Blood pressure, A1C testing can help patients from ‘falling through the cracks’

Understanding the importance of laboratory testing in relation to ocular disease is crucial, according to Bruce E. Onofrey, OD, RPh, FAAO.

“It’s essential to know what tests we need to order and what the values really mean,” Onofrey said in an interview with Primary Care Optometry News. “It’s for the primary care physician’s benefit as we send patients to them.”

Scott A. Edmonds, OD, FAAO, told PCON that if an optometrist has a reason to suspect a systemic issue in a patient, such as a high body mass index, elevated blood pressure, cholesterol build-up in the retinal vessels or any sign that would indicate further testing, it is well within the optometrist’s scope of practice to order tests when appropriate.

“We measure blood pressure in the office and we look in the eye to directly evaluate the retinal vasculature, which includes measuring the A/V ratio. No one else is in a position to do this level of observational testing for vascular disease. We look for risk factors,” Onofrey said. “Blood pressure is one of those things that should be performed by any health care provider. Anyone who is against that isn’t considering the patient’s best interests.”

Edmonds added that geography will affect the optometrist’s role in lab testing.

In an urban area, if the optometrist sees suspicious findings, Edmonds recommended asking a patient if he or she has a primary care physician and whether they have been tested for early diabetes, hypertension or cholesterol problems.

In a more rural setting, patients have an increased likelihood of only regularly seeing their optometrist. From a health standpoint, patients need and want to be able to maintain their vision, Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, said in an interview.

“We have a satellite office in a rural community, and there is no medical doctor there, but there is a nurse practitioner part-time,” Skorin said. “If I see something suspicious in a patient, I will more readily order the lab work there than in our urban location, where a patient is more likely to have a family physician.”

Optometrists in most states can order tests such as fasting blood sugar, lipid profile or A1C, Edmonds said.

“If you receive abnormal results, you then have a tool to tell the patient that this is a real, concrete situation and they need medicine,” he said.

“In Kentucky and Louisiana, where scope of practice laws are broad enough for optometrists to treat patients — while these laws haven’t been spelled out — ODs can order medicine for hypertension, diabetes and cholesterol, as those conditions broadly affect the eye,” Edmonds continued.

“Whether it’s an OD, nurse practitioner or physician’s assistant, anyone who gets their eyes on the patient should be involved in these types of systemic issues. Without it, this is how patients fall through the cracks,” Onofrey said.

Diabetes

Onofrey suggested optometrists start with diabetes, or metabolic syndrome.

Diabetes is the major systemic disease dealt with from an ocular health standpoint, he said. Patients are at risk for elevated glucose, blood pressure and lipids, in addition to secondary issues, such as renal failure, stroke, heart failure and vision loss.

The hemoglobin A1C test is not meant to diagnose, but it determines patient risk, according to Onofrey.

“If the results are elevated, you certainly have to consider further testing and sending the patient to a PCP,” he said.

If a patient does not know their A1C level, they are not practicing regular monitoring and are not taking care of themselves, according to Brian P. Den Beste, OD, FAAO.

He said the test can be completed before or after meals, and the value should be 6% or less.

In the case of a family history of diabetes and hypertension, where the patient has a family medicine doctor, Skorin recommends contacting that doctor to let them know the findings.

“We give the guidelines to the PCP but, usually, they will go ahead and do the tests,” he said.

When a patient lacks a PCP, Skorin says it behooves the optometrist to order the primary work-up.

“Doing so, the optometrist becomes the conduit for health care for the patient,” he said.

Den Beste looks at the optometrist as a health care cheerleader or first-line advocate for the patient to help them understand that what they do directly correlates with how they feel and how they see.

A fasting blood glucose at less than 100 mg/dL is normal, 100 mg/dL to 125 mg/dL is considered prediabetes, and 126 mg/dL or higher is considered diabetic, according to guidelines from the Mayo Clinic. In the last case, the glucose should be tested twice for confirmation.

