New research from the University of Colorado Department of Ophthalmology elevates the importance for diabetic retinopathy screenings targeting populations at risk of delayed presentation of diabetes-related eye disease.
In a review of 562 patients who presented with a new diagnosis of diabetic retinopathy at the Denver Health Eye Clinic at Denver Health Medical Center, CU researchers found that lacking a primary care provider and being uninsured were significant risk factors for getting into care late in the stage of disease. Patients with delayed presentation experienced worse visual outcomes, even with aggressive treatment.
“The goal of this study is to hopefully help craft future health policies and present evidence of where there are risk factors for delayed presentation,” says Niranjan Manoharan, MD, assistant professor of ophthalmology at the CU School of Medicine.
Early detection and care
Screenings are a crucial part of diabetic retinopathy care, explains Hongan Chen, MD, ophthalmology resident at the Sue Anschutz-Rodgers Eye Center. The condition, which affects retinal blood vessels in the eye and is often referred to as a “silent disease,” can cause vision loss and, in severe cases, blindness in people with diabetes.
“People can have severe retinopathy but be totally asymptomatic,” she says. “The best thing diabetic patients can do to reduce the risk of progression is ensure good control of their diabetes and complete recommended screenings, including eye exam screenings.”
For patients with type 1 diabetes, professional society guidelines recommend an annual diabetic retinopathy screening beginning five years after diagnosis. For patients with type 2 diabetes, the recommendation is screening at time of diagnosis.
“To get the best outcome for patients, we have to figure out what the risk factors and challenges are for patients that prevent them from getting treatment earlier,” says Manoharan, senior author of the study published in the September 2023 edition of the ARVO journal Translational Vision Science and Technology. “We often see many patients coming into the eye clinic for the first time with advanced stages of the disease. Despite aggressive treatment at that point visual, outcomes are just not the same as catching the disease earlier.”
Hurdles in access
Primary care physicians are often the first point of contact for patients when they’re diagnosed with diabetes. These physicians are also the ones who see diabetes patients the most throughout the year.
“They’re the gatekeepers of preventative care,” Manoharan says.
In the study, the lack of a primary care provider was highest in patients who presented initially with proliferative diabetic retinopathy, an advanced stage of the condition. However, researchers also found about 30% of patients with a primary care provider still did not receive an ophthalmology screening referral.
The advanced stage patients in the study were also twice as likely to be uninsured or underinsured.
Previous studies have found that lack of health insurance is a major obstacle in seeking eye care, in part due to fear of out-of-pocket expenses. Several other barriers to medical care affect these patients including lack of transportation, lack of health care literacy and inability to take time off work for appointments. These factors prevent patients from getting proper early screening and lead to adverse outcomes that can no longer be fully reversed.
Setting the stage for future work
To combat the problems that face early detection of diabetic retinopathy, Manoharan, Patnaik, and the other CU co-authors say screening programs targeting populations with identified risk factors are essential for improving outcomes, especially as the condition is on the rise.
Global projections estimate that adults with diabetic retinopathy will increase from 103 million to 161 million by 2040, with middle-and-low- income communities being most affected.
“These increased rates will lead to substantial rises in medical costs, lost productivity, and decreased quality of life,” the researchers say. “Policies aimed at early intervention are well supported by the literature.”
By pointing out risk factors that exist, the study can serve as a stepping stone to fixing a lack in screenings.
“Hopefully studies like this will help shed some light on how to move forward and provide the necessary care to patients who aren’t currently being served,” Patnaik says.
April 18, 2024