Janis Ecklund Winters

Reducing the risks of diabetes complications through diabetes self-management education and support.

People with diabetes are at risk of developing complications that contribute to substantial morbidity and mortality. In 2011, the American Association of Diabetes Educators convened an invitational Reducing Risks Symposium, during which an interdisciplinary panel of 11 thought leaders examined current knowledge about the reduction and prevention of diabetes-related risks and translated evidence into diabetes care and self-management education. Symposium participants reviewed findings from the literature and engaged in a moderated roundtable discussion. This report summarizes the discussion and presents recommendations to incorporate into practice to improve outcomes. The objective of the symposium was to develop practical advice for diabetes educators and other members of the diabetes care team regarding the reduction of diabetes-related risks. Optimal diabetes management requires patients to actively participate in their care, which occurs most effectively with a multidisciplinary team. Diabetes education is an integral part of this team approach because it not only helps the patient understand diabetes, its progression, and possible complications, but also provides guidance and encouragement to the patient to engage in proactive risk-reduction decisions for optimal health. A variety of tools are available to help the diabetes educator develop an individualized, patient-centered plan for risk reduction. More research is needed regarding intervention efficacy, best practices to improve adherence, and quantification of benefits from ongoing diabetes support in risk reduction. Diabetes educators are urged to stay abreast of evolving models of care and to build relationships with health care providers both within and beyond the diabetes care team.

Prevalence of pigmented lens striae in a black population: A potential indicator of age-related pigment dispersal in the anterior segment

Purpose. To determine the prevalence of pigmented striae of the anterior lens capsule, with or without associated glaucoma, in a black primary eye care population. Methods. Over a 16-month period, five practitioners searched for pigmented lens striae (PLS) among consecutive patients who underwent pupillary dilation during routine eye care provided within the primary care service of an urban eye clinic in Chicago, Illinois. Results. Meeting the inclusion criteria were 1608 blacks (mean age ± SD, 40.9 ± 23.7 years; range, 5 to 100; 1056 females, 552 males). Among the group, 29 (1.8%) subjects had PLS (mean age, 66.5 ± 11.3 years; range, 33 to 88; 25 females, 4 males). PLS were bilateral 89% of the time. Sixteen of the 29 (55%) blacks had central corneal endothelial pigment dusting (14 bilateral), frequently creating a well-formed Krukenberg’s spindle. Trabecular pigmentation varied among the PLS subjects from mild to heavy. Using multiple logistic regression, age (in years) (odds ratio, 1.05; 95% confidence interval, 1.02 to 1.07; p = 0.0003), female gender (odds ratio, 4.46; 95% confidence interval; 1.03 to 19.19; p = 0.045), and hyperopic refractive error (in diopters) (odds ratio, 1.35; 95% confidence interval; 1.09 to 1.67; p = 0.006) were significant predictors of PLS. Conclusions. PLS were present in about 1.8% (2.4% females, 0.7% males) of our black population, and they were frequently associated with other signs of intraocular pigment dispersion. Age, female gender, and refractive error were significant predictors for PLS. This is new information that is helpful for understanding a clinical sign that may be an indicator of age-related pigment dispersal within the anterior segment.

A cross-sectional study of Krukenberg spindles and pigmented lens striae in a predominately black population: two highly associated clinical signs of anterior segment pigment dispersal.