Onofrey recommends ordering a basic metabolic panel, which includes seven different tests such as renal function, liver function and electrolytes, providing much information about a patient’s general health.

At Optometry’s Meeting in June 2016, Edmonds said he attended a course sponsored by the American Optometric Association and the Johnson & Johnson Diabetes Institute on the role of optometry in diabetes care. Optometrists were taught how to do glucose readings in the office. The attendees wore a diabetic pump and practiced with a glucose monitor device, performing a finger stick.

Most states allow optometrists to perform glucose readings, he said.

“You put a drop on a strip and insert it into the glucometer and you get a reading,” he said. “The number can be either abnormal or normal, based on the timing of the last meal.”

Although simple to perform and providing invaluable information, there will be resistance, Edmonds explained.

“ODs aren’t used to doing these things,” he said. “We can’t say that everyone should do it, and you need proper training, but it is an important direction for optometry.”

Hypertension

Elevated blood pressure is the second arm of metabolic syndrome. Normal blood pressure is considered 120/80 mm Hg, and anything above 140/90 mm Hg is considered hypertension, at any age group, and probably requires treatment, Onofrey said.

He explained that JAMA and the American Heart Association differ on these levels; 150/90 is adequate according to JAMA, but the American Heart Association says 140/90 mm Hg is reasonable for people up to the age of 80 years.

Sripal Bangalore, MD, MHA, FACC, FAHA, FSCAI, director of complex coronary intervention at the Bellevue Cath Lab, and associate professor of medicine at New York University School of Medicine, said that anyone with blood pressure greater than 140/90 mm Hg should be referred to a primary care physician or a cardiologist.

He stressed that blood pressure must be taken correctly. He highlighted his own experience at his ear, nose and throat doctor, where his blood pressure produced an unusually high reading because it was measured incorrectly.

“When I directed them to their mistake and it was measured again, I was in the normal range,” Bangalore said.

Incorrect measurements can lead to anxiety and over-treating, he said. He noted that barbershop screenings have been shown to improve patient knowledge and physician referrals for hypertension.

“It is increasingly recognized that automated arm cuffs are better, with reduced interobserver variability,” Bangalore added. “Although wrist monitors can be used, the preference would be for automated arm cuffs.”

If a patient is pre-hypertensive, Skorin recommends that blood pressure is re-checked in 6 months. If blood pressure is 160/100 mm Hg to 180/110 mm Hg, the patient should be seen by a specialist that same month, and if it is 181/111 mm Hg or higher, they should be taken to the emergency room.

His staff will call primary care physicians the same day if a patient presents with a higher pressure than usual, to discuss the reading and so the PCP anticipates the patient visit.

“If you see changes in the retina, which is indicative of end organ damage, communicating that would be extremely helpful,” Bangalore said. “There is a lot that can be done with that kind of feedback for people to achieve blood pressure and cholesterol control. That kind of a closed loop would help and can have a positive impact on patient outcomes.

“I think it’s extremely important, especially since the optometrist is involved in the totality of care for a patient,” he added.

In light of the physician shortage, Edmonds believes ordering laboratory testing can be a proactive way to offer better care. He cites statistics from the Association of American Medical Colleges that claim the shortage is not improving and will worsen through the next decade.

Medical schools cite not having enough open slots to train doctors to meet the need, he added.

“When a patient’s test results come back positive, and you want to make a referral but there are still barriers to getting a patient to a physician, the optometrist can initiate treatment in progressive states like Louisiana and Kentucky. This is going to be the way of the future, where an OD can order a first-line blood pressure medicine. This is often the same medicine that we have safely prescribed in a drop for our glaucoma patients,” Edmonds said.

Beta-blockers are a common medication for hypertension and are also prescribed for glaucoma, he noted.

“We have many years of experience of prescribing beta-blockers for patients. We know the risks and side effects,” he said.

