The National Eye Health Education Program is coordinated by the National Eye Institute, National Institutes of Health, Public Health Service, U.S. Department of Health and Human Services. This administrative document may be reprinted without permission.

Fourth National Conference

Gathers Partnership, Cites Achievement

The Fourth National Eye Health Education Conference, held in San Antonio, March 19-21, 1997, gave members of the NEHEP Partnership an opportunity to celebrate the achievements of what is now an experienced educational program. Participants were upbeat as they recalled past Partnership efforts, shared program ideas, and discussed new programs, such as those that will focus on low vision. Plenary speakers reviewed trends in eye health issues and presented highlights from an evaluation of the NEHEP program. In workshops and roundtable discussions, participants discussed strategies that work and ways to meet new challenges.

Partnership and Networking

Noticeable at the meeting was a strong interaction among Partnership members. And this time around, Partnership members were the driving force for the conference's work-shop sessions, bringing their experiences to those discussions of eye health issues and programs. Eve Higginbotham, M.D., a NEHEP Planning Committee member, remarked later, "The NEHEP has developed a greater cohesiveness. At the Hilton Head Conference [in 1991], participants were more cautious and territorial. But there is more sharing today. The San Antonio conference was more interactive. And the Partnership is becoming more effective."

Dorothy Bradford, Ph.D., representing the National Black Nurses Association, participated in one of the roundtable sessions, where she described her local chapter's expanding program to provide eye health education to nursing professionals. She left the conference invigorated, remarking later, "I learned a lot and did a lot of networking. I came back home racing to get caught up with where I want to be."

Edward McManus, deputy director of the National Eye Institute (NEI), attended many of the sessions and remarked, "It was gratifying to see continued and expanded interest by the largest group of Partnership members yet to gather. I witnessed great enthusiasm and many innovative ideas, especially in the areas of low vision and grassroots programs."

Eye Diseases and Issues

The original mandate of the NEHEP was to prevent vision loss from glaucoma and diabetic eye disease by educating people about the importance of regular dilated eye exams. While the Fourth National Conference continued the tradition of focusing on those diseases, speakers were able to place issues in the expanded context of successful educational programs and societal trends.

James McGroarty, M.D., an ophthalmologist and a new member of the NEHEP Planning Committee, presented an historical perspective on diabetic eye disease. He emphasized how the studies of the 1970s and 1980s established the effectiveness of treatments and how educational efforts, such as those of the NEHEP, have begun to influence the behaviors of people with diabetes. He said a message that came through to participants was "When there is a plan, education will lead to results. You can't just hope that it will happen."

Dr. Higginbotham, Chair of the Department of Ophthalmology at the University of Maryland, spoke about early detection for glaucoma. She discussed risk factors and the need for screening methods that are as accurate as possible. Dr. Higginbotham felt that her message was conveyed to the group, remarking, "I received very positive feedback, especially for my message that tonometry alone is not sufficient for detecting glaucoma."

Low vision was the subject of workshops and a plenary session at the Fourth National Conference. Low vision is defined as a visual impairment, not correctable by standard glasses or contact lenses, that interferes with an individual's ability to perform activities of daily living. Donald C. Fletcher, M.D., of the American Academy of Ophthalmology, spoke eloquently of the need for better services for people with low vision, saying, "Humans are quite capable of dealing with low vision. Responding to low vision is not unlike other rehabilitation processes. However, techniques for low vision rehabilitation are still in embryonic stages; we need to develop them. Also, we need to get the word out to older people and their loved ones that low vision can be dealt with, quality of life can be improved. Thus far, we have done a poor job educating people about treating low vision."

Alberta Orr, M.S.W., of the American Foundation for the Blind, stressed the need for professionals to learn about legislation and funding that can support low vision treatment. Eye health professionals and the public in general need to advocate for more services and improved treatment technologies. Ms. Orr noted that vision problems in the elderly account for 80 percent of all vision problems in the United States.

