Ocular signs and symptoms can be the first manifestation of certain systemic diseases as well as an indication of progression and treatment efficacy. Optometrists, as primary care providers (PCPs), often serve as an entry point to the medical system and provide routine care that extends beyond the eyes.
This comprehensive approach aids in identifying systemic problems, guiding patients to integrated care and better health overall.
Role of optometrists as primary care providers
With thorough assessments, timely referrals, and collaborative management strategies, optometrists can address both ocular and systemic health concerns effectively.
The list below outlines how optometrists can thoroughly assess patients for systemic and ocular health concerns:1
- Gross observation: This provides initial clues that facilitate the identification of medical conditions. By looking at the whole patient, optometrists identify ocular and nonocular indicators that help tailor the patient history and examination.
- Patient medical history (PMHx): A thorough PMHx identifies the patient’s PCP, date of last examination, and explores any current medical conditions (systemic and ocular), trauma, or other symptoms while also ascertaining relevant details such as the most recent A1C or blood pressure measurement.
- Optometrists working in multidisciplinary settings (e.g., hospitals and health centers) often have easier access to patient records, diagnosis/medication lists, and recent lab results.
- Patient social history: A thorough social history includes various aspects of the patient’s personal life that identify potential risk factors and help personalize patient education and treatment plans.
- Family medical history (FMHx): A thorough FMHx provides insight into a patient's risk factors or predisposition to particular conditions (e.g., glaucoma or macular degeneration), encouraging proactive care through education and tailored clinical care.
- Medications: Relevant medication information includes current dose, recent changes, and/or change in medication or discontinuation and helps gauge the level of control, identify potential ocular side effects, and offers an opportunity to better understand patient compliance.
- Mental status/demeanor: Observing and noting a patient’s mood, alertness, and orientation to person, place, and time provides insight into their emotional state and cognitive function.2
- Blood pressure: By measuring blood pressure screens and/or monitoring for hypertension, optometrists can offer an additional data point to indicate the level of control and/or patient compliance. In many cases, routine eyecare can provide an entry point into the greater healthcare system.
- Obtaining blood pressure screening on adult patients can be an important part of the patient workflow. This is especially true in practice settings where patients present with myriad chronic diseases (e.g., metabolic syndrome, hypertension, diabetes, and obesity).
- Cranial nerve (CN) assessment: Comprehensive eye exams routinely assess CN II (visual fields, color vision, visual acuities, pupillary testing), CN III (pupillary testing, extraocular motility), CN IV (extraocular motility) and CN VI (extraocular motility).
- The remaining cranial nerves can be conveniently tested, and it's prudent to keep these assessments available should examination findings warrant further investigation.
Table 1: Straightforward CN assessments that can be implemented, if indicated.2
| Cranial Nerve | In-Office Testing |
|---|---|
| I - Olfactory | Have patient identify a smell (ex., coffee, vinegar, etc.) with eyes closed and one nostril occluded. |
| V - Trigeminal | Have patient identify and compare (right vs. left) light cotton wisp touch to forehead, upper cheek, jaw, and cornea. |
| VII - Facial | Have patient smile, frown, raise eyebrows, puff cheeks, and tightly close eyes while assessing facial symmetry. This is important for a Bell’s palsy workup. |
| VIII - Vestibulocortical | Have patient identify which ear can hear the sound while rubbing fingers together near one ear. |
| IX - Glossopharyngeal | Have patient open their mouth, says “ahh” and assess palate symmetry and uvula deviation. |
| X - Vagus | Have patient open their mouth, says “ahh” and assess palate symmetry and uvula deviation. |
| XI - Accessory | Have patient look side to side, then shrug shoulders and assess for asymmetry or weakness. |
| XII - Hypoglossal | Have patient stick out tongue and assess for deviation. |
Figure 1: Information adapted from Review of Optometry.
Common systemic conditions that require co-management
Many systemic conditions are complex and can have myriad ocular complications associated with the initial presentation and/or disease progression. Co-managing these conditions alongside other healthcare professionals provides patients with the comprehensive care essential for optimal health outcomes.
Optometrists, as primary care providers, must be knowledgeable about prevalent systemic conditions with ocular manifestations.
