Scott A. Edmonds, OD, FAAO, focuses his blog on the role of the optometrist in health care reform – moving from primary eye care to primary health care. He is the chief medical officer of MARCH Vision Care, the co-director of the Low Vision/Contact Lens Service at Wills Eye Institute in Philadelphia and a member of the Primary Care Optometry News Editorial Board. 

Disclosure: Edmonds is a consultant for March Vision.

BLOG: Optometry’s role in assessing vascular risk

A new study was recently published in JAMA Neurology by Lane and colleagues in London on the relationship between vascular risk factors in adulthood and brain pathology in later life.

This prospective study was done with a British cohort called Insight 46 and had 463 subjects born on the same week in 1946. The researchers looked at heathy, dementia-free subjects and the “vascular burden” defined as hypertension, obesity, diabetes and smoking.

The subjects were evaluated at ages 36 years (young adulthood), 53 years (mid-life) and 69 years (early late life).

The subjects were evaluated between ages 69 and 71 years for nonamyloid dementia with MRI and other neurologic testing. The study found that vascular risk was strongly associated with smaller whole-brain volume and greater white matter–hyperintensity volume, hallmarks of nonamyloid dementia. The strongest association was found with vascular risk in early adulthood. In light of these results, the authors recommended reducing vascular risk with appropriate interventions in early adulthood to maximize late-life brain health.

This study has strong implications for optometry and fuels our evolution from the eye care silo to primary health care. The prevalence of dementia in the U.S. is 13.9% (Plassman et al.). The prevalence of glaucoma in the U.S. is only 2.1% (Gupta et al.). Yet optometrists spend most of our medical time and energy testing, scanning and measuring the eye in the hunt for glaucoma. Even this all-consuming ocular disease is affected by the vascular risk factors (Orzalesi et al.).

Optometry has unique access to patients in early adulthood. People in this age group are beyond pediatric and developmental health problems and are not yet showing any signs or symptoms of age-related pathology. Unless injured or sick, they seldom see a health care provider. If, however, they have a refractive error, they often wear glasses or contact lenses and visit their optometrist on a yearly basis.

Optometrists also have unique access to the vascular system. As eye care providers, we routinely look directly at the retinal blood vessels. Historically we looked with the direct ophthalmoscope through an undialed pupil. We then evolved to looking through a dilated pupil and with fundus lenses that allow for a stereo view, with the addition of variable magnification at the slit lamp. Today we use scanning lasers and can view and measure the blood vessels and even see the capillary bed.

In spite of this exquisite access to study the vascular system, the examination is not helpful in a vacuum. A detailed history that includes background, family and social habits as well as measurement of the vital signs puts the vascular examination in context. The addition of fingerstick blood testing when indicated provides a complete assessment that will guide the optometrist to develop a treatment plan for each patient.

When working with the young adult population, the treatment plan should include lifestyle changes that can alter the modifiable risk factors. Although some optometrists have embraced in-office health and wellness programs, most should refer to a formal wellness program. These programs have strategies for weight loss, smoking cessation, diet, nutrition and exercise. Patients who are members of a health plan, in lieu of traditional health insurance, often have a case manager that can guide the member to in-plan covered wellness benefits.

As a profession, we need to look beyond our historic role of correcting vision with glasses or contact lenses. We also need to look beyond our traditional role in the diagnosis, treatment and management of ocular pathology. We need to use our modern tools, our unique access to patients at risk and develop education and interventional programs to help our patients live healthy lives. We have long known that good health is the best way to assure a lifetime of good vision. With this new study, we now know that it relates to mental acuity as well.


References:

Gupta P, et al. Invest Ophthalmol Vis Sci. 2016;doi:10.1167/iovs.15-18469.

Lane CA, et al. JAMA Neurology. 2019;doi:org/10.1001/jamaneurol.2019.3774.

Orzalesi N, et al. Graefes Arch Clin Exp Ophthalmol. 2007;doi:10.1007/s00417-006-0457-5.

Plassman BL, et al. Neuroepidemiology. 2007;doi:10.1159/000109998.