The NEHEP Evaluation

Victor Sierra, Senior Associate at Prospect Associates, a support contractor for NEI, presented the results of the NEHEP 5-year evaluation (see "Evaluating the NEHEP"). The evaluation involved a number of methods for collecting data--from January 1992 to December 1996.

Mr. Sierra reported that the evaluation indicated overwhelming favor with the NEHEP's programs and educational materials. The NEHEP has helped to increase credibility for Partnership organizations and expand their efforts locally. The NEHEP's public service campaigns have achieved widespread distribution.

Workshops

The Partnership organizations orchestrated workshop discussions of the following topics:

• Reaching people with visual impairment.
• Reinforcing the eye health message.
• Lions LEHP into action.
• Reaching people with diabetes--does the setting make a difference?
• Vision and aging.
• Reaching diverse audiences.

Robert E. Kalina, M.D., was called on to moderate the session on vision and aging. Dr. Kalina is the newest member of the NEHEP Planning Committee and a specialist in retinal diseases and professor at the University of Washington. He noted, "We have treatments for these diseases--glaucoma and diabetic retinopathy--which visit the elderly. But today, factors such as a fragmented system resulting from a lack of reimbursement and ignorance of the problems faced by the elderly slow progress." Dr. Kalina's session focused on ways to direct more money and research to the problem of low vision in the elderly and on methods of intervention.

In roundtable discussions, participants developed ideas about evaluating eye health education programs; National Diabetes Month; eye health education in managed care settings; a glaucoma awareness campaign; sharing information; new technologies; developing local networks; and developing a low vision program.

Achievement Awards

During a luncheon, Mr. McManus presented achievement awards to four NEHEP Partnership members for their participation in eye health education programs. The recipients were the American Diabetes Association, the CDC Division of Diabetes Translation, the Lions Clubs International Foundation, and the Links, Incorporated.

Lack of Symptoms Cited as Obstacle for Dilated Eye Exams

Citing the challenge of confronting eye diseases that often have no early symptoms, two prominent eye care professionals are urging Americans to get regular dilated eye examinations to protect themselves against glaucoma and diabetic eye disease. Both of these eye diseases can cause loss of sight and permanent blindness.

"One of the issues we face in dealing with glaucoma is that often there are no obvious problems associated with the disease," said Eve Higginbotham, M.D., Chair of the Department of Ophthalmology at the University of Maryland. "Generally, people aren't going to get dilated eye exams if they feel their quality of life is not affected. With so much medical information for Americans to absorb, messages that do not have relevance in people's lives get lost. Eye exams often end up last on the list. But it's important for us to continue emphasizing the importance of regular dilated eye exams for people at risk for glaucoma. It's the only way to detect the early stages of the disease."

Frederick Ferris, M.D., Director of the Division of Biometry and Epidemiology at the National Eye Institute, echoed a similar theme regarding diabetic retinopathy. "Patients with diabetes often believe if their vision is fine, there is no need to be concerned," Dr. Ferris said. "These people believe they are not having any vision trouble. What they do not realize is that they need a dilated eye exam to check for diabetic eye disease, which has no early symptoms. By the time they know they are having vision problems, the chances of successful treatment are considerably less."

Dr. Higginbotham and Dr. Ferris spoke about the importance of dilated eye exams for people at risk for glaucoma and diabetic retinopathy.

Diabetic Retinopathy

Dr. Ferris said although treatment for diabetic retinopathy is safe and effective, only about half of all Americans with diabetes receive regular dilated eye exams, which can detect the disease. "The other half either get no exam or an exam with eyes that are not dilated," Dr. Ferris said. "Many internists look in the eyes through an undilated pupil, and patients believe they have had an eye exam. Undilated eye exams are very likely to miss the development of diabetic retinopathy. In one way, undilated eye exams are worse than no exam at all, because patients believe they have received a proper examination to detect diabetic retinopathy, when in fact they have not."