Purpose:To investigate the relationship of Krukenberg spindles (KS) and pigmented lens striae (PLS), clinical signs related to iris pigment dispersal and possibly glaucoma. Methods:During a 31-month period, 5 practitioners in an urban, primary eye care setting examined consecutive patients for KS and PLS. Multiple logistic regression was used to evaluate relationships among KS, PLS, and other variables. Results:Krukenberg spindles were present in 65 patients (52 females), comprised of 57 of 2647 (2.2%) blacks, 5 of 303 (1.7%) whites, 2 of 121 (1.7%) Hispanics, and 1 of 55 (1.8%) Asians. PLS were present in 64 subjects (56 females), comprised of 59 (2.2%) blacks, 3 (1.0%) whites, and 2 (3.6%) Asians. KS and PLS were coexistent in 27 subjects. Mean age ± SD (range) of the KS and PLS subjects was 63.1 ± 15.0 years (24-88 years) and 67.0 ± 10.4 years (33-88 years), respectively. Mean refractive error ± SD (range) of KS and PLS right eyes was +0.55 ± 2.32D (−6.50 to +5.50D) and +1.34 ± 2.18D (−6.50 to +7.25D), respectively. Controlling for other variables, PLS were highly predictive (OR = 30.2, P < 0.0001) of KS, and KS were highly predictive (OR = 29.5, P < 0.0001) of PLS. Ignoring presence or absence of PLS, increasing age (in decades) (OR = 1.60, P < 0.0001) was strongly associated with KS. Ignoring presence or absence of KS, age (OR = 1.74, P < 0.0001), female gender (OR = 2.96, P = 0.009), and increasing hyperopic refractive error (OR = 1.30, P < 0.0001) were strongly associated with PLS. Conclusions:Krukenberg spindles and PLS were strongly associated in our patient population, and the likelihood of both increased with increasing age. Female gender and increasing hyperopic refractive error were highly significant predictors of PLS.

Pigmented striae of the anterior lens capsule and age-associated pigment dispersion of variable degree in a group of older African-Americans: an age,race, and gender matched study

Purpose: To investigate pigmented striae of the anterior lens capsule in African-Americans, a potential indicator of significant anterior segment pigment dispersion. Methods: A group of 40 African-American subjects who exhibited pigmented lens striae (PLS) were identified from a non-referred, primary eye care population in Chicago, IL, USA. These subjects were then compared to an age, race, and gender matched control group relative to refractive error and the presence or absence of diabetes and hypertension. Results: The PLS subjects (mean age = 65.4 ± 8.8 years, range = 50–87 years) consisted of 36 females and 4 males. PLS were bilateral in 36 (85%) of the40 subjects. Among the eyes with PLS, 21 (55%) of 38 right eyes and 22 (61%) of 36 left eyes also had significant corneal endothelial pigment dusting, commonly in the shape of a Krukenberg’s spindle. Ten (25%) of the PLS subjects had either glaucoma or ocular hypertension (7 bilateral, 3 unilateral).The presence of trabecular meshwork pigment varied from minimal to heavy. The mean SD (range) refractive error of the PLS right eyes was +1.61 ± 1.43D (-1.50 to +5.00D) and +1.77 ± 1.37D (-1.00 to +5.00D) for the left eyes. Based on these data, the PLS right eyes were +1.63D (Students t, p = 0.0001; 95% CI = +0.82 to +2.44D) more hyperopic on average than the control right eyes, and the PLS left eyes were +1.77D (p = 0.0001; 95%CI = +0.92 to +2.63D) more hyperopic on average than the control left eyes. Trend analysis showed a gradually increasing likelihood of PLS with increasing magnitude of hyperopia in both eyes (Mantel-Haenszel chi-square, p = 0.001). Among PLS subjects, 24 (60%) of 40 were hypertensive and 9 (23%) of 40 were diabetic. However, these proportions were not significantly different (two-tailed Fishers exact test; hypertension: p = 0.30; diabetes: p = 0.70) from the randomly selected controls. Conclusions: Among our African-American group, which consisted predominately of females >50 years of age, the likelihood of PLS increased with increasing hyperopic refractive error. This finding is consistent with the possibility that PLS may, in some circumstances, indicate a significant pigment dispersal process due to iris-lens rubbing that may be associated with crowding of anterior segment structures. Additional study is warranted to further assess the nature of PLS, their precise relationship with an age-related pigment dispersal process, and their true significance as a risk factor for development of glaucoma.