Assessing ocular effects of systemic disease
Tables 2-5: Common systemic conditions and their related ophthalmic effects.1,3,4
Endocrine disease
| Condition | Possible Ophthalmic Manifestations |
|---|---|
| PANCREAS | |
| Diabetes mellitus (DM) | Myopic refractive shift, diabetic retinopathy, macular edema, early cataract, and glaucoma |
| THYROID | |
| Hypothyroidism | Cataracts and papilledema |
| Hyperthyroidism | Proptosis, band keratopathy, and conjunctival calcification |
| PITUITARY | |
| Pituitary tumor | Visual field defects |
| Acromegaly | Visual field defects (bitemporal hemianopsia), ophthalmoplegia, optic atrophy, and nystagmus |
| ADRENAL | |
| Cushing's disease | Increased intraocular pressure (IOP) and central serous chorioretinopathy (CSC) |
| Addison's disease | Increased pigmentation around eye and optic neuropathy |
Cardiac disease
| Condition | Possible Ophthalmic Manifestations |
|---|---|
| Hypertension | Hypertensive retinopathy, choroidopathy, papilledema, optic neuropathy, and central retinal vein/artery occlusions |
| Atherosclerosis | Central/branch retinal artery occlusions |
| Hypercholesterolemia | Arcus senilis and xanthelasma |
| Cardiac embolism | Retinal embolism |
| Congestive heart failure (CHF) | Optic neuropathy |
| Carotid occlusive disease | Amaurosis fugax, retinal artery occlusion, retinopathy, and neovascular glaucoma |
| Atrial fibrillation | Retinal infarction and glaucoma |
Neurological disease
| Condition | Possible Ophthalmic Manifestations |
|---|---|
| Parkinson's disease | Dry eye, diplopia, and oculomotor disorders |
| Alzheimer's disease | Visual field defect |
Autoimmune/Inflammatory disease
| Condition | Possible Ophthalmic Manifestations |
|---|---|
| Systemic lupus erythematosus (SLE) | Keratoconjunctivitis sicca, ulcerative keratitis, scleritis, retinal vasculitis, and optic neuropathy |
| Rheumatoid arthiritis (RA) | Keratoconjunctivitis sicca, episcleritis, or scleritis |
| Sjögren's disease | Keratoconjunctivitis sicca, episcleritis, or scleritis |
| Irritable bowel disease (IBS) | Episcleritis and dry eye |
Infectious disease
| Condition | Possible Ophthalmic Manifestations |
|---|---|
| Syphilis | Keratitis, uveitis, chorioretinitis, and neuroretinitis |
| Coronavirus disease 2019 (COVID-19) | Conjunctivitis and dry eye |
| Lyme disease | Keratitis, uveitis, optic neuritis, neuroretinitis, motor nerve palsies, and early cataracts |
| Chlamydia | Conjunctivitis |
Tables 2-5: Information adapted from Patient/EMIS, Optometric Management, and Review of Optometry.
Example: Identifying diabetes in eyecare patients
Each year, optometrists diagnose over a quarter million cases of type 2 diabetes in patients who otherwise did not know they had the condition.5 It is not uncommon for patients to present with ocular findings of diabetes prior to having any systemic symptoms.
Figure 1: Moderate nonproliferative diabetic retinopathy in a 58-year-old female who was previously unaware of having type 2 diabetes, which was diagnosed by her optometrist.
Figure 1: Courtesy of Kevin Cornwell, OD.
Assessing ocular effects of systemic medications
Systemic medications can also impact the eyes and visual function. Vigilance regarding their potential effects is crucial, along with prudent monitoring, appropriate treatment, and/or referral.
Figure 2: Brief overview of potential effects of medications on the eye.6
Figure 3: Adapted from Ahmad et al.
