Ocular and retinal health are not usually considered part of primary care, but given the high and rising incidence of diabetic retinopathy, macular degeneration, and other serious eye disorders, more primary care doctors ought to be looking their patients directly in the eye.
A company called Retasure is making that a whole lot easier, with new retinal imaging technology that enables primary care physicians (or their clinical support staff) to provide thorough and accurate in-office retinal exams.
Retasure’s system is built around a state-of-the-art digital fundus camera that is easy to operate, and does not require dilation of a patient’s pupils. The process is painless, only takes a few minutes, and provides detailed high-resolution images of the retinal vasculature, nerves, macula, and optic discs.
The camera is connected to a dedicated computer system that adjusts and focuses the camera and also stores the images, which are transmitted via secure HIPAA-compliant connections to an ophthalmologist of the physician’s choosing or a member of Retasure’s network of ophthalmologist/optometrist readers.
Less Retinopathy, More Revenue
Though it can pick up a range of abnormalities, it is specifically designed to detect diabetic retinopathy, the number one cause of blindness among working-age adults. According to the American Diabetes Association, nearly 50% of all people with diabetes have some degree of retinopathy at time of diagnosis. Current guidelines recommend that diabetics get a retinal exam every year; those at high risk for diabetes should also be scanned frequently, as retinal deterioration begins long before it causes vision problems.
Retasure’s system creates a win for patients, by eliminating the time, energy and money spent on separate ophthalmologist visits. It benefits primary care physicians by enabling them to offer a service—and capture a revenue stream—that until now they’ve been farming out to specialists. And, it opens up a wide window for prevention, or at least, early detection of serious eye disease.
“We’ve picked up a lot of stuff: glaucoma, diabetic retinopathy, retinal changes secondary to uncontrolled hypertension, a number of serious eye problems,” said Randy Beckett, DC, FNP, a nurse practitioner and clinical manager of the Harvest Free Medical Clinic (HFMC), in Charleston, SC. Retasure has become an important new feature in the clinic’s spectrum of services.
“When you have to send people across town, and they have to take time off from work or their families, and they have to come up with a co-pay, compliance with retinal exams goes way down. If you can do it right on site during a primary care visit, it’s easy, and it gets done,” Mr. Beckett told Holistic Primary Care.
A Novel Practice Model
The Harvest Clinic, directed by family physician Dr. Bob Freeman, provides free, comprehensive care to indigent residents of Charleston. It is staffed entirely by medical volunteers drawn to the clinic’s core mission of caring for the poor. Combined, they handle about 6,500 patient-visits per year.
Dr. Freeman, who initially ran HFMC out of a van, is now able to provide broad spectrum care in a stable clinical setting through a unique synergistic relationship with Dettens Shipyards (pronounced “Detyens”), one of the nation’s few remaining ship refurbishment companies. Dettens covers the clinic’s operating costs, in exchange for which the clinic provides care for Dettens employees.
In both patient populations—the Dettens employees and the indigent visitors to the free clinic—prevalence of obesity, metabolic disorders, cardiovascular disease, and diabetes is high. “We see some of the sickest of the sick,” said Mr. Beckett. A large percentage of the patients are at risk for retinopathy.
Thanks to the advocacy of ophthalmologist Charles Beischel, who was among the physicians volunteering for Harvest, Dr. Freeman and his colleagues decided it made sense to bring the retinal exams in-house, rather than continuing to send patients to ophthalmologists.
A Simple Technique
“It’s really not hard to learn how to do this. The basic training takes about 4 hours. It is something a nurse or physician assistant can easily do, and since you don’t have to dilate the pupils, the patient doesn’t have to walk around with visual disturbance for hours,” Mr. Beckett said.
Dr. Beischel and his wife, an ophthalmology technician do the retinal readings for HFMC, but in most other clinics that use Retasure the images are sent to Retasure’s readers, who return a complete analysis and interpretation report within 72 hours.
Mr. Beckett noted that HFMC recently partnered with the University of South Carolina Medical School to host a “Save Your Sight Day” that included retinal exams for medical students, residents and others in the community. “We picked up a lot of stuff,” he said, underscoring the point that retinal damage can be indolent for many years before it robs someone of his or her vision.
The package cost for the Retasure camera & computer system plus training, connection to the secure server, and practice support, is approximately $25,000. Most insurance plans do reimburse for retinal exams under the 92250 “color fundus photography” code. Reimbursement varies from plan to plan, but ranges from $60 to $250 per patient encounter.
By enabling primary care clinics to do retinal exams, Retasure might appear to be “redistributing” the ophthalmologists’ wealth. In reality, ophthalmologists will benefit too. The truth is, many patients sent for retinal exams never get to ophthalmologists, owing to the inconvenience or cost. By doing the exams themselves, primary care doctors pick up patients with retinal disease who might have never gotten a retinal exam, but who will need ophthalmologic follow-up and treatment.
Retasure, developed by a British company called Digital Healthcare (www.digital-healthcare.co.uk), has been used on more than 4 million patients worldwide since it’s launch in 2000. It has been validated by the University of Wisconsin research team that led the Early Treatment Diabetic Retinopathy Study (ETDRS), and set the clinical standards for diabetic retinopathy detection and treatment.
