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The Effectiveness of Single Field Fundus Photography for Early Diabetic Retinopathy Screening in Community Free Clinics

Gayle Daniels O.D.


Demonstrating effectiveness of single field fundus photography in early screening for diabetic retinopathy, especially in community free clinics. Comparing digital imaging to current standards of screening methods. Introducing diabetic research project utilizing the varying demographics of the free medical clinics with retinal imaging for early screening of diabetic retinopathy in all diabetic patients.


1. Understanding Single Field Photography usage in community free clinics

2. Understanding Basic Diabetic Retinopathy
3. Demonstrating importance of early screening for diabetic retinopathy 


Gayle Daniels O.D.

Owns a practice in Fort Worth, TX



  • October 27, 2017
    4:15 PM
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Father I ask you just to take the mike Lord allow us to see how you want us to use the talent you've given us in the work that it needs when we're out in the community giving exams because they can then. So pretty much going to continue on with what Brad was talking about in diabetic retinopathy but from a different twist basically for early detection in our settings of payment free clinics which is going to be slightly different in your clinical settings and we're going to talk about specifically the single field funders photography versus the seven field and the optos and everything else because we are in a modified situation we're in a meant clinic so we're going to think a little differently but still have some of the resources that you would have in your own basic clinic. Again this is who I am and if you notice anybody here who cares there you go. There you go. And my there are in any financial endorsements by mankind my endorsements are all from above and so I am not paid by anybody here. Basically we want to start with just basic diabetic retinopathy want to one in a different way because Brad did a wonderful job of giving us the classifications of diabetic retinopathy so I don't want to repeat any of that when I'm basically going to talk about pretty much is just that. Close to ten percent of the population are diabetics out there children and adults alike. Approximately zero point seven million are diagnosed every year so it's not a condition or a dyke disease it's going to go away just keep getting worse specially with the diet that we have. There's about twelve percent Hispanics and African-Americans so minorities make up quite a bit of the population that suffer from diabetes out there now come in the community. It can go Kurd but they can occur at any any age as we know and it is a leading cause of preventable blindness in. What I'm really harping on when it comes to community free clinics and diabetes because it is preventable and it is mentioned impairment in the working age of Americans. So the survey shows that over forty years of age as what Brad mentioned before also that it will have diabetic retinopathy and a lot of times they're unaware of the changes that they're having inside and then generally after the ten years he had eighty percent my study showed seventy five but it doesn't matter the number semantics that the thing is that after ten years most people will have some form of diabetic retinopathy that we need to pay attention to. And of course as we know the stages that no symptoms until very late stages when there's a burning much else we can do for effect affective treatment so that's why early diagnosis and detection is really the key and that's what we're going for in our community settings with him and free clinics. So ninety percent of the vision loss if we're caught early and treated can be prevented from vision loss if we just catch it and treat it and the studies show that about sixty percent of the diabetics actually do receive some form of an examination to some degree but what we're trying to do in our screening start goals is that we want to. Identify treat educate and manage that's the biggest thing that we're doing in our free clinics. Before we have every verse of vision loss with our patients so some of the diabetic facts that we all know also that it's money takes a lot of money to first diagnosed diabetes cost a lot of money for direct care of diabetic patients and just as much money for indirect care with people going on disability and work loss and everything else so it's money is involved throughout the whole cycle of diabetes. And a no brainer the worst severity of the diabetic retinopathy in vision loss the higher the insurance cost. For us and for everybody else and that's just a no brainer so I was shown here that some of the initial screenings can cost slightly over one hundred dollars for just initial screening for some people who don't have it that's a lot of money still and then once we do have early detected written up at the one now we're looking at about eight hundred dollars per person and then the once it's gets the severity point of severe right now but they were looking at over twelve thousand dollars per person and that's what we're trying to prevent from getting to this point and even that point. So we have to remember again about one third of the diabetic patients will have some form of diabetic retinopathy when they're coming to our Frisco clinics Niger routine exam your clinic at home your private practice we're talking strictly in the community right now so obvious solution is prevention of course detect and treat before it even gets to that point how we can help the patients to this to prevent vision loss OK I know you guys I'm singing to the choir you know because I'm preaching right here to you could you know this already you do this every day with your patients in your private practice. So I created what we're going to call it I think we're going to identify treat educate and manage so we're now called the. Great and we want to do this and early detection with our screening programs so that we can catch the patients for appropriate referrals. Before they have vision loss that's the whole thing so we're going to do this through a single fill photography and we're going to utilize the Amen free clinics for these diabetic screenings that we want to do for early detection education so that we can reduce progression and preserve sight for the patients that come to him in free clinic. So a