Rates of vision loss from diabetic retinopathy (DR) have risen over the past 30 years. In response multiple new glucose lowering diabetes medications have been developed such as incretin mimetics and enhancers, sodium-glucose cotransporter inhibitors, long-acting insulins, and insulin delivery systems. While they show promise in tighter glucose control, they do also come with potential side effects. New therapies for diabetes have potent effects on glycemic control, obesity, and cardiovascular risk reduction, but some, including the popular semaglutide class of drugs, have also been implicated in worsening of DR. Given the rise in popularity of these drugs such as Mounjaro, Ozempic, Zepbound, Rybelsus, and Wegovy, understanding the risks to vision is important. With Ozempic use about 10-20% of patient’s retinopathy and macular edema worsen. Patients on semaglutide therapy are also at a higher risk of nonarteritic anterior ischemic optic neuropathy (NAION).
With the risks of worsening DR and vision loss that these medications carry, it’s important to build a screening program that protects your patients, your business liability, and your bottom line. Retina screening with handheld devices is easier and more affordable than ever. And many pharmacies and healthcare systems find slotting them in beside the other battery of tests offered one of the best decisions they have made.
Medicine Side Effects that Increase DR Risk
Medications are a valuable resource to help people get well from their illnesses, but they are also dangerous when given in the wrong circumstances. Every medicine has risks for side effects. It’s the duty of all healthcare providers involved in a patients’ care to ensure that these risks are fully explained to the patient and to monitor their patients for these possible side effects.
A pharmacist is responsible for providing the best care for patients. Mistakes with prescribed drugs can be dangerous and even deadly. If a prescription medication is given that causes an adverse reaction in the patient, the pharmacist may be held liable along with or instead of the prescribing doctor. Negligence must be determined on the part of the pharmacist.
With improved blood sugar and A1C, we typically see diabetic retinopathy and macular edema improve over time. However, early worsening of DR following tight glycemic control is a well‐described phenomenon evident in patients with type 1 and type 2 diabetes, in those who have undergone bariatric surgery and in pregnant women. It does not appear to be agent‐specific as it has been described in patients receiving diverse treatments, including intensive insulin therapy, sulphonylureas, thiazolidinediones, and GLP‐1 agonists. This risk is also included warning labels for insulin but the rapid improvement in HbA1c seen with GLP-1 agonists may pose additional risks.
Ann A. Giaconi, MD, at the Greater Los Angeles Veterans Administration and the Stein Eye Institute at the University of California, Los Angeles (UCLA) discusses this treatment paradox in an article from the American Academy of Ophthalmology EyeNet magazine. “The VA in Los Angeles recently made a GLP-1 formulary switch to semaglutide, which is great for glycemic control, but it worsens existing diabetic retinopathy. I have clinicians asking me whether to switch patients back to their old diabetes drugs” Giaconi notes.
But she still sees the long term, and whole health benefits to these treatment regimens if used alongside close patient monitoring.
“Semaglutide produces an impressive drop in blood sugar and hemoglobin A1c, so in patients for whom other medications cannot achieve control, it’s an important drug, because controlling blood sugar helps patients in the long run.
Expanding the Eye Care Specialist
With only about 11,000 ophthalmologists serving the entire US, and 38 million Americans with diabetes, expanding screening reach is an important task. Screening at non-ophthalmology appointments has been shown to increase adherence rates by those needing eye care specialist referrals by 37% compared to historical averages. So why aren’t more non-ophthalmology settings like Primary Care and Pharmacy not adopting these screening practices more readily? Rithwick Rajagopal, MD, PhD, an associate professor of ophthalmology and visual sciences at Washington University in St. Louis, St. Louis, Missouri discussed several barriers to the broader adoption of diabetic retinopathy screening in primary care in the October 24, 2024, Internal Medicine News article titled “Diabetic Retinopathy Poses a Threat to More Young People’s Sight.
“First is unfamiliarity with eye anatomy and physiology, which is associated with low level of comfort in capturing the photographs and interpreting the results (even though the cameras are increasingly easy to use, and that the AI software generates the diagnosis),” Rajagopal said. “Despite the above concerns, point-of-care screening offers a powerful solution to a long-standing problem: People with diabetes in this country are generally not adherent to recommended retinal screening guidelines. There are multiple causes of such poor adherence but point-of-care screening solves several of them: No need to take time off for an additional medical visit, no additional co-pay for eye doctor visits, and no need for dilation in many cases.”
A Plan in Place for Expanded Point of Care Testing
Pharmacies are emerging as a more holistic role in patient care. In addition to dispensing and managing prescription medications, pharmacies are now including services such as:
- Immunizations
- Pharmacist-led weight-loss programs
- Medication therapy management
- Adherence packaging & medication synchronization
- Point-of-care testing
- Blood Pressure (BP) Screening
- Flu Tests
- Cholesterol Screenings
- Strep Tests
- Respiratory Syncytial Virus (RSV) Tests
- Hemoglobin A1C Testing
- COVID-19 testing
In his peer reviewed article in Retina, Dr. Rajagopal also recommends widespread retinal screening before starting novel antihyperglycemic medications and suggests that point-of-care retinal screening assisted by artificial intelligence technologies may greatly aid such efforts.
Aiding in the adoption of this service is the Current Procedural Terminology (billing) code 92229 the American Medical Association introduced in 2021 for diabetic eye exams when ordered by a physician who is not an ophthalmologist. Medicare, many commercial health plans and state Medicaid programs now cover this service. And by simply billing this code any time during the measurement year meets HEDIS standard C09 (Eye Exam for Patients with Diabetes).
It is recommended for physicians to ensure patients are screened for DR before initiating semaglutide and on the basis of the stage of retinopathy, physicians and retina specialists need to discuss the risk benefit ratio in initiating the treatment.
The Aurora AEYE is a handheld non-mydriatic fundus camera that uses an cleared Machine Learning algorithm to screen for DR in a single image per eye in under a minute. Sensitivity (92%-93%), specificity (89%-94%), and imageability (over 99% of patients received a diagnostic result), are all very strong with the Aurora AEYE. Clinical and real-world studies have shown that Optomed Aurora camera platform is as effective as standard desktop fundus cameras in DR and diabetic maculopathy detection and has already been successfully implemented in DR screening programs. Meta-analyses of clinical trials with AI DR screening vs human graders showed that most AI screening programs are more economically efficient than traditional screening approaches for DR.
Expand your service offerings, improve patient safety, and make the intelligent choice with Aurora AEYE. Contact us today for a demo of the Optomed Aurora AEYE.
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