Video The Optometrist’s Role in Diagnosing and Managing Patients with Diabetic Retinopathy: Focus on the Importance of Prompt Referral [014543] Play Pause Volume Quality 480P 480P 480P Fullscreen Captions Transcript Chapters Slides The Optometrist’s Role in Diagnosing and Managing Patients with Diabetic Retinopathy: Focus on the Importance of Prompt Referral [014543] Overview Hi, everybody. My name is Dr Marc Dunbar and I'm an optometrist and I practice at the Basket Palmer Eye Institute in Miami, Florida Thank you for joining us in this webinar Siri's preventing inevitable blindness in the patient with diabetes and evidence based clinical successful referral roadmap for 2021. This is part of a multi modular, curriculum based learning. Siri's eso I program I'm doing today is one of several modules that you'll be able to tune in on, um, pretty much on demand. We've got other providers, retinal specialist endocrinologists and other optometrists that will also be contributing to the Siri's. So I hope that you're able to tune into all of them. I hope you learn a lot and and really get a lot out of these programs. I think we recognize that that optometry is on the front lines of managing patients with diabetes. We are really kind of the middle point between the endocrinologist primary care physician on one end and the retinal specialist on the other. I think we recognize that when you look at the staggering number of patients with diabetes, I think we're up to 29 30 million people in the United States have diabetes. About 80 million or so are pre diabetes. And optometry really is the one the gatekeeper that is going to see and manage these patients. And there's been, really, I think, a big paradigm shift in how we manage and treat these patients. And I think the role of the optometrist is really probably more important than ever in terms of being able to recognize the presence of diabetic retinopathy, being able to categorically stage diabetic retinopathy and then, you know, getting patients seen by the retinal specialist sooner than before. And so that's really kind of the goal of this program. Today it is a C M E n ce certified webinar, jointly provided by the University of Massachusetts Medical School and CMI Education. Resource is it's supported by an unrestricted independent grant from Regeneron Pharmaceutical. It may include discussions of off label or unapproved uses is of specific agents and then to receive CMI or C E credit. Click the CMI CE link below this video to access the online evaluation form. Oh, I have disclosure. I am a consultant for Al Organ, Carl, Zeiss, Regeneron and Genentech. Let me just say that that really is somewhat important, right? Because when we talk about the management of treatment of diabetes and diabetic retinopathy, both Regeneron and Genentech have to drugs, uh, to treat diabetic retinopathy between I lia, a vast in, um and Lucentis. Keep in mind, that is, optometrist. We will never be the ones who are going to make a decision on which drug a patient gets. And so I really give a lot of credit to a company like Regeneron who's supporting this grant because they know a ZAY said earlier that optometry is on the front line of this disease and that I think they recognize that there's more patients and we have that we can kind of take care of. And it really becomes a village, right? Everybody's got to do their part to manage and treat these patients and make sure they get sent onto the retina specialist on a timely manner. So, as I said from the beginning, optometry really plays a critical role, is part of the health care team and managing patients with diabetes. It is paramount to recognize the presence of diabetic retinopathy, and I think as an optometrist we all do a great job of doing that. We dilate our patients. Many of us use wide field imaging, so I think the ability to see and detect diabetic retinopathy is really not anything new to us. I think we've done it. We've done it well for a good many years. But as I said, Really at a point now it becomes more critical to recognize categorically what stage or what level of diabetic retinopathy a patient is. Traditionally, we would wait until patients develop proliferated disease. But again, that's changed. And one of the messages I want to convey today is really when does that patient have mawr than moderate, non proliferated disease? And that really maybe the barometer, not mild moderate But when it's more than moderate that maybe the time that these patients need to be seen by a rental specials that maybe the time, of course, that we need to refer these patients. So yes, accurate staging is important and we're in an era of technology. We have MAWR tools at our disposal with wide field imaging with O. C T and O. C T angiography to really you know, make that ah, critical part of our practice and really be, You know, I think very precise and accurate when we make those distinctions. So whenever I see a patient who has diabetes, when I'm dilating the pupil, I'm looking with my 90 or 78. Of course, the question is, Do I see any diabetic retinopathy? Do I see any hemorrhages or Michael aneurysms? No. I look for the presence of Venus beating or any Irma obviously any proliferated disease. When I'm looking at the macular with my 90 or 78 Do I see any retinal thickening? Does the patient have diabetic macular oedema? Of course, any level of retinopathy, the question becomes, then what is the extent of involvement? And I used to pride myself, kind of on the ability to categorically recognize