Welcome to the optometrist Foundational role in screening and referral of persons with diabetic eye disease Forging a critical partnership with diabetes, primary care and retina specialty community to optimize outcomes across the spectrum of diabetic eye disease. I'm paul chow's, I'm an optometrist in Tacoma Washington. I have a practicing emphasizes diabetes, I care and education. I worked closely with a number of endocrine specialist as well as retina specialist. I'm also a professor of optometry at Western University of Health Sciences in southern California. I teach a class they're called advanced topics in diabetes and diabetic retinopathy to second year students in optometry podiatry and pharmacy. I'm also the optometric representative to the national diabetes education program, one of the sub groups called the P PI, which is pharmacy podiatry, optometry and dentistry. So it's a collaboration to try to get those four professions to work with one another here. My disclosures and I've been a consultant to a number of companies in the eye care space somewhat in the diabetes space as well. Uh the activities supported by an educational grant from Regeneron, I think it's a pretty straightforward talk with uh hopefully no bias that you perceive in my presentation here are my key messages for the talk that I'm giving right now. Optometrist. In fact, a lot of patients that have both diagnosed and undiagnosed diabetes, you know, oftentimes an optometrist is the first patient or the first person healthcare provider to identify diabetes and patients that don't know they have it not typically through seeing diabetic retinopathy, although that does happen, but more often from profound changes and refractive error that signal huge shifts in glitzy mia. The next important message is that optometrists commonly use advanced technology to detect in great diabetic retinopathy and diabetic macular oedema severity. We have to all remember. The diabetic macular oedema is actually the leading cause of vision loss in people with diabetes doesn't typically cause blindness, but it can profoundly impact the patient's quality of life. Most patients with diabetes, including those with less severe diabetic retinopathy can actually be followed by an optometrist and referred when it's appropriate to do so For treatment, all optometrist look at the retina and we work closely with retina specialists wherever they are available in our communities. When we do detect more significant retinopathy that requires treatment, optometrist also commonly provide diabetes education. Uh that's intended to relate key messages and complimentary messages to people with diabetes that are hopefully consistent with messages delivered by other members of the diabetes care team, including primary care docs, internal medicine doctors and endocrinologists. And the bottom line here is that we're all in this together, right, diabetes and diabetic retinopathy or epidemics. We all see these patients regularly and if we work together, the goal is to achieve better outcomes, particularly with regard to eye disease for the purposes of this talk. So these are the most common eye diseases seen by optometrist. These are things that I see every day in my own practice. And what's interesting is that all of these are actually more common in patients that have diabetes. Diabetic retinopathy. Certainly the most important uh manifestation of diabetic eye disease. But dry eye cataract, glaucoma, even macular degeneration has been shown to be more common in people that have diabetes. We think it's a function of increased advanced applications and products. And there are these other retinal vascular abnormalities like retinal vein occlusion and hypertensive retinopathy. There are actually quite common and more common in people with diabetes. So let's talk a bit about diabetic retinopathy. An overview and the red the specialist are going to go into this in more detail. I know but it still remains true that diabetic retinopathy is the leading cause of new onset blindness and Americans of working edge. That is people under the age of 70, about 30%. Depending on what survey you you pay attention to. About 30% of people with diabetes have some degree of diabetic retinopathy. Only about 10% of what we call vision threatening diabetic retinopathy and that consists of severe nonproliferation retinopathy, proliferated retinopathy or diabetic macular oedema. And I'll show you some examples of those phenomenon. The other thing to know is that even people with pre diabetes, a substantial minority have findings consistent with diabetic retinopathy. So a number of surveys have been done showing somewhere between eight and roughly 13% of pre diabetes patients have retinal manifestations that are consistent with diabetic retinopathy. So I always ask the question is this pre diabetic retinopathy? No, the patient has end organ manifestation of a systemic condition presumably. And so we think that's why a lot of patients by the time they're diagnosed with diabetes, you know 67 years can go by and that's why written up these fairly prevalent actually at the formal diagnosis of type two diabetes, Nearly 12% of adults in the United States that have diabetes report vision disability including blindness. And that's 2018 data. So here again, it's just kind of a graphic representation of the prevalence of diabetic retinopathy and macular oedema in the United States. So about eight million cases of diabetic retinopathy of all stripes, all varieties. About