The document discusses the importance of broader blindness prevention through early detection and intervention of sight-threatening eye conditions. It presents referral data from EyePACS retinal screening, showing that over 8% of scans detected diabetic retinopathy and nearly 8% detected other conditions like glaucoma and macular degeneration. Recommendations are provided for a protocol to standardized detection and referral of optic nerve, retinal, and macular lesions. Guidelines establish timeframes for emergency, urgent, and moderately urgent referrals for different conditions. Future efforts include validating the protocol, integrating it into electronic records, and connecting treating clinicians.

1. Jorge Cuadros OD PhD
Tara Seymour

2. Significance of Broader Blindness
Prevention in Our Clinics
 Diabetic retinopathy is the main cause of
blindness in working age adults, but not
in all adults.
 More people will become blind from
macular degeneration and glaucoma.
 The majority of blindness could be
prevented with early intervention.
 Many sight-threatening conditions have
been detected and referred through
EyePACS

3. EyePACS Referrals
 8.21% of all EyePACS consults resulted in
referral for sight-threatening diabetic retinopathy
 7.83% of all EyePACS consults resulted in
referral for other sight-threatening conditions
 Glaucoma
 Cataract
 Maculopathy
 Papillopathy (optic nerve)
 Pigmented lesions
 Retinal degeneration

4. How Does Your Clinic Handle Eye
Referrals?
 No time frame given – all eye referrals
generally treated the same
 Urgent referrals (within 2 days) made with
sudden decreased vision or ocular pain; all
other referrals generally treated the same
 Clinic is able to differentiate conditions
requiring within 1 month from conditions
requiring referral within 2 days

5. What Is The Average Waiting Time For
Eye Care Referrals From Your Clinic?
 Less than one week
 One week to less than one month
 One month to less than three months
 Three months to less than six months
 Six months or more
 I don’t know how long my patients wait to see
an eye care provider.

6. The Challenge of Referral for
Other Conditions
 The retinal consult does not take the place
of a full eye exam.
 Sensitivity and specificity of referral based
on electronic consults have not been
validated for other conditions
 Disagreement about when to treat, when to refer
 Excessive variability in consultant
recommendations
 Less effective treatment
 Excessive over-referral

7. Scientific Committee
Recommendations:
 Purpose: Identify patients with sight-
threatening conditions.
 Develop protocol for acquiring necessary
information and images for consistent and
easily adapted detection system.
 Retinal image interpretation protocol for
identifying significant lesions in:
 Optic nerves
 Retinas
 Maculas

8. Optic Nerve Lesions
 Signs of glaucoma:
 Asymmetric cupping: greater than 0.2 dd cupping difference between the two
eyes
 Enlarged cup: optic nerve cupping equal to or greater than 0.7
 Rim notch or thinning: notch in or thinning of optic nerve tissue extending to edge
of the optic nerve or disproportionate thinning of rim tissue in inferior or superior
sections of optic nerve
 Optic nerve/Splinter hemorrhage: flame shaped hemorrhage near or at the rim or
in the substance of the cup
 Nerve fiber layer defect (NFLD): NFLD occupying greater than 10 degrees of arc
in the inferior or superior arcuate areas
 For screening purposes, referable glaucoma is considered sight-threatening,
well-established glaucoma that is likely to be treated immediately. Low risk
glaucoma suspects would not be referred from this protocol.
 Prominent pallor:
 pale optic nerve without cupping not previously identified
 pale swelling of segment of optic nerve with or without hemorrhage
 Papilledema:
 swollen, hyperemic disc with blurred margins in one or both eyes

9. Retinal Lesions
 Moderate/Severe nonproliferative diabetic
retinopathy (NPDR), as defined by the
International Clinical Diabetic Retinopathy
Disease Severity Scale
 Neovascularization
 New vessels or diabetes-related fibrous proliferation
anywhere
 Vitreous hemorrhage or pre-retinal hemorrhage
 Invasive lesions: eg melanomas
 Neovascularization of the iris
 Active retinitis: active retinal inflammation
 Retinal detachment (recent onset)

10. Lesions of the Macula
 High-risk drusen (large, soft drusen) especially
associated with:
 Pigment migration
 Geographic atrophy not involving the foveal center
 Disciform scar or prior chorodial neovascularization
 Macular edema, not clinically significant: hard
exudates within 2 disc diameters but more than one
disc diameter from the fovea
 Clinically Significant Macular Edema (CSME): hard
exudates within one disc diameter of fovea
 Subretinal neovascularization
 subretinal hemorrhage or lipid exudate with hemorrhage
within the arcades
 wet macular edema-intraretinal hemorrhage involving the
fovea
 cystoid macular edema with blood in cysts
 subretinal pigment epithelial blood (drusen visible over the
hemorrhage)

11. Other Referral Criteria
 Visual Acuity < 20/40
 Acute onset of pain and/or vision loss
 *Intraocular pressures
 *Initiation of systemic treatments
associated with vision loss:
 Hepatitis C treatment
 Plaquenil / quinine derivatives
 Steroids
 * Not part of the Prevent Blindness Northern
California Protocol

12. PBNC Referral Guideline
 Emergency Referral – 1-2 days:
 papilledema
 recent onset retinal detachment
 neovascularization of the iris
 active retinitis
 subretinal neovascularization
 acute vision loss
 acute onset of pain

13. PBNC Referral Guideline
 Urgent Referral (within 1 month)
 pale swelling of optic nerve or segment of optic
nerve (with or without hemorrhage)
 neovascularization
 clinically significant macular edema
 possibly invasive lesion
 Moderately Urgent Referral (within 6 months)
 retinal and optic nerve features blurred in all views,
with VA less than 20/40
 obvious glaucoma
 moderate to severe non-proliferative diabetic
retinopathy
 high-risk drusen

14. PBNC Referral Guideline
 Pass
 clear media; retinal and optic nerve features clear
 optic nerve margins sharp, vessels easily visible,
pink rim, less than 0.5 dd cup in both eyes
 retinal vessels visible and sharp, normal diameters,
no hemorrhages or pigmented lesions, minimal
microanerysms
 foveal reflex present, minimal drusen, no
hemorrhages, flat or pitted
 Non-Readable
 Unreadable photos will not be used to initiate
referrals; other screening results will be used instead

15. Future Efforts
 Validation of protocol
 Primary care provider certification for triage
purposes
 Automation and integration into electronic
medical records and referral systems
 Connect treating clinicians with EyePACS
cases
 Automated patient alerts
 Using retinal images for identification of risk
factors and biomarkers of systemic disease
 Validation of new technology and automated
algorithms