Diabetics don’t need Exams from Eye Doctors???

on September 8th, 2005 | Filed under Optoblog

Eyetel Imaging makes a product they call the DigiScope which they market to your family doctor (PCP). The way it works is your family doctor handling your diabetes medications can also save you a trip to your eye doctor by performing a “ten minute exam.” They dilate your eyes, take a picture, send it to Johns Hopkins, then recieve the results. This supposedly is better patient care because you are giving the patient a valuable service and saving them time. Of course, the family doc can bill for this (CPT code 92250), and if no problems, then don’t schedule with Dr. Eye, just revisit your PCP next year.

The Indian Health Service has been doing “teleophthalmology” for years using the IHS/Joslin Vision Network where remote facilities without an optometrist nearby use a tech to take retinal pictures which are analyzed at Phoenix Indian Medical Center. (Don’t quote me, but I believe optometrists are part of the reading/interpretation of the photos.) It’s a good idea considering Native Americans with diabetes have annual eye exams only 50-60% of the time. (Part due to no-shows, and part due to access to eyecare- not enough or no optometrists at location.)
So if we have a population that lacks access to eye care, a product/system like the DigiScope is a great idea. What if you live in a well populated area with lots of eye doctors around. Do you want your neighborhood PCP to go out and buy one of these?

Of course not! It cuts into our turf! They can’t do that, can they? When I get into private practice and if the local PCP decides to get one of these DigiScopes, then heck, I’ll start steeling his/her hypertensive patients. Yah, my state’s laws allow me to treat with any medication as long as it’s eye-related. Hypertensive retinopathy is eye-related, so I’ll be kicking out the lisinopril Rx’s left and right. I’ll have the patient come back for BP checks and everything. If it gets complicated, sure, I’ll refer to the “Blood Pressure Specialist.” How do you like them apples, PCPs-using-DigiScope?

Another note.
It’s been tattooed on our brains that before dilating, we must screen for possible angle closure by performing pupils, angles, and pressures. On their“Dilating Instructions” pamphlet, they simple ask about history of glaucoma and do a pen light test of angle depth. They cite the Baltimore Eye Survey as their justification for using only these two criteria to determine that it’s safe to dilate, but they actually reference a follow-up to the survey “Incidence of acute angle-closure glaucoma after pharmacologic mydriasis” published in the American Journal of Ophthalmology (Am J Ophthalmol. 1995 Dec;120(6):709-17.) Here is the abstract, and these are the quotes that stuck out to me:

. . .Of the 4,870 subjects whose eyes were dilated on screening examination, none developed acute angle-closure glaucoma. However, 38 patients of the 1,770 who were referred for definitive eye examination were judged to have occludable angles on the basis of gonioscopic methods. Of note, subjects aged 70 years and more were three times more likely to have occludable angles than those aged 40 to 69 years (P [less than] .004). . .These criteria provide 60.5% sensitivity and 93.3% specificity. CONCLUSION: If screening is performed accurately and the results are negative, the risk of dilating a potentially occludable angle was less than one in 333 subjects (negative predictive value, 0.997) in this population.

So if your family MD’s staff don’t properly apply the screening criteria, then roughly 2/100 patients could get occluded angles (the 38 of 1770 stat), but if they do it right, then 1/333. I’ll bet many family docs are willing to take those chances. It’s also interesting their pamphlet tells them to use tropicamide 0.5%. Since diabetics tend to dilate poorly, especially if they have brown eyes, I always use 1%. (I haven’t had a chance to use Paramyd because your federal government in strapped for cash, especially in IHS spending.)

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