TABLE 15-1 Concepts for Staff Education

Background diabetic retinopathy

Nonproliferative diabetic retinopathy

Proliferative diabetic retinopathy

Diabetic macular edema

TABLE 15-2 Goal of the Office

1. Education of the Staff

2. Health Literacy of the Staff

3. Compassionate Service: Art and Science of Medicine

4. Teamwork: The physician and staff are part of a team

What is the Mission Statement?

What do we as physicians stand for? Ask each of your new hires to articulate what should be the mission of the office in serving diabetic patients. What do patients want? “They want to get better” is the single most common answer. How do we convey this message as physicians and as staff members? To “get better” means that the vision will improve. Obviously, the improvement of vision may take weeks or months depending on the status of the patient’s diabetic retinopathy. What can the staff do to facilitate the patient’s sense of well-being despite his fears and anxiety about vision loss? To translate this into concrete terms: How can the staff make the patient feel that today’s visit to the retinal specialist is a “step in the right direction” in his search for quality health care in recovering eyesight? (Tables 15-3 to 15-14).

TABLE 15-3 Mission Statement

1. Integrity, Commitment, and Compassion

a.Delivery of health care

b.Committed to excellence of diagnosis, treatment, and service

c.Compassionate care

2. Educate the patient

3. Teamwork approach to diabetic retinopathy

a.The patient must want to do his part of compliance with treatment plans.

b.The physician and his office must educate the patient to increase his motivation for compliance.

TABLE 15-4 Telephone Triage: A Script

Your receptionist: Hello. This is Dr John Doe’s office. How can we help you today? (Say this with a smile.)

Patient: I would like to make an appointment. My doctor, Dr Joe Smith, says that I have a vitreous hemorrhage or bleeding in the eye.

Your receptionist: Yes, we have a cancellation today. You can come at 2 pm today or if you would like, you can be squeezed in at 9 am tomorrow. (Free up time for emergencies such as this patient with a diabetic vitreous hemorrhage.)

Patient: I am really nervous. Can you squeeze me in tomorrow?

Your receptionist: Yes I understand. Please give us your name and telephone number so we can input the information into the computer. We will see you 9 am tomorrow. (Be reassuring, kind, calm.)

Please bring all your eyedrops and pills for hypertension or diabetes. Bring in all your medications or a list of medications. Bring any lab tests that you might have from your visits with Dr Smith. Bring sunglasses because your eyes will be dilated and you will want sunglasses afterwards. The sunglasses will help you drive home. Bring your medical insurance card, as well. You can come a few minutes early to fill out our forms. The entire examination may take 2 hours or more, since we are squeezing you in. There might be a delay.

Patient: I can wait. I am so nervous that I want to be squeezed in. By the way, will I need to bring someone to drive me home?

Your receptionist: If that makes you feel more comfortable, yes. But if you want to drive home, it will be okay. Usually, after 20 minutes, you can drive home with sunglasses.

Patient: Thank you.

Your receptionist: Thank you. See you tomorrow. (Say this with a smile.)

TABLE 15-5 First Telephone Encounter with a New Patient

1. Establish rapport with the patients with sunny, happy, welcoming telephone voice.

2. Ask about name, telephone number, or whatever demographics that you need in order to schedule patients.

3. Tell them that the office visit may take 2 hours. Always underpromise and overdeliver. If you tell them

1 hour and the visit actually lasts 1½ hours, the patients will be angry. If you tell them that it will take

2 hours and they leave after 1½, the patients are ecstatic. It is all about expectations.

