America’s diabetes epidemic, like its citizens’ waistlines, is growing. Data from the 2011 National Diabetes Fact Sheet show that nearly 26 million Americans—8.3% of the population—have been diagnosed with diabetes. The prevalence increases by 6.5% annually, according to some estimates. By the year 2020, one out of three people over age 65 will have diabetes; 27% already do.

Worse still is the sobering news that more than seven million people suffer from the disease but remain undiagnosed, and that another 79 million people are considered pre-diabetic. Among adults, either manifest or incipient diabetes will ultimately become more common than its absence.

This is borne out in our clinics. Diabetes is the leading cause of new cases of blindness in US adults. A little over four million, or 28.5%, of people with diabetes age 40 or older had a diagnosis of diabetic retinopathy, and 4.4% have the proliferative form.

Literally millions more are waiting for appointments right now.

There are over 100 million eye exams performed annually (most commonly by optometrists) but only about 40 million visits to primary care providers for annual check-ups. Unfortunately, many patients—even those at high risk—are not compliant with annual physicals. So, there are at least twice as many opportunities for us to diagnose diabetes as there are for GPs or FPs in the course of one year.

Furthermore, type 2 diabetes occurs when patients are most likely to seek an eye examination, which is in the early 40s, around the age of presbyopia.

It is within our power to dramatically alter the course of diabetic eye disease, and diabetes itself—a systemic disease with multi-organ morbidity that may be first discovered in your chair.

We Set the Pace

This crisis highlights the profound importance of optometry’s role as the health care providers who initiate and coordinate diabetes care in collaboration with endocrinologists, primary care physicians, retina specialists and diabetes educators. As we all know, the only anatomical site where one can directly examine the human vasculature is the eye. This gives us unprecedented opportunity to initiate care for many patients.

Of course, changes in blood glucose might be identified prior to any sort of retinopathy, but improved diagnostic capabilities are helping optometrists to identify diabetes even prior to any retinopathy findings and now even prior to changes in A1C.
New technology that can measure autofluorescence of the lens (see this month’s ‘Research Review’) could enhance our ability to diagnose diabetes as much as six to seven years in advance of other clinical manifestations.

Furthermore, detecting and timely treatment of diabetic retinopathy with laser can reduce the development of neovascularization by an estimated 50% to 60%. And the Diabetes Control and Complication Trial showed that earlier diagnosis with well controlled blood glucose in patients with type 1 diabetes reduced the incidence of diabetic retinopathy by more than 75%.

Diabetes patients require an annual dilated examination; those diagnosed with nonproliferative diabetic retinopathy may be seen every six months to ensure that it is stable. Progression to proliferative diabetic retinopathy would then warrant involving the retina specialist.

In short, we set the pace of patient care.

Something Old, Something New

This patient population’s care requirements also dovetail nicely with traditional optometry.

Diabetes patients have a higher risk of glaucoma and greater propensity to develop cataracts prematurely; they also have dry eye in about 50% of cases, and over two-thirds of adults with diabetes and poor vision have a refractive error that can be improved with corrective lenses.

Let’s rely on our strengths in vision and eye health to serve existing diabetes patients’ needs while embracing our new responsibilities in not merely primary eye care but primary care, period, as we remain vigilant for those at risk.