what level of diabetic retinopathy a patient has. But, you know, over the years I've learned that that could be difficult, and I've really come to rely on some of the newer technologies wide field imaging devices to be able to look and and maybe look at areas that were I was concerned. Is this Irma resent neurovascular ization, or perhaps even missing Irma and Onley going back through wide field imaging and recognizing that the patient has maybe mawr, uh, retinopathy than what I previously would have imagined. I think most of us grew up kind of learning the et DRS classification of diabetic retinopathy that mild, moderate severe NPD are etcetera. I think the difficulty with that was that, you know, in the DRS Studies when they were categorizing levels of diabetic retinopathy was based on standard slides or standard photos. So, for example, if you're looking at moderate NPD are trying to decide is your patient have, you know, the level that's consistent with standards slide to a or in severe patients, you know, more than standard slide a day. And, you know, I think that became kind of difficult because, you know, from a clinical relevance perspective, we don't always recall what standards slide two way or a day waas. So in 2000, what 2000 and three went to this international scale, and I think it became a little more clinically practical, and you can look in, you know, the TDRS scale on an international scale on the right. I think we recognize the patient is mild. They have at least a micro aneurysm in each eye if they have more than that. So more than just micro aneurysms, maybe some hemorrhages and micro aneurysms. Um, extra date, etcetera. So more than just mild, but not as much as severe. Then a patient categorically has moderate NPD are. And I think most of us you know her pretty good about recognizing what that 4 to 1 rule is right. Significant hemorrhages and micro aneurysms and at least four quadrants Venus beating in at least two quadrants prominent Irma in at least one quadrant. If they had any of that. Categorically, that patient was at a level of severe. So again, when we look at you know what is moderate. So if they have anything less than what we categorize a severe than categorically that puts the patient at a moderate NPR. And then, of course, any patient has neo vascular ization, traction, retinal detachments, pre retinal or vitreous hemorrhage. Of course, categorically, that puts a patient at a level of a PDR or even a high risk PDR. So again, putting a picture with really what our description is I think you can recognize this patient has significant hemorrhages and micro aneurysms in at least four quadrants and categorically that puts a patient at that level of a severe NPR remember the whole reason we do this. Staging right is really looking at what is the risk of going on to develop proliferated disease in a year? And when you look at the mild and moderate cases, that risk was relatively low and mild. It was only about a 5% risk of going on to develop proliferated disease in a year, whereas with moderate that jumps up to about 12%. So that's why we would see these patients one year, maybe nine months. But then you look at that severe NPD our case and that patient, their risk of going on to develop proliferated disease in a year goes up to over 50% and when you look at their five year risk, that risk is over 75%. So that's why those patients traditionally we would see him every 3 to 4 months because we had to watch very carefully because we know once they develop PDR, that risk of vision loss or severe vision loss becomes much greater. And so this is, uh, the American a Captain America American Academy of ophthalmology, Irish registry data looking at about 53,000 eyes with newly diagnosed diabetic retinopathy and good vision at baseline. So they went on to look at what is the risk of going on to develop sustained blindness compared to the group who had mild and PDR? I don't think it's any surprise, right? The patients who had proliferated disease, their risk of going on Tiu have sustained blindness was four times greater than eyes with mild non proliferated disease. But look at the bullet before that, even the severe NPD our cases their risk was almost as high 3.6 times greater risk of going on to develop sustained blindness. So then that group in particular becomes a critical benchmark. And again, I think it speaks to how important it is to categorically recognize the severe NPD are patient, and we'll talk about in a second why it's important to make sure those patients are seen by a retinal specialist. I like this little kind of graphic here of really looking at the risk of vision loss in patients who have diabetic retinopathy. So you look at those mild and moderate patients, those guys girls, of course, they could go on for years and years with having very good vision. You know, their disease could be fairly stable and again, that's why we see those patients every year, maybe nine months. And most of these patients do very well. But look at when you get to that severe level right? There's a kind of a small window where we know once they reach that severe level, the risk of going on to develop vision, loss and rapid progression is very quick. So though they may be kind of slow and slow progression for years and years, once they reached that level of severe, the wheel can fall off very quickly again. I think that's why it's important to identify. Of course, I think we also recognize diabetic macular oedema can occur at any stage. Again, we can see