4. Ask about the medicines and a medicine list. Ask about lab tests. Ask about insurance last.

5. The encounter has to be soothing and calming.

6. Having a gruff pit bull as your receptionist is not useful. You want a kind nurse or nurse’s aide to answer the phone asking about patients. A pit bull receptionist serves as a barrier to more patient appointments

TABLE 15-6 Information for a New Diabetic Patient

1. Handouts about the definition of Type 1 and Type 2 diabetes mellitus

2. Diabetic recipes

3. Nutritionist information

4. Food pyramid

5. List of blood tests that are commonly needed by the ophthalmologist

a.Cholesterol, triglycerides

b.Fasting blood sugar

c.Hemoglobin A1c

d.Electrolytes, renal function

e.Complete blood count

6. List of diabetes complications and the eye

a.Diabetic retinopathy

b.Glaucoma

c.Cataract

d.Corneal problems

6. Common symptoms of diabetic retinopathy

a.Loss of vision

b.Decreased vision at near or decreased vision when reading or using the computer

c.Total loss of vision

d.Waxing and waning of vision loss

e.Central loss of vision when reading

TABLE 15-7 Patients Who Should Be Expedited

1. Abrupt loss of vision

2. Painful headache or eye ache with loss of vision with nausea and vomiting

3. Loss of vision lasting 10 minutes and then the vision returns

4. Partial loss of vision in one or both eyes

5. Sudden double vision

TABLE 15-8 Patients with Special Emotional Needs

1. Children and teenagers with new diagnosis of diabetes

a.This group may be emotionally unprepared for the diagnosis because of their developmental age

2. Adults with new diagnosis of diabetes

a.New diagnosis entails explanations and educational materials

3. Elderly patients who live alone with diabetes

a.Patients who do not have a family support system may need more interaction by the social worker

b.May need home health aids if they have vitrectomy surgery

4. Patients with sudden visual loss

a. Anxiety with loss of vision in a sighted world

b. Angle-closure glaucoma or neovascular glaucoma because of diabetic retinopathy

TABLE 15-9 Diabetic Retinopathy: Concepts and Definitions for Staff

1. Diabetic retinopathy affects the smallest vessels in the back of your eyes.

2. Diabetic retinopathy is a microvascular disease.

3. When blood sugar has been high for many years, the walls of the blood vessels fall apart and blood and fluid leaks out onto the retina, causing vision loss.

4. The retina is like the inside lining of the eye, the film inside a camera. This inside lining gets damaged with the leakage of blood and blood proteins.

5. Development of diabetic retinopathy is related to cholesterol levels and the overproduction of human growth hormone and the hormone leptin found in fat cells.

6. Eventually, the blood vessels become so abnormal, full of leaking holes, that new blood vessels form, “neovascularization of the retina.” These new blood vessels are abnormal and cause more blood leakage and more vision loss occurs.

a. Treatment is with laser or bevacizumab, an intravitreal injection of a monoclonal antibody. This is available at your retinal specialist’s office.

TABLE 15-10 Prevention: Points for Patients

1. See an ophthalmologist (eye MD) or eye care practitioner (optometrist) who has a lot of experience at looking at retinas for regular checkups.

2. To get a good look at the retina, a dilated exam will be done (eyedrops will be used to “dilate” or “open up the pupil” so that the ophthalmologist or optometrist will look inside).

3. Yearly eye exams with early laser treatment will prevent blindness.

4. If you do have diabetic retinopathy, your ophthalmologist or retinal specialist will perform a fluorescein angiogram. This involves a special digital camera which takes photos of your eye and analyzes the blood circulation around the retina. After a few photos, the ophthalmologist or retinal specialist will inject a special dye (fluorescein) into your arm, where it will travel through your blood vessels to the blood vessels of your eye. While the dye is traveling into the retina, more photos will be taken to examine the retinal blood vessels and determine if any retinal damage has occurred.

5. Laser could be the next step if you have diabetic retinopathy

TABLE 15-11 Laser for Diabetic Retinopathy: Points for Patients

1. Diabetic Macular Edema

a. The retinal specialist aims the laser, which is a high-energy beam of light, at the blood vessels leaking blood and sealing them so that they stop leaking.

b. For some forms of macular edema, the vision might not improve, but the laser will stabilize the vision so it will not get worse.

c. Yearly dilated examinations are important to pick up this condition before visual loss occurs.