two million cases more than that actually are undiagnosed. In addition, we have about 2.5 million people with diabetic macular oedema. And nearly a million of those patients are undiagnosed. So let's just spend a moment on the distribution of eye care providers in the United States. There are roughly 46,000 optometrists in the United States in about 23,000 ophthalmologists. And that includes about 2300 or so retina sub specialists. A significant number of patients with diabetes actually see an optometrist for their eye care needs, including correction of refractive error, but also for dilated eye examinations to detect any form of diabetic eye disease, including retinopathy and all the other things listed on the earlier slide. It's also interesting a lot of patients don't see other health care providers, often when they come to the optometrist, they don't have a family doc. They haven't been you know, to to an internal medicine doc or even a PCP. So sometimes optometrists actually recognize you know, symptoms and signs of diabetes. As the first provider that sees a patient, 88 million uh eye examinations were performed by optometrists in the year 2013 and that correlates with about 10 I examination today delivered by optometrists, which is a reasonable number. So here is just the uh the availability of both optometrists and ophthalmologists and counties across the United States. And on the left is the, you know, the geographic distribution and concentration of optometrists. And you can see it's a bit denser than it is on the right graphic showing ophthalmologists. Lot of ophthalmologists including retina specialists in metropolitan areas. But you know if you're so in more rural counties And as it turns out nearly 40% of US. counties, almost 25 million people have an optometrist president in that county but not an ophthalmologist, it's about 8% of the us population. Now. Ophthalmologists are often within you know, a driving distance an hour or so of a patient's locality. But typically an optometrist is closer talk for a moment specifically about optometry and diabetes care. As it turns out, diabetes and diabetic eye disease are a significant part of the four year postgraduate curriculum for optometrist and diabetes, you know, is a significant part of the clinical exposure in in our training. And I know this. I teach a course at a university where diabetes is really uh in large measure integrated into the curriculum. Most patients with diabetes and diabetic retinopathy in fact don't need ophthalmological care or treatment, but they do benefit from meticulous dilated retinal examinations. Uh use of advanced diagnostic imaging and delivery of consistent complementary diabetes management education that can be delivered by optometrists in our offices, Clinical practice guidelines have been written for optometry. I had a hand in the first iteration of those back in 2014. And those guidelines call for routine dilated fund its examination at least annually, which in some cases maybe overkill if the patient has no no retinopathy and has excellent metabolic control. But the other part of the guideline is to make sure that the PCP the endocrinologist, gets a consultation letter about the results of the I examine whether the patient has any diabetic retinopathy or not. And also the guidelines really expressly call for referral to retina. Sub specialist within ophthalmology for treatment of diabetic retinopathy that's more than moderate and if there's any diabetic macular oedema. So in the year 2017 Retrospective chart analysis showed that optometry is diagnosed more than 400,000 cases of diabetic retinopathy that had not heretofore been diagnosed. And again, you know, the studies vary on this, but somewhere between 20 and as high as 40% of patients With type two diabetes have some degree of retinopathy upon diagnosis. It's typically not severe, but occasionally, I've seen patients coming in with really severe diabetic macular oedema and vision loss right after the initial diagnosis of type two diabetes. As it turns out, the onset of diabetes and its progression, uh you know, corresponds very nicely with the onset of presbyopia, the need for reading glasses or bifocals, lenses. So, you know, pre diabetes rates go up in the forties and fifties and 60 so to Type two diabetes rates. So again, oftentimes the optometrist is one of the first health care providers that somebody with undiagnosed diabetes or recently diagnosed diabetes is going to see. So here are some of the tools used by optometrists in caring for patients who have diabetes. So very commonly, you know, hopefully it's 100% patients receive a dilated stereoscopic eye examination and that's really important to detect diabetic macular oedema, but also for the assessment of glaucoma. You need to look at the optic nerve in stereo. Most optometrists better than 90% have a retinal camera and that's really nice because it allows you to survey the patient's retina in detail without shining bright lights in their eyes for minutes on end. It really allows you to scrutinize the retina and you can use filters that are really helpful for picking up on diabetic retinopathy lesions like red green filtration helps very much with retinal vascular abnormalities. We have a photo here. I'll just demonstrate it. This is the color photo of the area of interest. We have some hemorrhaging there and with the red free filter, it just makes blood pop. So that's that's very useful. The other thing that's really common in optometry now is the