Jorge Cuadros OD PhD        Tara Seymour
Significance of Broader BlindnessPrevention in Our Clinics Diabetic retinopathy is the main cause of  blindness in workin...
EyePACS Referrals 8.21% of all EyePACS consults resulted in  referral for sight-threatening diabetic retinopathy 7.83% o...
How Does Your Clinic Handle EyeReferrals? No time frame given – all eye referrals  generally treated the same Urgent ref...
What Is The Average Waiting Time ForEye Care Referrals From Your Clinic?   Less than one week   One week to less than on...
The Challenge of Referral forOther Conditions The retinal consult does not take the place  of a full eye exam. Sensitivi...
Scientific CommitteeRecommendations: Purpose: Identify patients with sight-  threatening conditions. Develop protocol fo...
Optic Nerve Lesions   Signs of glaucoma:     Asymmetric cupping: greater than 0.2 dd cupping difference between the two ...
Retinal Lesions   Moderate/Severe nonproliferative diabetic    retinopathy (NPDR), as defined by the    International Cli...
Lesions of the Macula   High-risk drusen (large, soft drusen) especially    associated with:     Pigment migration     ...
Other Referral Criteria Visual Acuity < 20/40 Acute onset of pain and/or vision loss *Intraocular pressures *Initiatio...
PBNC Referral Guideline   Emergency Referral – 1-2 days:     papilledema     recent onset retinal detachment     neova...
PBNC Referral Guideline   Urgent Referral (within 1 month)     pale swelling of optic nerve or segment of optic      ner...
PBNC Referral Guideline   Pass     clear media; retinal and optic nerve features clear     optic nerve margins sharp, v...
Future Efforts   Validation of protocol   Primary care provider certification for triage    purposes   Automation and i...
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LC 09-2011-Broader Blindness Prevention

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LC 09-2011-Broader Blindness Prevention

  1. 1. Jorge Cuadros OD PhD Tara Seymour
  2. 2. Significance of Broader BlindnessPrevention in Our Clinics Diabetic retinopathy is the main cause of blindness in working age adults, but not in all adults. More people will become blind from macular degeneration and glaucoma. The majority of blindness could be prevented with early intervention. Many sight-threatening conditions have been detected and referred through EyePACS
  3. 3. EyePACS Referrals 8.21% of all EyePACS consults resulted in referral for sight-threatening diabetic retinopathy 7.83% of all EyePACS consults resulted in referral for other sight-threatening conditions  Glaucoma  Cataract  Maculopathy  Papillopathy (optic nerve)  Pigmented lesions  Retinal degeneration
  4. 4. How Does Your Clinic Handle EyeReferrals? No time frame given – all eye referrals generally treated the same Urgent referrals (within 2 days) made with sudden decreased vision or ocular pain; all other referrals generally treated the same Clinic is able to differentiate conditions requiring within 1 month from conditions requiring referral within 2 days
  5. 5. What Is The Average Waiting Time ForEye Care Referrals From Your Clinic? Less than one week One week to less than one month One month to less than three months Three months to less than six months Six months or more I don’t know how long my patients wait to see an eye care provider.
  6. 6. The Challenge of Referral forOther Conditions The retinal consult does not take the place of a full eye exam. Sensitivity and specificity of referral based on electronic consults have not been validated for other conditions  Disagreement about when to treat, when to refer  Excessive variability in consultant recommendations  Less effective treatment  Excessive over-referral
  7. 7. Scientific CommitteeRecommendations: Purpose: Identify patients with sight- threatening conditions. Develop protocol for acquiring necessary information and images for consistent and easily adapted detection system. Retinal image interpretation protocol for identifying significant lesions in:  Optic nerves  Retinas  Maculas
  8. 8. Optic Nerve Lesions Signs of glaucoma:  Asymmetric cupping: greater than 0.2 dd cupping difference between the two eyes  Enlarged cup: optic nerve cupping equal to or greater than 0.7  Rim notch or thinning: notch in or thinning of optic nerve tissue extending to edge of the optic nerve or disproportionate thinning of rim tissue in inferior or superior sections of optic nerve  Optic nerve/Splinter hemorrhage: flame shaped hemorrhage near or at the rim or in the substance of the cup  Nerve fiber layer defect (NFLD): NFLD occupying greater than 10 degrees of arc in the inferior or superior arcuate areas  For screening purposes, referable glaucoma is considered sight-threatening, well-established glaucoma that is likely to be treated immediately. Low risk glaucoma suspects would not be referred from this protocol. Prominent pallor:  pale optic nerve without cupping not previously identified  pale swelling of segment of optic nerve with or without hemorrhage Papilledema:  swollen, hyperemic disc with blurred margins in one or both eyes
  9. 9. Retinal Lesions Moderate/Severe nonproliferative diabetic retinopathy (NPDR), as defined by the International Clinical Diabetic Retinopathy Disease Severity Scale Neovascularization  New vessels or diabetes-related fibrous proliferation anywhere  Vitreous hemorrhage or pre-retinal hemorrhage Invasive lesions: eg melanomas Neovascularization of the iris Active retinitis: active retinal inflammation Retinal detachment (recent onset)
  10. 10. Lesions of the Macula High-risk drusen (large, soft drusen) especially associated with:  Pigment migration  Geographic atrophy not involving the foveal center  Disciform scar or prior chorodial neovascularization Macular edema, not clinically significant: hard exudates within 2 disc diameters but more than one disc diameter from the fovea Clinically Significant Macular Edema (CSME): hard exudates within one disc diameter of fovea Subretinal neovascularization  subretinal hemorrhage or lipid exudate with hemorrhage within the arcades  wet macular edema-intraretinal hemorrhage involving the fovea  cystoid macular edema with blood in cysts  subretinal pigment epithelial blood (drusen visible over the hemorrhage)
  11. 11. Other Referral Criteria Visual Acuity < 20/40 Acute onset of pain and/or vision loss *Intraocular pressures *Initiation of systemic treatments associated with vision loss:  Hepatitis C treatment  Plaquenil / quinine derivatives  Steroids  * Not part of the Prevent Blindness Northern California Protocol
  12. 12. PBNC Referral Guideline Emergency Referral – 1-2 days:  papilledema  recent onset retinal detachment  neovascularization of the iris  active retinitis  subretinal neovascularization  acute vision loss  acute onset of pain
  13. 13. PBNC Referral Guideline Urgent Referral (within 1 month)  pale swelling of optic nerve or segment of optic nerve (with or without hemorrhage)  neovascularization  clinically significant macular edema  possibly invasive lesion Moderately Urgent Referral (within 6 months)  retinal and optic nerve features blurred in all views, with VA less than 20/40  obvious glaucoma  moderate to severe non-proliferative diabetic retinopathy  high-risk drusen
  14. 14. PBNC Referral Guideline Pass  clear media; retinal and optic nerve features clear  optic nerve margins sharp, vessels easily visible, pink rim, less than 0.5 dd cup in both eyes  retinal vessels visible and sharp, normal diameters, no hemorrhages or pigmented lesions, minimal microanerysms  foveal reflex present, minimal drusen, no hemorrhages, flat or pitted Non-Readable  Unreadable photos will not be used to initiate referrals; other screening results will be used instead
  15. 15. Future Efforts Validation of protocol Primary care provider certification for triage purposes Automation and integration into electronic medical records and referral systems Connect treating clinicians with EyePACS cases Automated patient alerts Using retinal images for identification of risk factors and biomarkers of systemic disease Validation of new technology and automated algorithms

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