Diabetic Retinopathy Screening: An Academic Practice Partnership

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1 Diabetic Retinopathy Screening: An Academic Practice Partnership Kristine D. Warner PhD MPH RN Cindy Wolff PhD MPA RD Dr. John McDonald, Optometrist Amber Genato BSN RN - Graduate Assistant California State University, Chico

2 Overview Northern California Diabetic Retinopathy Screening (NorCalDRS) is a mobile clinic association providing diabetic retinopathy screening at multiple sites in the Quad County area of the Northern Central Valley. Clients with known diabetes seeking care at low and no-cost health care agencies are screened for retinopathy and provided nutrition & lifestyle counseling. Partners: CSU Chico School of Nursing CSU Chico Center for Nutrition and Activity Promotion Dr. John McDonald private optometry practice County Health Departments UC Berkeley Optometric Eye Center

3 Background Diabetic retinopathy is the most common cause of blindness in adults. Those most at risk include individuals with limited or inconsistent health care. The region served by our university has a high rate of unemployment, increasing the levels of uninsured and underinsured. Many health insurance programs do not include comprehensive vision assessments

4 Diabetic Retinopathy Diabetic retinopathy is damage to the eye s retina that occurs with long-term diabetes. Vascular changes in the eye result from leaking of blood and fluid into the surrounding tissues resulting in vision problems: Floaters Shadows or missing areas of vision Difficulty seeing at nighttime Blurred vision and gradual vision loss A diabetic is 25X more likely to go blind than a person in the general population After 20 years nearly all type 1 diabetics and over 60% of type 2 diabetics have some degree of retinopathy

6 Screening issues Screening with dilation Higher resolution of pictures Requires licensed health care provider Results provided to clients immediately Adverse events: acute angle closure glaucoma, photophobia and cylcoplegia (near blur) Screening without dilation Lower resolution of pictures approximately 10% cannot be interpreted (e.g. cataracts) Does not require licensed health care provider Clients must wait for results Use of laptop download of pictures improves resolution students can retake pictures immediately

7 Program Initial 40 hours of training and screening per semester 3-4 students participating each semester 4 screening sessions at health departments, free clinics and high risk areas. Revised 40 hours of training of students in semester prior to PHN (4 th semester) independent study 40 hours of screening during PHN experience (5 th semester); assist in training of 4 th semester students Oversight by graduate assistant

8 Outcomes ~30 clients screened in past 2 semesters (4 sites) ~3 clients identified with Diabetic Retinopathy and referred for evaluation/treatment 8 Undergraduate students and 1 Graduate student trained and conducted screenings All screenings required optometrist present (several clients required dilation) No students have been certified by EyePACS Arranged 3 additional sites for Fall 2011/Spring 2012

9 Challenges Cost of camera ~$10, Cost of uploading and reviewing the images with EyePACS UC Berkeley Digital Health Referral to ophthalmologist for positive results (arrangements for those without insurance) Certification of students requires 10 good images evaluated Adequate time for training of students

10 Screening Session April 2011 Dr. McDonald, PHN student and client

11 Screening session April 2011 Dr. McDonald, PHN student and client

12 Spring 2011 Senior Nursing students present project at College of Natural Science Poster Session

Healthy Retina http://eyedocs.us/sitebuildercontent/site builderpictures/fundusnormal.jpg Retinopathy http://www.otm1.com/userfiles/diabeticretinopathya dvanced.

jpg Assessment Recipients interviewed prior to screening to identify retinopathy risk factors.

Diagnoses Visual disturbances related to retinopathy as evidenced by patient visual complaints, dark spots on retinal photos, & optometrist diagnosis.

Planning Students were trained by a local optometrist on how to appropriately provide retinal screenings. Evidenced based practice regarding retinopathy was reviewed prior to care.