use of wide field and ultra wide field retinal imaging. And this allows us to more accurately stage diabetic retinopathy because some patients in fact have more retinopathy in the peripheral retina than they do in the posterior pole. And studies from the Josslyn diabetes Institute suggests that patients that have a lot of peripheral retinopathy are actually dramatically more likely to progress on to more severe disease, including proliferated diabetic retinopathy. The other important tool that a lot of optometrists uses optical coherence tomography, kind of an optical ultrasound that lets you take a cross section of the retina and it's the most sensitive test for detecting diabetic macular oedema. I'll show you examples of that momentarily. Now. Some less common tools that are used include optical coherence tomography and geography, and that is really superb at picking up on areas of non profusion and the retina as well as early retinal vascular changes. And then a lot of optometrists, including myself do tests of visual function, things like color contrast threshold sensitivity testing. So we have color vision is abnormal and diabetes long before retinopathy lesions show up with clinical examination. So it's another tool for looking at retinal dysfunction and diabetes earlier on other things like electrophysiology with electro retina, grams, macular pigment, optical density, which is a measurement of how much lutein zeaxanthin, meso zeaxanthin or in the macula that's been correlated with increased risk of retinopathy but also with diabetes itself. And then artificial intelligence is you know on the forefront now it's it's emerging as a tool that's being used more and more often. I'll show you examples of all of these now. So first of all, let's start off with optical coherence tomography on the left. We have a patient with a normal macula, you can see the nice depression and the phobia there and on the right we have a patient with a lot of intra retinal fluid. This patient has severe diabetic macular oedema and it's experienced vision loss. So we have to always remember DME is the leading cause of vision loss to diabetes. About 40% of a optometrist use optical coherence tomography. You know, I'd like it to be 100% and I encourage my colleagues if you don't have one of these devices work with someone who does either an optometrist or an ophthalmologist that has one. Here's just an example from my own patients uh photographs of a patient that had subclinical diabetic macular oedema. You can see that little dark area kind of there in the middle of the phobia. The whole region has been thinned out actually as a function of long term diabetes. So the neurological elements of the retina thin out. So this is now called retinal diabetic neuropathy. But this patient has some has some subclinical diabetic macular oedema never going to be detected by clinical exam. And is it important? Well this patient doesn't require treatment of their DME but this patient is far more likely to progress on to more severe DME and needs to be followed more closely. So it's another argument for routine use of O. C. T. In eye care practice in patients that have diabetes. Here's an example of an ultra wide field retinal image. And in this particular photograph we can see a lot of retinal hemorrhaging in the peripheral retina outside of that posterior pole, which is where we always think of the action being. So this patient is in fact a dramatically elevated risk for developing proliferated diabetic retinopathy because he or she has far more lesions in the retina periphery than in the posterior pole. Here's an example of Oc tien geography. The patient list on the right here has diabetes. The phobia lay vascular zone. You can see as much larger the dark area compared to the normal person on the left side, there's capillary drop out. We can see subclinical micro aneurysm formation. So we don't have any great data yet that says okay if the OC ta shows specific findings, this patient requires treatment. But whenever I see this in my practice, this is a patient. I really try to hunker down and get them to achieve better metabolic control and watch them much more closely. Here's a case example of artificial intelligence that I used recently in my own office. So it's a 33 year old male with type one diabetes and I didn't disclose this at the beginning. But I will now I've had Type one diabetes myself now for 52 a half years and I developed proliferate retinopathy in my Early 20s and nearly lost eyesight. I was lucky that it was discovered in time by my optometrist who referred me to a retina specialist. So when I see these type one males that are kind of in denial, you know, these are the people I'm trying to focus on like a laser. So the patient was referred by the endocrinologist. The last exam had been five years ago of the eyes. The A. One C. Is not particularly uh you know good at 9.1%. The patients on basal bolus, insulin therapy takes a lot of insulin every day and it's relatively spelled. So I don't think insulin resistant but you know, I'm not positive about that. But taking a lot of insulin and we know insulin dosage isn't a risk factor for worsening retinopathy. His visual acuity is 2015. Better than normal. He has zero symptoms. I did an in office blood glucose and it was 413. So not not not doing very well metabolically from a glycemic standpoint. So here are his funders photos and I submitted these to AI so I'm asking you rhetorically, what stage of retinopathy does this patient