Mark Horton

Proliferative Retinopathy in NIDDM: Incidence and Risk Factors in Pima Indians

The incidence of proliferative diabetic retinopathy was determined in the Pima Indians of the Gila River Indian Community in Arizona. Over 4 yr, this complication developed in 25 of 953 subjects ≥9 yr of age with non-insulin-dependent diabetes. No cases were diagnosed in <35-yr-old subjects, and the incidence was strongly related to the duration of diabetes. The cumulative incidence of proliferative retinopathy after 20 yr duration was 14%. All cases of proliferative retinopathy occurred in subjects with background retinopathy. Younger age at diagnosis of diabetes was associated with a higher incidence of proliferation when subjects with diabetes of similar duration were compared. A higher incidence of proliferative retinopathy, after controlling for age, sex, and diabetes duration, was associated with hypertension, proteinuria, renal insufficiency, absence of Achilles tendon reflex, elevated total serum cholesterol concentration, and insulin therapy.

Telehealth practice recommendations for diabetic retinopathy, second edition.

Ocular telemedicine and telehealth have the potential to decrease vision loss from DR. Planning, execution, and follow-up are key factors for success. Telemedicine is complex, requiring the services of expert teams working collaboratively to provide care matching the quality of conventional clinical settings. Improving access and outcomes, however, makes telemedicine a valuable tool for our diabetic patients. Programs that focus on patient needs, consider available resources, define clear goals, promote informed expectations, appropriately train personnel, and adhere to regulatory and statutory requirements have the highest chance of achieving success.

Special Requirements for Electronic Health Record Systems in Ophthalmology

UNLABELLED The field of ophthalmology has a number of unique features compared with other medical and surgical specialties regarding clinical workflow and data management. This has important implications for the design of electronic health record (EHR) systems that can be used intuitively and efficiently by ophthalmologists and that can promote improved quality of care. Ophthalmologists often lament the absence of these specialty-specific features in EHRs, particularly in systems that were developed originally for primary care physicians or other medical specialists. The purpose of this article is to summarize the special requirements of EHRs that are important for ophthalmology. The hope is that this will help ophthalmologists to identify important features when searching for EHR systems, to stimulate vendors to recognize and incorporate these functions into systems, and to assist federal agencies to develop future guidelines regarding meaningful use of EHRs. More broadly, the American Academy of Ophthalmology believes that these functions are elements of good system design that will improve access to relevant information at the point of care between the ophthalmologist and the patient, will enhance timely communications between primary care providers and ophthalmologists, will mitigate risk, and ultimately will improve the ability of physicians to deliver the highest-quality medical care. FINANCIAL DISCLOSURE(S) Proprietary or commercial interest disclosure may be found after the references.

Clinical Components of Telemedicine Programs for Diabetic Retinopathy

Diabetic retinopathy is a leading cause of new-onset vision loss worldwide. Treatments supported by large clinical trials are effective in preserving vision, but many persons do not receive timely diagnosis and treatment of diabetic retinopathy, which is typically asymptomatic when most treatable. Telemedicine evaluation to identify diabetic retinopathy has the potential to improve access to care, but there are no universal standards regarding camera choice or protocol for ocular telemedicine. We review the literature regarding the impact of imaging device, number and size of retinal images, pupil dilation, type of image grader, and diagnostic accuracy on telemedicine assessment for diabetic retinopathy. Telemedicine assessment of diabetic retinopathy has the potential to preserve vision, but further development of telemedicine specific technology and standardization of operations are needed to better realize its potential.

Telehealth and Indian Healthcare: Moving to Scale and Sustainability

Telehealth innovation has brought important improvements in access to quality healthcare for American Indian and Alaska Native communities. Despite these improvements, substantive work remains before telehealth capability can be more available and sustainable across Indian healthcare. Some of this work will rely on system change guided by new care model development. Such care model development depends on expansion of telehealth reimbursement. The U.S. Indian healthcare system is an ideal framework for implementing and evaluating large-scale change in U.S. telehealth reimbursement policy.

The Success of Telehealth Care in the Indian Health Service.

The Indian Health Service has been a leader in implementing telehealth programs and technologies that increase access to and efficiencies in care, particularly in the fields of mental health and ophthalmology.

Operational Components of Telemedicine Programs for Diabetic Retinopathy

Diabetic retinopathy is a leading cause of new-onset vision loss worldwide. Treatments supported by large clinical trials are effective in preserving vision, but many persons do not receive timely diagnosis and treatment of diabetic retinopathy, which is typically asymptomatic when most treatable. Telemedicine evaluation to identify diabetic retinopathy has the potential to improve access to care and improve outcomes, but incomplete implementation of published standards creates a risk to program utility and sustainability. In a prior article, we reviewed the literature regarding the impact of imaging device, number and size of retinal images, pupil dilation, type of image grader, and diagnostic accuracy on telemedicine assessment for diabetic retinopathy. This article reviews the literature regarding the impact of automated image grading, cost effectiveness, program standards, and quality assurance (QA) on telemedicine assessment of diabetic retinopathy. Telemedicine assessment of diabetic retinopathy has the potential to preserve vision, but greater attention to development and implementation of standards is needed to better realize its potential.

Prevalence of diabetic retinopathy and diabetic macular edema in a primary care-based teleophthalmology program for American Indians and Alaskan Natives

Background Diabetes and its complications are more common in American Indians and Alaska Natives (AI/AN) than other US racial/ethnic populations. Prior reports of diabetic retinopathy (DR) prevalence in AI/AN are dated, and research on diabetic macular edema (DME) is limited. This study characterizes the recent prevalence of DR and DME in AI/AN using primary care-based teleophthalmology surveillance. Methods This is a multi-site, clinic-based, cross-sectional study of DR and DME. The sample is composed of AI /AN patients with diabetes (n = 53,998), served by the nationally distributed Indian Health Service-Joslin Vision Network Teleophthalmology Program (IHS-JVN) in primary care clinics of US Indian Health Service (IHS), Tribal, and Urban Indian health care facilities (I/T/U) from 1 November 2011 to 31 October 2016. Patients were recruited opportunistically for a retinal examination using the IHS-JVN during their regular diabetes care. The IHS-JVN used clinically validated, non-mydriatic, retinal imaging and retinopathy assessment protocols to identify the severity levels of non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), DME, and sight threatening retinopathy (STR; a composite measure). Key social-demographic (age, gender, IHS area), diabetes-related health (diabetes therapy, duration of diabetes, A1c), and imaging technology variables were examined. The analysis calculated frequencies and percentages of severity levels of disease. Results Prevalence of any NPDR, PDR, DME, and STR among AI/AN patients undergoing DR teleophthalmology surveillance by IHS-JVN was 17.7%, 2.3%, 2.3%, and 4.2%, respectively. Prevalence was lowest in Alaska and highest among patients with A1c >/ = 8%, duration of diabetes > 10 years, or using insulin. Conclusions Prevalence of DR in this cohort was approximately half that in previous reports for AI/AN, and prevalence of DME was less than that reported in non-AI/AN populations. A similar reduction in diabetes related end-stage renal disease in the same population and time period has been reported by other researchers. Since these two diabetic complications share a common microvasculopathic mechanism, this coincident change in prevalence may also share a common basis, possibly related to improved diabetes management.