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Fig. 1a Indirect ophthalmoscopic examination of the retinal periphery. Source: Reprinted with permission from the Department of Ophthalmology, The University of Iowa Carver College of Medicine
abnormalities (IRMA). As in the right eye, the center of the macula appeared thickened with some microaneurysms and lipid within the central macula (Fig. 1a and 1b).
Fig. 1b Left fundus photograph of diabetic macular edema.
Source: Reprinted with permission from the Department of Ophthalmology, The University of Iowa Carver College of Medicine
Systems-Based Competency
This vignette provides an example of many of the challenges of managing diabetic retinopathy in older people. Diabetic retinopathy is a common cause of vision loss in people over age 50 in the United States,1 and growing in incidence
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concomitant with the increasing prevalence of obesity.2 Before getting to the management of the patient’s retina problems from a medical knowledge competency standpoint, it is important for the comprehensive ophthalmologist to realize that he or she represents a part of an entire team of healthcare providers (nurses, technicians, the primary care physician, the endocrinologist, podiatrist, social worker, the family) who must work together with a patient who has diabetes in the management of diabetic retinopathy. Coordination of care, patient and family teaching, and insuring glucose monitoring and control require a system-wide effort that includes of course the treating ophthalmologist.
Communication Skills and Professionalism
Related to this important interaction, one of the Physician Quality Reporting Initiative (PQRI) initiatives for patients who have a diagnosis related to diabetic retinopathy, the treating ophthalmologist is encouraged to communicate with other providers of care for the patient’s diabetes.
Such communication might have reduced the chance for a gap in this patient’s continued eye care. The patient had not had a dilated fundus examination from an ophthalmologist in over 3 years, even though the patient reports having had some level of diabetic retinopathy identified at that last exam. Even if only mild, nonproliferative diabetic retinopathy with no macular edema was noted, the patient should have had at least an annual examination to watch for progression of retinopathy for which treatment might be indicated to reduce the risk of vision loss. There may be an increased difficulty for some older people to get to even one physician, because of multiple medical problems. This problem can be compounded for the older person with diabetes, where frequent examinations with many specialists might be necessary, including for example, a primary care provider, an endocrinologist, an ophthalmologist, a podiatrist, a cardiologist, and renal specialist.
Also of note in this patient is the potential confusion of the older patient with diabetes to be aware of which medications he or she is taking, since some of these may have an impact on the ophthalmic care, for example, on choice of ocular antihypertensive medications. Some patients might consider actually bringing their medications to the examination for accurate recording, or at least a carefully developed list.
Furthermore, this case highlights the difficulties with understanding the concept of hemoglobin A1C.3 First, this patient apparently confused the term ‘‘hemoglobin A1C’’ with hemoglobin and the concept of anemia. Second, although the hemoglobin A1C is a convenient laboratory value to judge control of diabetes, which is critical to reducing the chance of progression of retinopathy,4 this patient, as is true in many patients may not understand the concept.
Also, it is clear that this patient may not realize that the progressive vision loss is not from cataract or an incorrect spectacle correction. The physical examination indicates that his cataracts can be seen with a slit-lamp