have? So here's the right eye. You see the white stuff, right? That's hard. Exit date, lipid exit eight. We can see some retinal hemorrhages there, look really closely at the retinal veins there. Beated like sausage casings. And we know this is one of the hallmark features of people that have more than mild non proliferated diabetic retinopathy. So that's that's a red flag. Right off the bat. Here is a nasal photos of the photo of the same patient. You can see there the white area. That white patch, that's a cotton wool spots. So it's localized retinal ischemia. The retina died turns goes away usually within a week or two. Here's the left eye. We see more vain beating, a little more hemorrhage. We see hard exited formation Again, cotton wool spots. Here's the nasal retina again showing more cotton wool spot formation but a lot of vein beating. This is hallmark for severe non proliferated diabetic retinopathy. I told the patient you need to see a retina specialist. You've got severe nonproliferation retinopathy. We have therapies now that can make this better and prevent you from developing proliferated disease. Things that can cause vision loss like center involved diabetic macular oedema as well. So here's the report and this comes from a company in Los Angeles called I Nook. And so they can grade you're diabetic retinopathy by submitting the photos to the cloud. Ai grades it and send your report back usually within a couple of minutes. And it confirmed my original diagnosis. And so I said to the patient, you see, I'm not making this up. You've got severe retinopathy. I showed him a normal retina and his retina. He was unmoved. I was hoping a I might persuade him. You really do need to see a reading specialist. And this is finally what worked for me. And this is kind of my new phraseology with patients that need treatment but are not willing to go either because they're afraid or they perceive no problem because their visual acuity is good in the real world. And I told him you're standing at the edge of a cliff. Now we can pull you back from the edge of the cliff or you can keep going down the road you're on and you're going to take another step forward and fall off the cliff. And to my happy surprise, the patient, it kind of sat there and looked at me and shook his head for a 32nd gap and he said, okay, I'll go to the retina specialist and subsequently he received anti TNF therapy in his retina looks dramatically better now and I'll show you an example of that in a moment, patients just don't realize that they need to get their eyes examined on a regular basis and more importantly, they don't understand that the most common symptom of diabetic retinopathy is no symptoms whatsoever. And that's when we want to catch the disease, because that's when we can intervene with metabolic control with, you know, lifestyle recommendations and even with therapy with anti vascular into field growth factor therapy, the critical message all of us in diabetes care need to deliver and reinforce one another. Is that good vision on an eye chart or even in daily life doesn't mean your eyes are healthy. Uh you know you have great vision with diabetic retinopathy until the day you touch. And that was my experience. I was 21 years old. I woke up with vitreous hemorrhage, couldn't see anything. And so obviously we don't want to let our patients get to that point. So we all got to convey the message about the importance of routine dilated exams. So let me circle back to the point I made earlier that most diabetic retinopathy doesn't require a referral to a retina specialist. As it turns out, 70% of patients that have diagnosed diabetes don't have diabetic retinopathy or macular oedema, but they require surveillance and education about prevention and mitigation of disease. Two thirds of patients with d. Are in fact don't have vision threatening disease. It's only about 10% of the total population. So that's severe nonproliferation. Retinopathy. Proliferated diabetic retinopathy or macular oedema. Patients with mild or retinopathy are not gonna receive ophthalmological intervention. So these patients can very safely be followed by an optometrist who can educate them and follow them serially. And the big message here is we don't want to overtax overburden our colleagues and retina specialty. They're dealing with 60 70 80 patients today. And so sending them patients that don't require therapy. Does it make a lot of sense? From a utilization standpoint all optometrists, as I've already said, examine the retina and have a referral network of ophthalmology colleagues including retina specialist wherever they are available. Narrow communities to whom we commonly refer. Optometrist really are eager to provide consultative services and communication to primary care doctors, endocrinologists and other diabetes providers. We really do want to be part of the diabetes care dean. Here's my message about accurate grading. So accurate grading is how you assess a patient's risk for losing their vision to diabetic retinopathy. So here we've got the representation with these Russian nesting dolls of all the patients with diabetes, 30% of some degree of diabetic retinopathy, but only 10% of the total have sight threatening retinopathy. including proliferate retinopathy and diabetic macular oedema. Here are the grading scales that are commonly used. We're all going to be more familiar with the top scale, the international grading scale. Where red Ganapathy is generally broken up into either there's none. They