little bit of history about photography. Right now photography was introduced way back in the mid eighty's hundreds so they had some form of photography that pointed as everything else evolves and has evolved greatly. Renel camera basically again anatomy of the retina just take the superficial layers out there with basic photography and the typical. Camera would give you about that much angle back there except for the white view that pragmatist mentioning again this is for I screening purpose that we'll use in the community so it's going to give us a little bit different than the optos that we would use and inside a clinic I wish we could have an up close to travel with us that would be beautiful when. They are the Daytona. And the Daytona if we could get a grant for that it would be ideal but that's what eighty five thousand. Are coming down. The moving of it and that's all we do. Right so the advantages of some of the newer models out there. You don't have to worry about the dialing drops some of them have automatic I alignment if you've seen a V S P camera that's on their mobile then it really lines the patient up and everything you just push a button and don't do anything it lines it up and snaps the photo for you and everything and it's really improving how we're doing diabetic eye care generally everywhere we're just having a photography and of course the red free unfortunately the for the camera that we have that we're carrying with us does not have this feature and I wish it did and I told that to the company so maybe perhaps they'll have that is in addition or a filter to put in or something that will help with the red green. So what got me interested in wanting to do something in regards to this is I came across the study from the American carrier. And basically they were doing as they were evaluating whether single fundus photography can be used as a screening tool to identify written up at the well it seems like it should be it's just a no brainer but they actually did research to show this so I wanted to read their research and their conclusion was is that nothing is a substitute for complete comprehensive exam which we all know and which we say at the eggs are free clinics However it is evidence that it can serve as a screening tool for diabetic retinopathy to identify patients and then for referral for evaluation a managed. Which is the whole basis of a free clinic in the community in my opinion where they're to identify to try to educate the patients of what's going on and then put them in appropriate hands for treatment and for us that's what I want the vision I care department to be for a pathway or a man or anybody else in the community because a lot of times the patients don't have time to sit and talk to the doctor or afraid to talk to the doctor and to tell or not anymore so this is our chance to really educate with them showing a picture of their eye versus an eye out of the textbook rather Google that's my really big push so the advantages of a single field. Photography is that it's very easy to use just one particular photograph it's convenient and we're able to detect something in this setting that we have a nice free clinics so the early treatment diabetic retinopathy study little bit more intensive like what Brad was bring into a view for us it involved the seven field standard stary optic fundus photography's in they use the army house classification and it required scale photographers dilated pupils in film at this time so it was very intense for them to do in a kind of photography using this study and this particular classification I mean it's a seven field with thirteen complex levels you know all we have to level eighty five to determine the degree of diabetic retinopathy in our setting I just want to find if they have it and educate the patient the importance of getting that monitored and move on as far as letting them understand what's going on so it doesn't have to be this intense at our community in a setting so again seven field right had a better picture for this and identifying how they take the different shots in the put them all together for that compared to the one single field that we take out in the field in the communities so advantages again it's just easy one shot actually we do two or three just to have the doctor compare a couple of shots versus just one that can be. The ability to detect right now with the if it's there and that's and to feel. The potential to improve the quality of our screening because that's what really we do as a modified screening exam and then we can see so many patients at one of it which of course you know is a bottom line at this screening system see as many people as we can reach. Than an advantage is again quick and easy large field dilations not required patients like that and we can actually keep the photos in and use them over time because believe it or not we go to the same cities we see the same people they use us for their annual exams and that's scary to me because if I have a diabetic patient we don't have a camera I'm asking them to go get seeing him and I see them next year oh yeah for you oh I saw you last year when did you go to the doctor like I said no no no I knew you'd be back this year that's scary so at least with a camera I think that gives us a little bit more confidence to take that picture look in the back and give them a little bit more education try to get them understand the importance of having that complete exam that this is not replacing your complete annual exam so the disadvantage of the photography of course is two dimensional and it doesn't give us the depth sometimes a cataract will interfere in artifacts will interfere with the actual picture and then the probability for most like the Daytona you don't want to travel with that and then the cost of the camera itself can be a little pricey for that but I found that the least expensive and expensive one I found so far is about one to ten thousand. So again a standard of care we will never ever ignore or deviate away from the standard of care for diabetic patients which is a complete eye exam that includes dilation that will never be replaced so to bring a back to a little bit of life here this is what we did in Detroit in the Motor City for a main clinic that we had there. So this is the first time we had a camera on site loan to us we did a ten question survey of the patients prior to taking the photo so we. Had sixty seven