it up mild. We know that it's more common, probably moderate and severe, but again just kind of understanding and recognizing how things could be fairly slow and indolent, and then boom over a really short period of time. Once they reach that level of severe NPD are vision loss can occur very quickly. So this is our international scale the one that I think most of us grew up with. The idea that we're kind of using that stop light color, right? We're green and yellow is is a little more safer. Patients tend Thio have very good vision, and once you kind of go through on through the course of that scale from moderate into severe NPD are as we already spoke about, that risk of vision loss becomes much greater. And, of course, by the time they develop PDR, obviously that risk of vision loss and blindness becomes even greater. I want to draw your attention so there's kind of another severity scale that, sandwiched in between moderate and severe NPD are, and that's that moderately severe. So if we look at what the severe NPD are was is with that 4 to 1 scale that we already talked about if you think about moderately severe. So instead of hemorrhages and micro aneurysms and four quadrants, you've got severe hemorrhages and micro aneurysms in 2 to 3 quadrants, and instead of Venus beating into quadrants, it's Venus beating and at least one quadrant. So again, that's another layer that goes on after moderate. That's that moderately severe NPR again. I don't wanna kind of think that any of us, even a retinal specialist, you know, our great at being ableto really slice and dice and accurately diagnosed when it's moderately severe to severe. You know, these were a classification that was really developed in the clinical trials when both Lucentis and you know, I lI and these drugs were going through clinical trials when they were developing the clinical trials that were reading centers and those reading centers. We're really looking at photos more accurately able to really distinguish some of these sub categories, and it becomes important because what we're gonna learn in a few minutes, it's really that moderately severe to severe NPD are that becomes a critical window. You're going to hear Burbage about level of 47 to 53 again that was born out of the clinical trials. And again, that's 47 to 53 is that moderately severe to severe? NPD are stage, and I think we need to be very familiar with. So, of course, when we kind of categorize and recommend follow up schedules, this is the AOA guidelines that were just published about a year ago. This is November 2000 and 19. I want a very briefly go through that what the new guidelines are in terms of how we follow these patients and when really referral guidelines are recommended. Of course, no diabetic retinopathy or even mild NPD are the recommends that these patients have annual eye exams because optometry we recognize the importance really of of educating our patients, helping them understand their disease. We talk about diet. Do you know what your blood sugars are? Do you know what you're a one sees are These are the ones we make sure they understand the disease and they understand the importance that they've got to come in every year for that annual eye exams course that moderate and PDR case. You know, again, we know that the risk of vision loss is a little greater still a little over 10%. But those air patients that we see maybe every 6 to 9 months taking a picture using imaging, but making sure patients understand that we need to see that patient back 6 to 9 months. That moderate NPD our patients. That's not a patient you need to send to a retinal specialist, unless you're not comfortable managing diabetic retinopathy or you're not sure. But I think these patients are again very practical to follow these patients and are optimistic offices. But again, once you develop that severe NPD are you, look, that's where really things change? Told you. I used to follow these patients in my practice anymore. I don't do that. These air patients that I get in to see a retinal specialist within that 2 to 4 weeks, these air patients that are a lot that I rely on, Why field image ing to be ableto maybe accurately make sure is it severe or just moderately severe? NPR And again, I think it goes without saying when you look at that PDR and high risk PDR, those patients, particularly high risk PDR, needs to be seen within that 24 to 48 hours. And we recognize, as we've already said, that diabetic macular oedema can occur at any stage of diabetic retinopathy in those patients. When you see it should be seen by a retinal specialist within 2 to 4 weeks, and so just a few examples, right? Just kind of putting a picture toe. What we categorize is mild. NPD I remember at least one micro aneurysm again. With a micro aneurysm, you can have leakage, so you may see some extra date like we see in the in the photo on the left. But again, if you look carefully, there's a couple micro aneurysms that were there. And I think all of us would feel very comfortable diagnosing this patient and, you know, talking about blood sugar, making sure that patient comes back in that one year. The annual follow up visit you can see in this case it's a little bit worse, right? You've got Mawr Micro aneurysms. You have some hemorrhages, but yet it's not at the level of severe NPD are so multiple Micro aneurysms dot in blood hemorrhages. You can get Venus beating and at least one quadrant, and that can still be moderate. NPD are so again that more than mild but less than severe. So