13 Healthy Retina builderpictures/fundusnormal.jpg Retinopathy dvanced.jpg California State University, Chico Nursing Program Diabetic Retinopathy Screening Project Sophia Giusti, Anni Ma, Raynell Walker Nursing Process Assessment Recipients interviewed prior to screening to identify retinopathy risk factors. Students take one photo of outer eye and three shots of retina at various angles with a Topcon retinopathy screening machine. Photos are uploaded to online EyePACS database for optometrist review. Diagnoses Visual disturbances related to retinopathy as evidenced by patient visual complaints, dark spots on retinal photos, & optometrist diagnosis. Poor health maintenance related to patient apathy as evidenced by ineffective blood sugar maintenance & little history of retinal screening. Planning Students were trained by a local optometrist on how to appropriately provide retinal screenings. Evidenced based practice regarding retinopathy was reviewed prior to care. Implementation Individuals with diabetes to were affiliated with low income community health facilities were invited to attend retinal screenings in April 2011 at these sites. The team optometrist reviewed recipient results and referred patients to appropriate health professionals as needed. Evaluation Patients provided team with verbal feedback regarding their experience after the screenings. Students were encouraged to review their own performance and make adjustments when necessary. Public Policy Assembly Bill no.175, Section outlines that ocular medical data can be reviewed by an optometrist at a later date without the patient present. The bill also specifies that patients who inquire about an optometrist consultation should be offered one within 30 days of their request. Goal To provide low-cost retinal screenings within the community to identify retinopathy cases at earlier, more manageable stages. Risk Factors Prolonged diabetes High cholesterol Elevated blood pressure Uncontrolled blood sugar Smoking Extras usg= O0F80VUVVZikm2_LR35_vvKDr9M=&h=193&w=250&sz=23&hl=en&start=32&zoom=1&tbnid=IRiMbVnaryZaiM:&tbnh=147&tbnw=190&ei=WJmjTZeyC4eiuQ Oy7sX0BA&prev=/search%3Fq%3Ddiabetic%2Bretinopathy%26um%3D1%26hl%3Den%26rlz%3D1C1SNNT_enUS406%26biw%3D1600%26bih%3D775%26tbm%3Disch 0%2C646&um=1&itbs=1&iact=hc&vpx=1235&vpy=150&dur=713&hovh=154&hovw=200&tx=88&ty=65&oei=UJmjTfoxhYa5A82XlfgI&page=2&ndsp=32&ved=1t:429,r :6,s:32&biw=1600&bih=775 Statistics In 2002, diabetic retinopathy was the 3rd causes of blindness in the U.S. 60% of people with Type II diabetes and nearly all individuals with Type I diabetes contract retinopathy in 20 years of their diabetes diagnosis. Only 50% of diabetic patients get their recommended annual diagnostic retinal screenings. Results Early screening and detection is essential in preventing complications of retinopathy like blindness. Retinopathy advancement can be slowed via laser treatment if caught in its early stages. Of the 8 individuals screened, 1 patient was newly diagnosed with retinopathy. Resources Benbassat, J., & Polak, B. (2009). Reliability of screening methods for diabetic retinopathy. Diabetic Medicine, 26(8), Bloomgarden, Z. (2007). Screening for and managing diabetic retinopathy: current approaches. American Journal of Health-System Pharmacy, 64S8-14. Gillibrand, W., & Holdich, P. (2010). Evidence-based management 20. Assessment of retinopathy. Practice Nursing, 21(6), Morello, C. (2007). Etiology and natural history of diabetic retinopathy: an overview. American Journal of Health-System Pharmacy, 64S3-7. Paulus, Y., & Gariano, R. (2009). Diabetic retinopathy: a growing concern in an aging population. Geriatrics, 64(2), Rowe, S., & MacLean, C. (2007). Quality indicators for the care of vision impairment in vulnerable elders. Journal of the American Geriatrics Society, 55(S2), S Wong, T., Mwamburi, M., Klein, R., Larsen, M., Flynn, H., Hernandez-Medina, M., &... Mitchell, P. (2009). Rates of Progression in Diabetic Retinopathy During Different Time Periods: A systematic review and meta-analysis. Diabetes Care, 32(12),

14 Fall 2010 PHN Students show great flexibility in providing high resolution retinopathy screening at a local senior housing site.

OAKLEIGH EYE CENTRE. THE EYE Before looking at diabetic retinopathy it is important to understand what the healthy eye looks like and how it works.

OAKLEIGH EYE CENTRE. THE EYE Before looking at diabetic retinopathy it is important to understand what the healthy eye looks like and how it works. ABN: 80 836 359 971 Dr Mark Steiner 345 799X 135 Warrigal Road Dr Helen Steiner 292 419A OAKLEIGH VIC 3166 Tel: 03 9568 7706 Fax: 03 9568 4498 E-Mail: oakeye13@bigpond.com DIABETIC RETINOPATHY DIABETES