Sight for seniors: A summary of findings and challenges to providing community-based eye care to low-income seniors

PURPOSE The Sight for Seniors (SFS) program was developed to provide eye care and eyeglasses to low-income seniors. METHODS Residents from a Chicago Housing Authority senior development participated in SFS. A community liaison promoted SFS and enrolled residents. Patients received transportation, eye care that took place at the Illinois Eye Institute, and spectacles at no out-of-pocket cost. RESULTS Eighty-nine patients were seen. The mean age was 71.8 years (standard deviation, 7.2). Fifty-six (62.9%) patients were women, and 73 (82.0%) were black. The last eye examination was reported within a year by 16 (18.0%), and 44 reported that their last medical examination was within 1 year. All patients required and received eyeglasses. Seventy-four (83.1%) improved Snellen distance visual acuity by 1 line or more and 26 (29.2%) by 3 lines or more. Twenty (22.5%) had glaucoma, and 9 had diabetic retinopathy. Sixty-three (70.8%) reported a history of hypertension (HTN) and 33 (37.1%) type 2 diabetes mellitus (DM). HTN was controlled in 4 (15%) of those with HTN and DM and 12 (34.3%) of those with HTN but not DM. CONCLUSIONS Last reported eye examination, medical history, and examination findings support the need for eye care in this population. These findings are applicable to similar populations.

Anterior Chamber Depth, Lens Thickness, and Related Measures in African American Females With Long Anterior Zonules: A Matched Study With Control for Refractive Error.

Purpose:To investigate anterior chamber depth (ACD), lens thickness (LT), vitreous body length (VBL), and axial length (AL) in African American females with long anterior zonules (LAZ) while controlling for refractive error. Methods:The eyes of 50 African American females with LAZ were compared with 50 controls matched with age, race, sex, and refractive error. Central ACD, LT, VBL, and AL measurements were obtained in a masked manner using a-scan ultrasonography. Results:LAZ cases had a mean age±SD of 67.1±7.6 years (range, 52 to 85 y) and a mean refractive error of +1.85±1.41 D (−1.75 to +4.75 D). Parameters were similar for controls. Mean ACD for cases was 2.45±0.34 mm and 2.57±0.38 mm for controls. Mean LT for cases was 4.94±0.43 mm and 4.83±0.45 mm for controls. Mean VBL for cases was 15.00±0.72 mm and 15.17±0.76 mm for controls. Mean AL for cases was 22.39±0.82 mm and 22.57±0.76 mm for controls. Using multiple logistic regression to control for any residual differences in age and refractive error, no significant differences were present between LAZ eyes and control eyes relative to the a-scan variables (P>0.1). Conclusions:When refractive error was controlled for, this group of African American females with LAZ did not exhibit clinically significant differences in ACD, LT, VBL, and AL as compared with controls.

Coordinating eye and primary medical care in a low-income and uninsured population: the experience of the Vision of Hope Health Alliance.

PURPOSE The Vision of Hope Health Alliance (VOHHA) was developed to provide an integrated system of eye and primary medical services to low-income and uninsured patients who were referred from nonmedical and medical agencies. METHODS Partnerships were formed to facilitate patient referrals. Eye examinations and ophthalmic materials were provided at no cost to patients. Interpretation services and follow-up care were provided as needed. If applicable, patients were scheduled with a primary care physician at a Federally Qualified Health Center. Findings were documented by VOHHA team members or obtained through retrospective record review. RESULTS Over a 2-year period, 1,753 patients were examined. About half (52.5%) were women. Most (80%) were black or Hispanic. Average age was 49.4 years (range, 18 to 83). Of those with diabetes mellitus (DM), 30.9% reported a last eye examination within 15 months. Of those without DM, 23.6% reported last eye examination within 15 months. Most (60%) reported last medical examination to be within 1 year. Most (85.7%) received spectacle prescriptions. Follow-up eye care appointments were kept by 367. Appointments with primary care physicians were scheduled for 165. Of those, 121 kept appointments. CONCLUSIONS VOHHA demonstrated a model program that provided eye care and referral for primary medical care to individuals without the means to otherwise obtain care.

