Internet may help prevent blindness in Medicaid patients with diabetes

A Wake Forest University Baptist Medical Center team is launching a high-tech study to determine if early screening using a special camera and images transmitted over the Internet can prevent blindness in Medicaid patients with diabetes.

"Medicaid patients are rarely screened and are at risk of becoming blind," said Ramon Velez, M.D., M. Sc., the principal investigator. Diabetes is the leading cause of preventable blindness in the United States and Velez said the study will determine if early referral to ophthalmologists will help.

The project – "I See in NC" – is being pilot-tested at Downtown Health Plaza of Baptist Hospital, where Velez is medical director, and then will be offered to two rural networks of Community Care of North Carolina. One is Central Piedmont Access II, the other is Access III of the Lower Cape Fear. About 2,000 Medicaid adults with diabetes will be asked to participate.

The other networks of Community Care will get the usual treatment, and Velez and his colleagues will determine whether the screening indeed reduces blindness among patients with diabetic retinopathy because ophthalmologists can act early. Diabetes can lead to changes in blood vessels in the retina called diabetic retinopathy.

Digital photography is the key to the proposal. Trained nurses will take retinal photographs using a special digital camera, and the digital images will be transmitted over the Internet and read at a new screening center at Wake Forest University School of Medicine, Velez said.

The project is being supported by a $465,034 grant from the Duke Endowment to establish the reading center; a $456,203 grant from the Kate B. Reynolds Charitable Trust will pay for the screening in the two networks, and the North Carolina Rural Health Foundation will pay for evaluation.

Velez said Medicaid data would be used to follow the patient outcomes in both the screening group and in the controls.

"Adults with diabetes continue to go blind despite the availability of effective treatment for sight-threatening diabetic retinopathy," said Velez. "These cases of blindness are partially attributable to the low levels of screening. Screening identifies changes in the eye that the patient may not recognize. If treated early, blindness can be prevented."

But, he said, among Medicare patients who have diabetes, more that 30 percent do not get the recommended annual eye screening examination by ophthalmologists. The rate of screening among N.C. Medicaid patients is about 14 percent.

"Primary care physicians rarely perform dilated eye examinations, and the reliability of their examination has been shown to be low," said Velez, a professor of medicine at Wake Forest University School of Medicine and a primary care physician himself. "A recent review of diabetic patients at the Downtown Health Plaza showed that fewer than 20 percent reported having been to an ophthalmologist in the previous three years."

He said that taking retinal photographs in primary care settings is a potential alternative to early testing by ophthalmologists. He said that early trials using film or Polaroid cameras had been effective.

"The recent development of digital retinal photography has spurred a movement to employ this new technology with images transmitted by the Internet to central reading centers," Velez said.

He said that in the pilot testing stage, the team is using a Canon retinal camera, acquired through a grant from the North Carolina Lions Foundation. A diabetic retinopathy reading center is being established at the School of Medicine in cooperation with the Department of Ophthalmology. William P. Moran, M.D., formerly head of the Section on General Internal Medicine, is co-investigator.