2. Proliferative Diabetic Retinopathy

a. If you have proliferative diabetic retinopathy, the type of eye finding where all the blood vessels leak and new abnormal ones are created which leak even more, the retinal specialist will use a “scatter laser treatment” also known as “panretinal photocoagulation” to stop the bleeding.

b. The laser treatment uses a laser to destroy many different parts of the retina where the abnormal blood vessels are growing wildly. It is thought that the laser, which destroys some parts of the retina, prevents further signals that lead to new vessel growth. Researchers feel that the laser may thin the retina, thereby increasing the amount of oxygen that can get to the good retina, and may induce parts of the eye to produce certain chemicals that prevent the growth of new vessels.

TABLE 15-12 Vitrectomy Surgery for Serious Diabetic Retinopathy: Points for Patients

1. If you have a lot of bleeding inside your eye from proliferative diabetic retinopathy, then you may need a “vitrectomy” to improve your vision.

2. In this procedure, you will be given a local or general anesthetic. You may or may not stay overnight in the hospital, depending on your overall health and eye-surgery findings.

3. During the vitrectomy, the retinal surgeon will make a tiny incision in your eye and will remove the bloody vitreous gel, which is the gel inside your eye, next to your retina. The gel gets replaced with a saline solution. This is okay since most of the vitreous is mostly liquid anyway.

4. At the same time, the surgeon will repair your retina if it is damaged.

5. When you go home, your eyes may be red and sensitive for a few days. You will have to wear an eye patch and plastic or metal eye shield at bedtime to protect your eye for a few days or weeks depending on the severity of your surgery. You will be given antibiotic drops to use in the operated eye.

6. If you need the procedure done in both eyes, your doctor will schedule the second eye after the first one heals

TABLE 15-13 Other Eye Conditions: Points for Patients

1. Patients with diabetes are likely to develop other eye conditions than other people without diabetes.

2. Glaucoma

a. Fluid from inside the eye does not drain through normal channels. Instead, fluid builds up inside the eye, increasing the pressure inside the eye, eventually destroying the optic nerve.

b. The diabetic patient is twice as likely to develop this common form of glaucoma, called “open-angle glaucoma.”

3. Neovascular Glaucoma

a. In diabetic patients with new vessel formation, the type of diabetic retinopathy called “proliferative diabetic retinopathy,” neovascular glaucoma occurs because the abnormal blood vessels grow over the normal drainage system inside the eye. High-intraocular pressure can occur, and pain can occur in the late stages. In the early stages, the patient may not know that he has this type of glaucoma until he sees the ophthalmologist or retinal specialist. This needs medications, laser surgery, and other forms of surgery. This type of glaucoma may require the services of a glaucoma-trained ophthalmologist.

4. Cataracts

a. Cataracts occur when the lens of the eye becomes cloudy or opaque. Then, there is mild to severe vision loss. Although cataracts occur in nondiabetic patients over the age of 65, they occur earlier in diabetic patients. They can occur in children with uncontrolled Type 1 diabetes. Cataracts can be easily treated with surgery. The cloudy lens becomes replaced with an “intraocular implant,” a new, tiny plastic lens that fits inside the eye.

TABLE 15-14 Drugs That Are Contraindicated with Diabetes

1. Chromium

a. The exact amount of chromium needed in your diet is 15 to 50 μg a day. If you take too much, chromium will be accumulated in your liver where it can be toxic. Some studies have shown excess chromium can cause cancer.

b. On study in China showed that people with Type 2 diabetes, who were chromium deficient, are given large doses of chromium. They improved hemoglobin A1c, blood glucose, and cholesterol while reducing their insulin requirements. However, most patients in America do not have chromium deficiency.

2. Cinnamon: No evidence that this works.

3. Aspirin: No evidence that this works.

4. Pancreas formula: Mixture of herbs, vitamins, and minerals to help diabetes. No evidence this formula works.

5. Gymnema Sylvestre: Part of alternative medical treatment called Ayurvedic medicine. This has never been tested in a controlled study in humans. No evidence that this works