diabetic patients that were seen identified as diabetic on the form so if we had some that didn't identify when we did not know. That we had sixty one percent were female. And we had the majority were African-American at this location the last eye exam was over two years the majority of patients. In the last dilated exam was also greater than two years so again of their primary physician speaking to them at all or referring them yearly exams or do they even go yearly even to the physician. How long we've been diagnosed with diabetes will more than ten years so we've both had said that after ten years there's a seventy five eighty percent chance that they're going to have some kind of retinopathy after ten years and that's evident there. And then what medications most of whom are just taking any type of pills that they admitted to and they had sixteen percent that were taken anything. Last I exam if it's been more than two years what would you say is the main reason why you haven't had Dr checked course the biggest thing is lack of insurance and the second is the cost of the exam in their opinion and their transportation to and from the clinic and this is what I thought was cool and they didn't think was a priority and why they didn't have an exam done so again the communication between As Brad ended his his talk the communication between us the primary physician is everything else is really key for these patients that are diabetic. And then they have been told I am well I don't know if I believe the results on this one quite so much because it's kind of high for people to say that they they were told all the effects but yet they still don't come and get their eyes checked or dilated or anything else so I don't know if they just said that just to say that because we asked that question when we actually do this survey next year we got to think of a better question to see if I can understand so if you guys have any good research questions please let us know because I don't quite like that when I don't think that results are right and then what health insurance do they have most of them had nothing and so that's why they were going in getting their eyes evaluated or check the latest and haven't they already said it was too expensive for them. And in the likelihood of having an exam from now on of course they're going to say that in front of us there oh yeah of course I get my age check you're sitting right here front of me. All right so this is what I said the i team circle of orange I already for the four we're going to identify treat educate and manage circle of orange and why the color orange I'm just a happy person orange comes out to be full of joy full of change health some of the key words that have described oranges basically why I just wanted to come up with something that helps fit that also so the circle of orange basically is a pilot program that I'm trying to institute for next year where we're going to link the Amen free clinics so if you've heard there's approximately sixty clinics that have been slated for next year in that those sixty clinics we have one camera. We're going to pick the camera that has the largest number of providers tent so the largest number of providers of the more patients will be surveyed and researched and we're going to link together them with the volunteer eye care providers that attend the clinics as well as local community eye care providers and I explain that in a minute in the mission for the circle warning I do if I treat educate manage people with diabetes who are at risk of vision loss or an eighteen month period and I say eighteen months because we're going to have clinics from January to December for those patients seen in December I would still like to follow up for six months which would take it to the eighteenth month point. In our service will be all diabetic patients that are registered for services that are payment free clinics not just those for eye care I would like to position the camera someplace where every patient who is identified as a diabetic will be screened and now we can really capture everybody they might also have a veil ability next year to have A one C. screenings besides just the blood sugars of the blood sugars elevated to a point past the criteria they will have A one C. at the same time so I want the camera close to medical maybe even so that everybody that is identified as diabetic will have the screened not just those coming to vision. So identified this is a camera unit here is a unit or a utilizes portable camera to take that single field fundus photographer shot this particular gentleman is the technician who's learning how to use it right now this is my nephew and my nephew is basically learning how to be an optician through the program we have in Fort Worth and so he's adapted to how to take the camera shots and has been practicing so that will be proficiency next year and this is the camera this actually was developed by I think off the Molly just in India and the body here comes apart in the storage in a case that can be put in your overhead compartment and then everything else breaks down and puts in another suitcase so the. Completely breaks down and can travel into suitcases completely durable. Guy just going overhead. Oh just like a regular. Flu case and this is very very durable unfortunately we found out first hand this got dropped. And it still works extremely durable. Streaming and they even said that they said that it was designed and manufactured for that because they use it they said in India they would put on the back of bikes and take it out to areas where you see. So then the clinic on site I would like to after the Identify we have a provider actually review the pictures in Detroit this isn't a live one is off Google but in Detroit we had three doctors that that were there practicing for doctors when they had a patient I was diabetic it was identified on their exam form and they just went to take a look at the images on the camera and they came back and discussed it with the patient so every diabetic patient that was identified in that survey there was evaluated on site by the doctor. Of course just to go through typical medical records we will have a form that will use next year for those that have pictures taken so we can properly document because as you know anything that's not recorded was never done so we want to make sure that it's documented that we saw the look in the back of the