It is now in use at leading medical centers including Case Western Reserve University and the Wilmer Eye Institute at Johns Hopkins University, as well as in the clinics of roughly 1,000 primary care doctors in the US.
More to Vision Than Meets the Eye
“Vision accounts for 90% of everything a person learns in their lifetime. It is also the foundation of connection, and a cornerstone of presence as well as intimacy,” says optometrist Jacob Liberman, a visionary in the field of eye health and light/color therapy. In his view, healthy vision is much more than good acuity and absence of degenerative disease.
“Think of vision as the body’s guidance system, a portal through which the outside world is received and comprehended.” The ability to see is clearly, of course, very important. But equally important is what one is able to do with what comes in through the eyes.
A 3D Stereoscopic Reality
There are four basic components of seeing: aiming, focusing, tracking, and eye-teaming. “Life is always moving, and the eyes need to move continually. They are wedded to the movements of life. This is what allows responsiveness. Focus leads to clarity, understanding, and the ability to respond appropriately and gracefully to the challenges of life.”
We have two eyes for a reason: each sees a different perspective. The visual processing centers of the brain take these two perspectives and synthesize them into a meaningful 3D stereoscopic reality. “Binocular vision is the crown jewel of creation. It is an exquisitely complex system that guides the whole human energy system.”
Conventional thinking posits that common vision problems are due to irreversible abnormalities in ocular morphology. “What we weren’t taught is that the morphology of the eyes can change. Ocular morphology, like all tissue morphology, is highly plastic and adaptive (or maladaptive) to life conditions.”
People who spend most of their time indoors, in front of computers or TV screens and under artificial lighting put tremendous strain on their visual systems which are made for open spaces, large depths of field, frequent shifts between nearfield and distance viewing, and diurnal variation in light and dark.
A chronically constricted visual field begets muscle tension, vasoconstriction, shallow-breathing, emotional stress and fatigue. Over time it can distort the shape of the eyes, and lock the muscles controlling them into very tight patterns. It is, therefore, very important that people working in such conditions go outside periodically for eye breaks.
Visionary & Validated
Dr. Liberman is the creator of the EyePort Vision Training system (www.exerciseyoureyes.com), an easy to use and affordable tool for reversing vision abnormalities and reducing the need for glasses or contact lenses. The device takes the eyes through a brief but diverse sequence of exercises designed to improve focus, tracking and acuity.
“Training the eyes is training the entire nervous system. Five 90-second sessions per day can make a huge difference. It’s really pretty easy,” he told Holistic Primary Care. “It increases the speed with which the eyes can change focus and depth of field. This improves the speed and span of perception.”
EyePort has been the subject of 4 clinical studies. All show significant improvement on multiple visual performance measures with as little as 10 minutes of exercise per day for three weeks. Two studies involved college students who showed increases not just in visual acuity but in overall attention, an important finding since the study included kids with ADHD (Laukkanen H, Rabin J. Optometry. 2006; 77: 508-514).
“The dogma is that after age 18, you can’t significantly improve comprehension. We’re seeing significant increases in reading efficiency and comprehension in adults. The nervous system has far greater plasticity than previously thought. People take the eyes as separate from the brain. They’re not!”
A third study involved 12-year-old Little Leaguers, “from the losing-est teams in our area!” After 3 weeks of daily practice with EyePorts, the kids were pitted against pitching machines. Each kid was told to strike at 40 consecutive curve balls pitched at 50 mph. “The number of hits improved by 90% on average, and this team went on to win a division championship,” said Dr. Liberman. As an added benefit, several kids reported improved school performance (Bowen T, Horth L. J Behav Optom. 2005; 16: 143-148).
The system was also tested by the Maui City Police Department. Officers undertook visual training for 3 weeks, followed by testing of license-plate recognition in simulated night conditions. “We sat them in a totally black room, 7-10 feet from a wall on which were flashed 6-digit/letter license plates—at 1/100th of a second.” There was a significant increase in the number of digits the officers saw accurately (Liberman J, Horth L. J Behav Optom. 2006; 4: 87-92).
In the future, Dr. Liberman hopes to undertake large “gold standard” trials to determine whether EyePort can prevent vision deterioration in children with significant impairment, and whether it can eliminate or retard the need for glasses in people over 40. His many years of clinical work as well as his own personal experience indicate that these are obtainable goals.
From childhood, Dr. Liberman was plagued by severe near-sightedness and astigmatism. In college, reading became very difficult and the condition worsened with each prescription increase. But this engendered a deep interest in vision.
In optometry school he began experimenting with vision exercise systems, with the aim of reducing his prescription strength. “I would reduce it by 5-10%, then continue vision training and only use the glasses when I was driving or examining patients.” Eventually, he was able to wean himself off glasses altogether. That was 34 years ago, and he hasn’t worn glasses since.
Over the years he has helped thousands of people—children to seniors, office workers to high-performance athletes—improve their ability to see. In many cases, they have been able to eliminate the need for glasses. “We need to redefine what it means to see. Vision is intimately connected with awareness, attention, learning, self-worth, interpersonal connection, and realization of one’s full potential.”
For more on ocular health, subscribe to our Premium Web Access and read our online-only article about Dr. Liberman’s work with light, color and circadian rhythms.)