiber layer defect (NFLD): NFLD occupying greater than 10 degrees of arc in the inferior or superior arcuate areas For screening purposes, referable glaucoma is considered sight-threatening, well-established glaucoma that is likely to be treated immediately. Low risk glaucoma suspects would not be referred from this protocol. Prominent pallor: pale optic nerve without cupping not previously identified pale swelling of segment of optic nerve with or without hemorrhage Papilledema: swollen, hyperemic disc with blurred margins in one or both eyes
- 9. Retinal Lesions Moderate/Severe nonproliferative diabetic retinopathy (NPDR), as defined by the International Clinical Diabetic Retinopathy Disease Severity Scale Neovascularization New vessels or diabetes-related fibrous proliferation anywhere Vitreous hemorrhage or pre-retinal hemorrhage Invasive lesions: eg melanomas Neovascularization of the iris Active retinitis: active retinal inflammation Retinal detachment (recent onset)
- 10. Lesions of the Macula High-risk drusen (large, soft drusen) especially associated with: Pigment migration Geographic atrophy not involving the foveal center Disciform scar or prior chorodial neovascularization Macular edema, not clinically significant: hard exudates within 2 disc diameters but more than one disc diameter from the fovea Clinically Significant Macular Edema (CSME): hard exudates within one disc diameter of fovea Subretinal neovascularization subretinal hemorrhage or lipid exudate with hemorrhage within the arcades wet macular edema-intraretinal hemorrhage involving the fovea cystoid macular edema with blood in cysts subretinal pigment epithelial blood (drusen visible over the hemorrhage)
- 11. Other Referral Criteria Visual Acuity < 20/40 Acute onset of pain and/or vision loss *Intraocular pressures *Initiation of systemic treatments associated with vision loss: Hepatitis C treatment Plaquenil / quinine derivatives Steroids * Not part of the Prevent Blindness Northern California Protocol
- 12. PBNC Referral Guideline Emergency Referral – 1-2 days: papilledema recent onset retinal detachment neovascularization of the iris active retinitis subretinal neovascularization acute vision loss acute onset of pain
- 13. PBNC Referral Guideline Urgent Referral (within 1 month) pale swelling of optic nerve or segment of optic nerve (with or without hemorrhage) neovascularization clinically significant macular edema possibly invasive lesion Moderately Urgent Referral (within 6 months) retinal and optic nerve features blurred in all views, with VA less than 20/40 obvious glaucoma moderate to severe non-proliferative diabetic retinopathy high-risk drusen
- 14. PBNC Referral Guideline Pass clear media; retinal and optic nerve features clear optic nerve margins sharp, vessels easily visible, pink rim, less than 0.5 dd cup in both eyes retinal vessels visible and sharp, normal diameters, no hemorrhages or pigmented lesions, minimal microanerysms foveal reflex present, minimal drusen, no hemorrhages, flat or pitted Non-Readable Unreadable photos will not be used to initiate referrals; other screening results will be used instead
- 15. Future Efforts Validation of protocol Primary care provider certification for triage purposes Automation and integration into electronic medical records and referral systems Connect treating clinicians with EyePACS cases Automated patient alerts Using retinal images for identification of risk factors and biomarkers of systemic disease Validation of new technology and automated algorithms