side in the single field shot and in treatment so anybody that needs treatment what I would like to do with this I team circle of orange is that I would like to identify providers within a five or ten mile radius of the clinic where it's going to be so that if there's treatment is needed we've already contacted them ahead of time to see whether or not they would be willing to take our patients on for treatment. So I want to recruit we're going to ten mile radius any private practice group practice our health clinic and I want to ask them that if we have patients that we identify with retinopathy you know would they be willing to see them in a frequency. And if they don't have any right now for the at all maybe still six months for that routine dilated exam because we're never going to step away and ignore that standard of care and of course a lot of patients who attend these clinics as you know have insurance some of them do have insurance not everybody is without So if they have insurance and the clinics are willing to you know. File that's totally up to them we're not going to say no but I do want to find one or two providers that would be willing to be part of our circle of orange so when we do identify patients we can refer them so we have a few three four or five providers you know they might only get one or two people it's not like they're going to get thirty they're not going to get sixty it's going to be just a few that will actually have diabetic retinopathy or need to screenings. And the treatment that will be told into them to do their medical insurance the professional courtesy to be part of this what we're trying to do is really make this a research program we're actually trying to seek and other monies to help grant this program for next year and so if we do get granted anything we could even offer to be help with the cost for treatment for the patients that we identify that really do have vision threatening right now apathy in the back of the eye and then we want to educate we have that circle of orange and we also have nurse practitioners that are involved in that circle not just optometrist who are willing to make phone calls to these patients and we want to give them general diabetic facts and education we want them to be completely informed so we want to give them general ever and ever information we want to give them information how to properly take their medication and when to take their medication I say that because one nurse practitioner was speaking to this is what she does right now at one of the hospitals in Fort Worth and she said that one guy came in for evaluation before he being discharged from the hospital and the sugar was ridiculously high and she was like did you take your insulin today and he said Yeah I took it today and it was still you know elevated above to fifty and she was like how going to be so happy took your insulin show me how you took your insulin and I just did this and show. Well you so big he didn't realize he shot his shirt. And didn't shoot himself so even something that simple just to communicate with the patients to see whether or not they're taking their medication properly and at the proper time and then to record it properly she's a Briley being on there she's a great person that's going to be an asset to the circle of orange because she likes to educate how to properly even log your number so that when you go to your provider they're fully informed of what's going on with the sugar. And then we want to actually give them a personalized diabetic diet plan that will encourage them to eat right to also affect their overawed blood sugar level and control and then the exercise program we want to personalize it we want to find out what they like to do again all this would be just done with that those people were identifying because if you tell me let's let's plan an exercise program in my mind I think this and I think this and I think this and I don't want to exercise so let's find a way that they would enjoy exercising what they like to do maybe a simple walk around the park we can encourage that's exercise but anything else more strenuous they're going to immediately tune you out because that's what I do. And then of course we want to educate spiritually also if they're around a local church where they are doing done or to include any other tracks or anything else that we can feed to them and filter to them for their spiritual education also and then the manager we want to manage them again through our circle of three six and twelve months either through a text and email telephone call just to encourage them along this way to make sure that they're keeping up with their appointments so we want to make sure that they're keeping up with their daily with their schedule dilations with the providers and any other treatment that that provider has so it's going to be a big working network between the i team and the local providers and the patient this is what we would like to do so at the end we can see if we kind of hold hands with that patient. Did we help them along did they did they get things their exam done that they understand is that they even take better control of their sugar in managing their sugar we just want to see what this would do if we just gave them a little bit more education and a little bit more follow through than just saying you have this and go. So in summary this there is evidence that a single pill funded photography is a screening tool and that's all that we're seeing it as a screening tool to identify patients with the retinopathy for referral and we just want to take that referral further and help manage that patient for at least six twelve eighteen months to see if they can continue on after that with that proper education so I teamed circle of Orange is a network of health care providers we want to personalize diabetic eye care so we can reduce vision we just want to work together as a team so I guess the bottom line is all of these findings illustrate that there is a tremendous need for community based diabetic retinopathy programs surveillance programs and that's what a man is striving to be so are you willing. Thank you this media was brought to you by. A website dedicated to spreading God's word through free sermon audio and much more if you would like to know more about. If you would like to listen to more sermons lead to visit W W W dot. Org.


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