have nonproliferation diseases that can be mild, moderate or severe or the patient has proliferated diabetic retinopathy. Now for clinical studies we have these other scales that are commonly employed the ET. DRS. Scale and the modified scale. So I'm gonna be talking momentarily about a two step improvement in diabetic retinopathy severity. And that refers to the bottom scale. The modified E. T. D. R. S. Scale. So here's a patient with mild non proliferation retinopathy has a micro aneurysm or to this patient should be re examined probably in 12 months but maybe as as conservatively as in six months but referral is not required whatsoever. The key here is to optimize metabolic control. This in fact is when metabolic control is most effective before there's retinopathy or when it's mild 10% reduction in hemoglobin A one c reduces the risk of a worsening by two steps of diabetic retinopathy. In patients with mild disease by about 43%. That's based on D. C. C. T. And U. K. P. D. S findings. Now here's a case of moderate non proliferated disease. The patient has some hard exit eight. We can see they're kind of in the center of the screen has a few more retinal micro aneurysms and hemorrhaging. And I appointed an arrow there at some early vein beating that I've tried to highlight here and so because of the vein beating this is somebody that could be considered for referral for a flourishing angiogram for instance. But generally these patients can be safely watched by an optometrist or a general ophthalmologist. They don't necessarily require treatment. Again the mantra here is to optimize individually optimize the patient's metabolic control. Now here's severe non proliferated diabetic retinopathy and these patients have a really high risk for progressing to proliferate of diabetic retinopathy. More than 50% progress to P. D. Are within a year once they develop severe NPR and there's this pneumonic We use an eye care the 4-1 rule. So if the patient has a lot of hemorrhaging in four retinal quadrants, vein beating in two or more quadrants or Irma. And anyone quadrant. Those are all flags for severe non proliferated diabetic retinopathy. Irma are simply intra retinal micro vascular anomalies. Sometimes they're called abnormalities. These are sea beds for imminent neo vascular ization. They're hard to say except when they're obvious and you can pick these up with fluorescent angiography. Better. These patients have to be referred to a retina specialist. And here again is just from the E. T. D. R. S. Studies showing that a patient with baseline mild nonproliferation retinopathy has a very low risk of progressing to proliferated disease over the next year even over the next five years. But when you get to severe NPR the risk goes up substantially as well as for moderately severe nonproliferation retinopathy a little more than moderate, a little less than severe. So here are examples of proliferated retinopathy on the left. The patient on the far left has florida optic nerve revascularization. Can see these fine lacy vessels on the optic nerve. The patient next to that as a pre retinal hemorrhage. Whenever we see this in the eye, we always assume neo vascular ization. You know whether the patient has diabetes or not. And on the writer is an example of a patient with diabetic macular oedema. A lot of lipid exited. If you look at the macula stereoscopic lee at the slit lamp you'll see the retin is thickened and you can totally see it on the O. C. T. There A lot of diabetic macular oedema it's been highlighted with a false color image. Can see all the intra retinal fluid there and these patients obviously need referral as soon as possible but certainly within a couple of weeks to a retina specialist all the guidelines so ofcom interests really are aware of the increased prevalence of diabetes and diabetic retinopathy and macular oedema. I lecture it optometric, see meetings all the time. They're very well attended and I get really high level questions from many of my colleagues who are are passionate about great diabetes care. Optometrist know what the diabetic retinopathy lesions are. They know about the strong association between how long you have diabetes and you're mean blood glucose levels as well as your blood pressure and your blood lipids and the likelihood of developing diabetic right now with your macular oedema Optometrist actually are quite familiar now with the diabetes prevention program. I've been drumming this into the heads of my colleagues for the last, you know, 20 years when I lecture. And so we can actually help patients with pre diabetes by uh, hopefully uh repeating the messages that you and primary care and endocrinology have already delivered about strategies to lower the risk of conversion. The diab diabetes type two diabetes, including lifestyle change with exercise and sometimes met foreman optometrist know that anti DeGette therapy is the gold standard for the treatment of diabetic macular oedema. It's almost totally supplanted laser focus regulation for diabetic macular oedema. And now, you know, all the new evidence is showing us that for patients with more severe nonproliferation, diabetic retinopathy, antiviral therapy can cause regression, an improvement in the disease severity that lowers the risk of patients having a vision threatening complication like PDR. Or anterior segment. Neo vascular ization iris, rubio sis in other words, or center involved diabetic macular oedema. These are the things that cause blindness and diabetes. We're