Diabetes Update
Evaluating the Diabetic Patient
Let's go beyond the mundane, annual dilated eye examination.
Every doctor reading this is quite capable of detecting macular
edema, microaneurysms, intraretinal microvascular abnormalities,
dot/blot hemorrhages, hard and soft exudates, vitreous hemorrhages,
etc., in the diabetic patient.
The greater challenge for many of us is how to better partner
with the patient's physician primarily responsible for his
or her diabetic care to help prevent these ocular complications.
Patients with diabetes, like patients with glaucoma, need consistent
encouragement with their compliance and care.
One aspect of diabetes care that is particularly helpful is
knowing the hemoglobin A1C percent concentration. This is measured
as the fraction of hemoglobin that is "glycosolated hemoglobin." It
is read as the percentage of hemoglobin that has glucose binding.
Since the red blood cell life cycle is about 120 days (4 months),
clinical testing for HbA1C provides information on the average
blood glucose control over the previous four-month period.
However, because of the relatively short life span (high turnover
rate) of RBCs, the A1C reading is skewed to reflect blood glucose
levels closest to the time the test was done. That is to say,
about 50% of the A1C percentage reflects blood glucose levels
over the most recent four to six-week period.
 It is well established that diabetic eye disease is closely associated
with the A1C fraction. Most physicians typically perform this
blood test every four months. The A1C fraction in non-diabetic
patients is less than 6%. The A1C percentage levels in diabetic
patients commonly range from 4 to 12%. The higher the percentage
over 7, the poorer the glycemic control, and the higher the likelihood
of complications becomes, especially for diabetic retinopathy.
In well-controlled diabetics, the A1C fraction ranges from 5%
to 6.5%.
We use this barometer of glucose control to help encourage
and congratulate (or admonish and warn) our patients. If the
patient's A1C value (by history or obtained in your office)
is 7% or higher, we take an extra minute to encourage them to
work harder at their diet, exercise and medication compliance.
Conversely, if their A1C is 6.5% or less, we congratulate and
further encourage them in their efforts.
It is both amazing and frustrating to us that most patients
we encounter have no idea what their A1C number is. Either
their doctors are not taking the time to discuss the importance
of this test with their patients, or perhaps the patients are
simply apathetic about learning and remembering their A1C number.
Whatever the case, this is a sad commentary on the state of
diabetes care in America. Optometric physicians need to step
in and help fill this knowledge gap whenever appropriate. This
can occur on three levels:
- Obtain the most recent A1C readings from the patient’s physician’s
office (in whatever manner you choose).
- Obtain the A1C level in your office using the “A1C Now” test
(Metrika)—and send a copy of this to the patient’s treating
physician as part of your diabetic eye evaluation report.
- Most importantly, take a minute to explain what hemoglobin
A1C is and its importance to the patient. If the patient’s
treating doctor is not doing this, it is certainly a public
health service that we can, and should, provide.
Such patient care involvement elevates you from retinal evaluator
to co-managing physician, which hopefully results in an enhanced
level of patient care that improves their quality of life.
We all need encouragement in one form or another, and our patients
with diabetes often struggle with their glucose control. Whatever
we can do to go the extra mile for our patients, whatever their
ocular needs, should make our days in the office even more
meaningful, fulfilling and rewarding.
A1C for the Optometric Office
Obtaining a random blood glucose assessment in the office is
about as clinically relevant as a one-time IOP measurement.
Obtaining three or four IOP measurements at different times
and/or on different days is much more clinically meaningful.
Likewise, being able to obtain in-office hemoglobin A1C levels
would be much more clinically relevant than a spot check
of the blood glucose level at that particular moment.
A new test is now available that is FDA-approved for in-home
or in-office assessments of hemoglobin A1C. Just as many thousands
of you already provide blood glucose measurements in your office,
now you can just as easily provide state-of-the-art A1C assessment.
No additional laboratory or regulatory paperwork or certification
is required.
These tests are inexpensive and can be immensely helpful in
the care and management of our patients with diabetes. For
information on providing hemoglobin A1C testing in your office,
visit www.a1cnow.com, or call 1-877-212-4968.
Metrika, the company who developed this test, also has a variety
of excellent doctor and patient education materials that nicely
discuss hemoglobin A1C and its testing. This is yet another
way our fine profession can play a crucial role in the care
of our patients with diabetes.
It is imperative that your patient's primary care physician
and/or endocrinologist receive a report of your eye findings.
We have developed the the following form to expedite this vital
communication link. It is yours to dowload and use at your
pleasure.
One important note, many physicians (and your patients) may
not be aware of your competence to perform comprehensive diabetic
eye evaluations. It is crucial that your educate your patients
of your abilities in this role, or their naive and well-meaning
physicians may benevolently steer them to an ophthalmologist
they know and trust. This occult patient tranfer ocurs regularily
by well-meaning physicians who simply think they are doing
their best for their patients. It is your responsibility to
inform and educate your patients regarding your clinical competence.
One way to "sieze the moment" is to discuss the hemoglobin
A1C parameter with your patients.
PDF File - If you do not have at least the FREE version of
Adobe Acrobat Reader on your computer, you will need to install
the "Free Reader" onto your system, than go back
and click on the form you want. If you need Acrobat Reader,
just click on the button and follow the instructions for
your particular computer. You will need only the "Reader" to
view and print the reports.
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