again, that's a patient you want to talk about coming in in that 6 to 9 months period. You don't need to refer that patient again unless you're uncomfortable. Or maybe you're worried that there could be diabetic macular oedema. There's another patient, a right and a left I This is a patient of mine that I have been following for some time. She's had type two diabetes for the last 14 years. Again, you look at the A one c not as good as we would like. It's about 9.5, she says. Over the last four days, her blood sugar has been very high over 200. So you look at the right eye and I think you do see a little bit of diabetic retinopathy. President, I'm gonna give you a better image in just a second. The left one again. You know, again, that mild to moderate disease. I think when you look at the macula along the superior arcade, you can see that there's some or hemorrhages. Let's take a look at that right eye, and I'm looking with an O. C. T angiography. And I think this does a nice job, Ossetia and an optometric practice to really look at a micro vascular level, you can see some, you know, more micro aneurysms at a at a micro vascular level. Some dilation and maybe even I don't want to say ischemia, but you get a nice shot of that phobia lol a vascular zone. Look at the left eye and again I think you see again, especially along the superior arcade Cem or hemorrhages and micro aneurysms and micro aneurysms. You see a cotton wool spot just below the macula and again on the O. C. T. We see that their retinas not thickened, although, you know, on our thickness map below the macular, you can see perhaps, or some thickening. And this may be some non center involved diabetic macular oedema. But again, on the O. C. T A. You can see that there's some Meskini. And again I think the O. C. T. A. Does a nice job of just providing a perspective that you may not be able to see on your clinical exam. Here's a patient who has a little more severe diabetic right now, but this is a severe NPD are, and this is a wide field image that gives you that mawr kind of wide field perspective. Let me blow it up here so we look a little from Marcato Arcade and I think you can see at least in the right eye, you know that hemorrhages and micro aneurysms and at least four quadrants and the left eye. Maybe it's not as bad. Maybe that would be a moderately severe. You look carefully at the vessels, or maybe a little bit Venus beating present there. This is a different patient, but I wanted to draw your attention to in the fact that you're able to see some Irma there. And just sometimes it really does take an image to be able to study, to recognize that Irma's may be present. So this is a patient who has, maybe moderately to severe NPD are. And that's a patient that again I would recommend getting seen by a retinal specialist. So we know that anti veg F has really become the mainstay in treating patients who have diabetic macular oedema. This is a great example, right of a patient who has significant DME before treatment. They end up having an anti veg F treatment, and here you are 24 months later and no surprise. You look at the diabetic macular demon and it goes away. But also, you know, I want to draw your perspective. Just, you know, look at the level of diabetic retinopathy that you saw before treatment and after treatment. So no, no doubt the diabetic macular oedema goes away. But you look at the level of the diabetic retinopathy and you can see that the retinopathy is much less. Here's another example. This is a patient went high risk PDR who somehow was enrolled in the study. They had diabetic macular oedema. You look 24 months later and again the diabetic macular oedema is gone. But also look at the level of diabetic retinopathy and we've been, in a sense, able to turn the clock back. The level of diabetic written up the is much, much less so. No question we established the effectiveness of these anti veg F drugs. But the other thing that we kind of learned as a byproduct is that perhaps were able to turn the clock back on the level of diabetic retinopathy. So it really begs the question, you know, is there a benefit of maybe treating these patients earlier? If we treat him early, instead of waiting till the developed proliferated diabetic retinopathy, would we have better visual outcomes? Would be be ableto have maybe fewer number of injections. That was really the purpose, at least of one of the studies that was done by Regeneron. This is a Panorama study. It was a phase three double mask prospective study of looking at a flipper, cept in patients who had that moderately statistics moderately severe to severe NPD are that level of 47 to 53 is we already talked about so one group in that staging group gets treated. The other group gets followed. You were followed initially for 24 weeks and then on to 52 weeks and upto a 100 week. I don't wanna get kind of lost in the minutia of the study. There's others that we'll talk about that in more detail. But suffice it to say there was two treatment groups, one that had every 16 weeks, one that was every eight weeks and then compared to a sham group. This is the 24 week data, and again I think a picture is worth 1000 words. Remember, the goal was to look at the percentage of patients who had a two step improvement. And again, this is looking at the different groups compared to that sham group, and you can see almost a 60% of the treatment group have that to step improvement, so that treatment effect happened very quickly. At 24 weeks, it was sustained