Den Beste noted that many patients do not wish to take another medication, claim they are taking too many or have read something negative about it and are afraid.

“We live in a day where patients take out of the literature and social media what they want to hear,” he said. “You’re constantly seeing something on your computer, telling you not to be eating grains or you should be taking this, etc. Patients get lambasted with different views and sometimes they decide not to take any medication.”

When he finds retinal vascular changes consistent with elevated cholesterol, he will tell a patient that it is not harmful now, “but it makes me think your carotid arteries are having trouble or your lipids are too high,” he said. “And that’s not why you’re here today, but it wouldn’t be right to not tell you about it.”

Criticism

Many optometrists do not want to look at vital signs and blood pressure, Edmonds said.

“If an optometrist doesn’t look at vital signs, a patient cannot say that you missed something during an exam,” he said.

In 2015, March Vision Care, where Edmonds is the chief medical officer, instituted vital signs as a required element for Medicaid members. Soon after, a petition was filed against him claiming that this was beyond the optometric scope and not what optometrists wanted to do.

He said the petition failed, and the required element remained and went on to be an important aspect of primary care for Medicaid members.

“I think patients almost anticipate vital signs and testing from anyone they may see,” Skorin noted. “My dentist takes my blood pressure, and I’ve talked to podiatrists who monitor blood sugar.”

“There aren’t many of me out there singing this song, but from a public health standpoint, I think it’s critical,” Edmonds said. “We need to get serious about systemic medical problems. We know that they all lead to eye disease down the road, so you don’t need to wait until you have diabetic retinopathy to start talking about treating disease.”

The overarching principal is that health care professionals are sending patients the same message.

“We aren’t going to be the primary people treating these diseases, but we need closer relationships with the physicians who are,” Edmonds said. “Give the care that makes sense at the time and do not be afraid to refer it out.”

By proactively examining a patient’s systemic health, optometrists have the potential to increase patient knowledge and medication compliance, according to these experts.

The fact remains that patients may pay attention once they know their vision is at risk. – by Abigail Sutton

• References:
• Diseases and Conditions: Diabetes. Mayo Clinic. Accessed: Sept 22, 2017. http://www.mayoclinic.org/diseases-conditions/diabetes/basics/tests-diagnosis/con-20033091.
• New research confirms looming physician shortage. AAMC. Accessed September 23, 2017.https://www.aamc.org/newsroom/newsreleases/458074/2016_workforce_projections_04052016.html.

• For more information:
• Sripal Bangalore, MD, MHA, FACC, FAHA, FSCAI, is director, complex coronary intervention, Bellevue Cath Lab; director of research, cardiac catheterization laboratory; director, cardiovascular outcomes group; associate professor of medicine, New York University School of Medicine; and principal investigator ISCHEMIA-CKD trial. He can be reached at: Sripal.Bangalore@NYUMC.org.
• Brian P. Den Beste, OD, FAAO, has been providing consultative eye care and optometric education to both practitioners and optometric externs in Orlando, Fla., since 1987. He is currently president of LP Eye Consultants and can be reached at: besteyedoc@aol.com.
• Scott A. Edmonds, OD, FAAO, is the chief medical officer of March Vision Care, the co-director of the Low Vision/Contact Lens Service at Wills Eye Hospital in Philadelphia and a member of the Primary Care Optometry News Editorial Board. He can be reached at: Scott@EdmondsGroup.com.
• Bruce E. Onofrey, OD, RPh, FAAO, is professor and executive director of continuing education programs at University of Houston School of Optometry and a member of the PCON Editorial Board. He can be reached at: BOnofrey@Central.UH.edu.
• Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, practices at the Mayo Clinic Health System in Albert Lea and Wells, Minn., and is a member of the PCON Editorial Board. He can be reached at: Skorin.Leonid@Mayo.edu.

Disclosures: Bangalore, Den Beste, Onofrey and Skorin report no relevant financial disclosures. Edmonds is a consultant for March Vision and OcuHub.