In addition to the lack of symptoms for diabetic retinopathy, Dr. Ferris cited time constraints and financial factors as reasons for why people with diabetes may neglect to have regular dilated eye exams. "People with diabetes often are seeing many specialists, and this takes time away from work," he said. "If they are not having vision problems, it's easy to forgo a dilated eye exam. Also, many people are busy and forget they need one. And there is a financial disincentive for people who do not have insurance and are worried about the cost of a dilated eye exam."

Dr. Ferris said that early detection, in addition to intensive efforts at controlling blood sugar levels, can slow both the progression of diabetic retinopathy and the rates of blindness. "If we can successfully implement this kind of intensive treatment and detection, we can improve on our progress in preventing blindness," he said.

Dr. Ferris believes new attitudes in health care may change the way medicine views these exams. "There has been discussion that some providers may view dilated eye exams as part of overall good health care and require patients who have diabetes to have regular dilated exams or risk losing their coverage," he said. "That could make a big difference. Another change is the HEDIS (Health Plan Employer Data and Information Set) score given to HMOs. The HEDIS score is a way of comparing quality within HMOs. The HEDIS score can motivate HMOs to increase the number of patients with diabetes having regular dilated eye exams so their scores will improve.

"For the past 25 years we have accumulated extensive data that prove how dramatically effective laser surgery is for the treatment of diabetic retinopathy," Dr. Ferris said. "This treatment is effective in the same way penicillin is effective for treating pneumonia. If you had pneumonia, you would seek appropriate antibiotic treatment, and if you had diabetic retinopathy, you would want it treated effectively. The only difference is that with pneumonia, you have symptoms and know that you need treatment. People can have diabetic retinopathy and not know they need treatment, dramatically increasing their risk of vision loss."

Glaucoma

Dr. Higginbotham said groups at higher risk for glaucoma include "everyone over the age of 60; African Americans over the age of 40; people who have a family history of glaucoma; and people who have a tendency toward nearsightedness or who are myopic. These people need to receive regular dilated eye exams--not just a screening test or change in glasses."

Screening techniques have improved, Dr. Higginbotham noted, and they can be helpful in educating people about the risks of glaucoma. But she warned Americans not to use screening as a substitute for a dilated eye exam and challenged health care providers to take a more active role in encouraging their patients to get a dilated eye exam.

"The science of screening has evolved," Dr. Higginbotham said, "particularly now that there is increased awareness that tonometry is not the best strategy for screening. Prevent Blindness America has certainly made some inroads in the screening area with its support of visual field devices. Questionnaires have been used to screen for various risk factors. And screenings are effective ways to get out the message of the importance of dilated eye exams, particularly when literature is provided and the screening becomes an educational forum."

"A word of caution, though--screening is not a replacement for a dilated eye exam," Dr. Higginbotham continued. "That is the difficulty with screening people for glaucoma--there is no fail-safe way to detect glaucoma by screening. Health care providers need to encourage their patients to have a dilated eye exam, perhaps by calling them to offer reminders."

Dr. Higginbotham credits organizations such as those participating in the NEHEP Partnership with improving the delivery of health care messages. "The 'science' of delivering health care messages has seen improvement," Dr. Higginbotham said. "The organizations in the NEHEP Partnership have done a wonderful job involving lay people with message delivery.

In the past, the dilated-eye-exam messages were delivered in such a way that they were not relevant to high-risk groups. The message was not translated into any meaningful language for those who most needed to hear it. We've made progress, but we have a long way to go."

The new treatments for glaucoma on the horizon should provide encouragement for those at risk for the disease to seek early detection, according to Dr. Higginbotham. "There are many medications that have recently become available in the past two years," she said. "There are new eyedrops that don't affect the patients' quality of life as adversely as did previous eyedrops. There are also methods that allow eye care professionals to diagnose glaucoma at an earlier stage. But current and new treatments for glaucoma mean little unless Americans at higher risk for the disease get regular dilated eye exams."