Accommodative and vergence difficulties interfering with image clarity through a binocular indirect ophthalmoscope

Purpose. This study sought to identify accommodative and vergence deficiencies that could explain why some students have difficulty seeing clearly when using a binocular indirect ophthalmoscope (BIO) containing its standard +2.00 D lenses. Methods. A survey was distributed to Illinois College of Optometry 3rd- and 4th-year students. Based on the information supplied by the survey, students were divided into two groups: those who are unable (“BIO plano”) and those who are able (“BIO plus”) to obtain a clear image with the +2.00 D lenses in their BIO’s. Forty-seven subjects participated: 22 in the BIO plano group and 25 in BIO plus group. Two of the authors, masked to subject group, measured all subjects’ accommodative amplitudes and facilities, monocular estimation method (MEM) retinoscopy, negative relative accommodation and positive relative accommodation (NRA/PRA), distance and near vergence ranges, distance and near phorias, Worth 4-dot test, and near point of convergence (five times). Results. The Mann-Whitney U analysis of numerical data for the two groups showed a statistically significant difference for accommodative facility in the right eye (p = 0.004). The difference between the two groups approached significance for accommodative facility with both eyes (p = 0.02), facility in the left eye (p = 0.03), distance base-out blur (p = 0.02), near base-out break (p = 0.02), and near base-out recovery (p = 0.04). For all findings in which the difference between the two groups was significant or approached significance, the BIO plus group had higher median values. When subjects were classified by difficulty with the plus side of the flippers during accommodative facility testing, there was a statistically significant difference with both eyes (Fisher exact test, p = 0.003) and with the right eye (p = 0.008) between the BIO plus and BIO plano groups. When subjects were classified by the presence or absence of an accommodative or binocular vision syndrome, categorical data analysis showed the difference between the two groups approached significance, with more BIO plano subjects having syndromes (p = 0.03). Conclusion. No one test absolutely defined who would have difficulty with the +2.00 D lenses in the BIO. There are several skills required; less developed plus acceptance and convergence may cause difficulties.

Long Anterior Lens Zonules and Intraocular Pressure

Purpose To investigate the relation between intraocular pressure (IOP) and the idiopathic long anterior zonule (LAZ) trait. Methods Patients presenting for primary eye care were examined for LAZ, identified as radially oriented zonular fibers with central extension >1.0 mm beyond the normal anterior lens insertion zone (estimated via slit lamp beam length). Ocular, systemic health, and lifestyle data were collected via comprehensive exam and questionnaire. Multivariate regression was used to assess the relationship between IOP (Goldmann) and LAZ. Results There were 2169 non-LAZ and 129 LAZ subjects (mean age: 49.8 ± 15.0 vs. 62.6 ± 10.2 years; 63.6% vs. 76.0% female; 83.2% vs. 91.5% African American). Right eyes with >trace LAZ (n = 59 of 110) had higher unadjusted mean IOP than control eyes (16.4 ± 3.3 vs. 15.0 ± 3.3 mm Hg, P = 0.005), and with control for numerous factors, LAZ eyes had an average IOP of approximately 1.3 ± 0.4 mm Hg higher (P = 0.003) than non-LAZ eyes. Final model covariates included sex (P = 0.001); spherical-equivalent refractive error (D; P < 0.0001); body mass index (kg/m2; P < 0.001); presence of diabetes (P < 0.001); having >high school education (P < 0.001); systolic blood pressure (mm Hg; P < 0.0001); being an ever smoker (P = 0.006); and having history of any site cancer (P = 0.01). Conclusions The LAZ trait, with potential prevalence near 2%, was associated with a higher IOP. This observation is consistent with the hypothesis that the trait is a marker for underlying mechanisms that elevate glaucoma risk.

Retinitis pigmentosa: distribution of inheritance patterns in a VA blind rehabilitation center population

Objectives: This purpose of this study was to characterize retinitis pigmentosa (RP) patients at the Southeastern Blind Rehabilitation Center (SBRC) by inheritance pattern, and compare the results with similar studies. Study Design: Records of all RP patients who were in the blind rehabilitation program at the SBRC between 1989 and 1993 were reviewed (n=50). Patients were included in the study who could be personally contacted and whose records were complete (n=43). Pedigrees were obtained through review of records and patient interviews. Results: The analysis showed 24 patients (55.8%) were simplex (no family history of RP), 8 patients (18.6%) were autosomal dominant, 4 patients (9.3%) were probable autosomal dominant, 4 patients (9.3%) were autosomal recessive, 2 patients (4.7%) were probable autosomal recessive and 1 patient (2.3%) was X-linked recessive. Conclusions: Unique trends were apparent in the distribution of inheritance patterns. Clinicians should be aware of the large number of simplex patients found in this and the majority of similar studies.