up to 52 weeks. So again you look at the different kind of treatment algorithms, but again comparing treatment to non tree. But you can see almost 80% having a two step improvement. And then when you look up to 100 weeks, so looking at 24 year and up to 100 weeks, I think again it's pretty powerful data to show that when these patients were treated with the flipper Sepp, 80% of them, or 60% of metal week 100 had a two step improvement. Then you look at, you know, preventing the development of some of these more difficult complications like proliferated, disease and tear segment, new revascularization or center involved Diabetic macular oedema. Again, this is maybe one of the most powerful, you know, slides that we can look at when you look at preventing the development of PDR or anti segment neurovascular ization. You're looking at an 85 to 80% 88% risk reduction again looking at the risk reduction of going on to develop center involved diabetic macular oedema, 79% or 73%. When you look at all of those complications combined, this was at 52 then I'm going to show you what week 100. Similarly, the fact that by treating these patients by catching them within that critical window, were able to not only put the clock back but really prevent them from developing some of these more severe complications that we're so familiar with that we see in our patients who developed diabetic retinopathy. So vision threatening complications were reduced by over 80% or 85%. You know, compared to the sham injection, the development center involved, diabetic macular oedema was reduced by 68 to 76% compared to the sham group. And again, this is just a kind of a picture. We talked about that level of 47 to 53 years, the patient that has a two step improvement. This is before treatment and as you go on to two years and a number of injections looking at after treat and again one of the other studies. That was kind of Regeneron's data. This is Genentech's. Charlie Wykoff was the author of both of these studies where the other study was a prospective study. This was a retrospective, really looking at the pivotal data that led to the FDA approval of Of Lucentis. This is the ride and rise clinical data again, specifically looking at that level 47 to 53 almost 750 patients that were randomized again. I don't want to get caught up in the minutia, but really, the data of the outcomes is very similar to what we saw in the other study. And and again, if you look specifically at that moderately severe to severe NPR patients, E. I mean, look how powerful that data. It's 78%. We're getting that to step Regression compared Onley 12% in the sham group. And again, I think the nice part of this study is again they looked at that mild to moderate group, right, and then they looked at the moderate and high risk group, and again we were able to have a treatment effect. But when you look specifically targeting at that level of 47 to 53 I think it's very clear that that becomes the sweet spot in this disease where we're able to really make a difference and I think it's so important. Why is optometrists when we see these patients to be able to categorically recognize that level of moderately severe to severe NPD are and why we need to get those patients seen by a retinal specialist, So they're able to show at month 24 that level of 47 to 53 80% of eyes had a two step improvement with Wrana busy mob versus 12% of eyes and the regression though it occurred, it was really not seen like what we saw in that level of 50 47 to 53. And so I'm going to kind of summarize what we just talked about, right? And really the key questions from what is the OD goal and management of patients who have diabetic retinopathy is we talked from the outset. Number one is diabetic retinopathy. President. I think we're all very good at recognizing that with our 98 78 many of us use imaging to be able to take a photograph and help us. And really, being able to determine is diabetic retinopathy present, but then being able to accurately categorize what level of diabetic retinopathy is present, You know, when is it more than moderate? NPD are so again significant hemorrhages and at least two or more quadrants? Is there any Venus beating? Is there any Irma? If so, that puts that patient on more than moderate NPD are, and I think that's the patient that we need to make sure it gets seen by a retinal specialist. Now they may not always treat it right. They may look at it, and for various reasons, the treatment decision lies on them, and they may delay or or they might treat. But I think it needs to get out of the odious hands and into the hands of a retinal specialist. And then, obviously, I think that gives the patient the best chance for having visual recovery. And then the last thing, of course, that we're all good at. Is there any diabetic macular oedema? Whether you're using your nine year 78 or those who have O. C. T being ableto scan the macula, is it center involved in non center, involved in making sure that patient, if they do have diabetic macular oedema, gets seen by a retinal specialist again within that 2 to 4 weeks. So with that, let me thank everybody for listening in. I hope you found that this was valuable. And I would encourage you to go on and listen to the other modules because I think there's a some great information being discussed by some of the best retinal specialist of optometrists in the country in this area. Thank you very much for your time. Published Created by
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