getting a lot of education from industry now and from insurance companies aimed at optometrist to do a better job with patients having diabetes. Optometrist know that it's important to get patients the retina specialist when treatment is indicated. So what are some obstacles to diagnosing and treating diabetic retinopathy? From an optometric perspective, we know still, despite all the work, we're all trying to do that only about 60% or so of people with diabetes get an annual dilated exam. So if you make it every other year, The adherence goes up but it's still under 80%. And this is based on a decade's worth of data from in Haines. The other problem purely from patients not coming in is that I see patients sometimes that you know, I'll ask them to have diabetes at the start of the exam. You know, they've got to they've got a checklist for their case history and it wasn't marked off and then patients say at the end, well I've got diabetes, you know, do I have any eye problems? Well it would have been nice. You know, it's not necessary but it's helpful to all of us if we have an inkling, the patient has diabetes at the at the start of the eye examination. So we need to really try to make sure patients reveal all all of their medical diagnoses and have access actually to the medical record. And then the other problem I just mentioned because this is something I see every day poor dilation because patients with diabetes have autonomic neuropathy that affects pupil dilation. And also a publication of the papillary muscles, makes it sometimes harder for the pupils to dilate. This is especially true. And people that have had diabetes more than 10 years and those that have sub optimal blood glucose control, why don't patients get eye exams? So here's here's an interesting chart. And the most common reason was they hadn't thought of it. They didn't proceed any need, There was no reason to go. So this is where we all come in to educate them. That's not true. But there are some other really legitimate, you know, environmental socioeconomic factors that determine whether patients get their eyes examined, like the cost of an eye exam or lack of insurance, access, lack of transportation. So we all need to help patients get into the eye doctor and you know, encourage them to do so on a regular basis who would benefit from earlier referral to a retina specialist. You know, when I got out of training when a patient had proliferated disease. For macular Dina you always referred. But before that it was kind of let's watch them and see what happens. But we have a lot of evidence now, particularly from the panorama trial using a flipper set that if you give patients with moderately severe which is level 47 nonproliferation retinopathy or severe nonproliferation retinopathy, that's level 53 on the E. T. D. R. S. Scale. That these patients have a dramatically higher chance of having regression of their disease severity. And the likelihood of having a vision threatening complication goes down between 70 and 80% in these patients. So this is becoming kind of the new thought process in diabetic retinopathy is to treat earlier than we would have heretofore. Here's an example of a patient that has severe non proliferated diabetic retinopathy. Level 53 on the E. T. D. R. S. Scale. Level six on the modified ET DRS. So a two step improvement as I said earlier refers to that modified ET DRS scale. So this patient went from level six severe NPD are to moderate NPD are level four with a series of anti D. Jeff injections. You can see the dramatic improvement in the appearance of the retina. And this patients just at a dramatically lower risk of losing vision because we turned back the clock as it were a lot of people who are referred to retina specialist and even those once they see the retina specialist for the first time, become lost to follow up or follow up non attended fun at. So about a quarter of patients treated with anti veg F for diabetic macular oedema didn't come back for follow up visits within the first year. So they got one injection, they didn't show up again. We know this results in worse outcomes, even patients with proliferated retinopathy. The surveys show somewhere between a quarter and a half don't come back for follow up within a year or two. And we know patients that get only antibiotic therapy for proliferated disease appear to be far more likely to get traction, retinal detachment. That's what team the R. D. Stands for. So I think there's a real argument when patients have proliferated retinopathy and Tv Jeff works great, but patients need cereal treatment. So for the patients that are more likely to be non attendant to follow up, I think there's a strong argument for putting some laser focus graduation down to prevent the patient from losing eyesight. I'll show you what a case example from my own practice of that in a moment. The highest risk for being lost to follow up. And maybe it mimics what you see in primary care and in endocrinology is younger patients, lower socioeconomic status. People of color, people that have worse visual acuity actually have worse follow up as it turns out, especially if their vision doesn't improve after therapy. So, one analysis, I think it's very interesting for all of us looked at people that didn't show up for their following and they track these people down and they got enough of them to answer the question, which was why didn't you come back for follow up? You were told to do so and you didn't come back and what was identified by the patients themselves as factors that would have helped them to follow up with the following, being connected to other people with the same diagnosis. So there may in fact be an argument for diabetes. Support groups for diabetic retinopathy and macular oedema support groups. I'm running one out of my office now for this very reason, more disease specific education. So patients said that if they felt they understood the disease better, there would have been more likely to comply with the follow up recommendations. And then the other thing was easier transportation to the office. So that's something we should all be focussed on. Like a laser along with lower socioeconomic status. We also know depression and foot disease as well as diabetic neuropathy or risk factors for patients not showing up after initial therapy. So I'm getting down to my final messages here. Communication between all of us is really important. You know, I send letters every time I see a patron of diabetes to every healthcare provider, they see uh including the PCP, the endocrinologist, nephrologist, the podiatrist. Because I'm trying to get us all on the same page and communicating with one another. Very interesting study that is here that showed if the PCP or endocrinologist sends a ladder to the eye care provider, patients were more likely to adhere to recommend a dilated eye examination scheduling than if the eye care provider sent the same kind of letter to the endocrinologist or PCP. And so I'm not sure exactly why this is. Maybe it's you know, if the eye care provider sees boy, the endocrine specialist or the PCP is really concerned about this patient. I gotta make darn well sure I'm following up on this patient. The other thing it does is it allows us all to be on the same page about individualized glycemic targets so that if you tell a patient with cardiovascular disease who is 80 years old, I want your A one C to B. 8% or less, but not under seven because of cardiovascular risk. You know if the eye care provider knows that we can reinforce that message that was delivered by you taking care of the patients systemic health. Here's an example of the patient that I wanted to kind of end with. So this gentleman came in with severe proliferated diabetic retinopathy. It looked like a traction retinal detachment to me. But it wasn't it's all fi broke vascular proliferation. The patient can't see much of anything but light. I said the patient that day to a retina specialist who did laser photo coagulation. And I saw the patient a year later and this is what the retina look like. So the patient went from you know maybe hand motions vision To 2060 visual acuity is a functional vision. Unfortunately the patient out of my hands now developed recurrent neo vascular ization. Saw the same retina specialist who gave him an injection of an anti vascular into field growth factor agent. And the patient showed up in my office about three years later looking like this. So now the patient really is blind, the macula is off, he's had a traction retinal detachment. So again, this is another reason we all gotta follow up when we refer patients to retina specialty providers, we gotta make sure the appointment was kept in that the patient knows it's important to return. It's not a one off deal. When you see a retina specialist, we need to all work together to prevent vision loss caused by diabetes, patient care and outcomes. You know, my hypothesis is we're going to be optimized when we all coordinate our efforts together and that includes primary care, doc's endocrine specialist and all the eye care providers optometrist just as a function of the diabetes epidemic are going to see a lot of diabetes and consequently a lot of diabetic retinopathy. All of us in optometry work closely with ophthalmology and reds and specialists, collaboration amongst optometrists and ophthalmologists, including retina specialists and primary care docs is really critical to identify diabetic retinopathy and macular oedema early so that we can find patients that need treatment and get them in before vision is lost. I want to mention one other thing. I've seen patients that have come into me six months after diagnosis referred by their PCP because their hemoglobin a one c let's say it was quite high and the PCP thought correctly that refractive error, The prescription in the eyeglasses is likely to change is the patient's blood glucose and proofs. And that's 100% true. But here's the big but We know more than 20% of patients have some degree of retinopathy diagnosis. So it's really important. You send those patients in early to the eye care provider for a dilated exam to detect retinopathy at its earliest stages so we can intervene or more severe stages so that uh interventions from ecological interventions can be undertaken. So don't don't wait to refer the patient. So their hemoglobin A one C is normalized. Eye. Doctors know that we're not going to give somebody a prescription for eyeglasses when they're like oscillated hemoglobin is 10% or 12%. And so I teach this to my colleagues, which is ideally wait for the A. One C to be under 8% before you prescribe glasses. But we still want to look at the patient's retina so we can make sure they don't lose vision with that. I want to thank you. It's been a very high honor for me to have this chance to speak at the American Diabetes Association's scientific meeting. I wish everybody well and hopefully we get back to normal sometime within the next year, uh, at the latest. Thanks much.