Table 6: List of medications for systemic diseases and their potential effects on the eye.
| Drug Class | Medication | Condition(s) Treated | Common Ophthalmic Manifestations |
|---|---|---|---|
| Antiestrogen | Tamoxifen (Nolvadex) | Metastatic breast cancer | Crystalline retinopathy, macular edema, and whorl-like keratopathy |
| Antiarrhythmic | Amiodarone (Pacerone) | Atrial fibrillation | Whorl-like keratopathy |
| Anticholinergic | Dicyclomine (Bentyl, Dibent, Dicyclocot) | IBS | Reduced accomodation |
| Antituberculosis agent | Ethambutol (Myambutol) | Mycobacterial disease (tuberculosis) | Optic neuropathy |
| Bisphosphonate | Alendronate (Fosamax) | Calcium bone loss | Orbital inflammation, uveitis, and scleritis |
| Calcium channel blockers | Verapomil (Verelan), Amlodipine (Norvasc), Diltiazem (Dilacor) | Hypertension | Glaucoma |
| Carbonic anhydrase inhibitor | Topiramate (Topamax) | Epilepsy and migraines | Angle-closure glaucoma |
| Cardiac glycoside | Digoxin (Digitek, Digox) | Atrial fibrillation | Xanthopsia (yellow vision) |
| cGMP Inhibitor | Sildenafil (Viagra), Tadalafil (Cialis) | Erectile dysfunction | Blue vision, ischemic optic neruopathy |
| Chloroquine-based | Hydroxychloroquine (Plaquenil) | RA, SLE, Sjögren's disease | Retinal toxicity |
| Diuretic | Hydrochlorothiazide (Aquazide H, Hydrocot, Microzide) | Hypertension | Glaucoma |
| Selective alpha-1 adrenergic receptor antagonist | Tamsulosin (Flomax) | Prostate enlargement | Floppy iris syndrome |
| Sphingosine 1-phosphate receptor modulator | Fingolimod (Gilenya) | Multiple sclerosis (MS) | Macular edema |
| Tetracycline antibiotic | Minocycline (Minocin) | Acne | Papilledema |
Table 6: Adapted from Review of Ophthalmology, Review of Optometry, and Mayo Clinic.
Basis for and urgency of referral
The basis for and urgency of referral hinges on several factors. Patient symptoms, medical history, risk factors, alongside clinical findings, diagnostic test results, and level of risk posed to the patient—whether to their vision or overall health—all contribute to this decision-making process.10
Understanding the underlying causes is essential to referring the patient to the most suitable specialist in a timely manner. Typically, routine referrals to appropriate specialists suffice to address underlying systemic or medication-related causes for asymptomatic patients with significant clinical findings.
However, there are occasions where more emergent referrals are necessary. For instance, systemically, a blood pressure measurement of 180/120mmHg necessitates immediate attention.10
During ophthalmic exams, suspicion of the conditions below, which could lead to imminent and irreversible vision loss, warrant urgent care:
- Optic neuropathy (e.g., due to amiodarone)
- Angle-closure glaucoma (e.g., from anticholinergics, topiramate)
- The presence of extensive corneal changes (e.g., from bisphosphonates, phenothiazines)
- Retinal findings (e.g., toxicity from tetracyclines, tamoxifen, or Plaquenil)
For a deeper dive into how optometrists can streamline the referral process and a downloadable referral template, check out Ways to Increase Optometry Referrals from Primary Care and Specialty Providers!
Creating a co-management plan
A systematic procedure is the best way to get things done efficiently, effectively, and consistently; and ultimately, co-managing is no different.
Creating a co-management plan can be broken down into 5 steps:11
- Conduct a thorough ocular examination: Identify any existing conditions, systemic or ophthalmic, or other concerns that require co-management between healthcare providers.
- Communicate and collaborate: Communicate, written or verbal, with relevant specialists following each patient encounter in a timely manner. Clearly define co-management goals, provider roles, your ocular findings, the proposed treatment plan, and/or follow-up schedule.
- Develop a comprehensive treatment plan: Co-management plans integrate input from all involved healthcare providers. This includes patient preferences and potential interactions between treatments to formulate a coordinated, multi-disciplinary approach.
- Continually monitor and evaluate progress: Regularly monitor the patient's progress and evaluate the effectiveness of the co-management plan through follow-up appointments, tracking the patient's response to treatment, and making any necessary adjustments with the co-managing team.
- Educate patients and encourage active participation: It is important to consistently educate the patient about their personalized care plan and any adjustments made. This emphasizes their role in following treatment protocols, attending appointments, and communicating with the healthcare team.
Improving patient outcomes with interdisciplinary care
Optometrists can develop and maintain relationships with co-managing healthcare professionals by:11,12
- Identifying local providers and initiating contact: Potential co-managing partners include PCPs, endocrinologists, cardiologists, rheumatologists, etc. Optometrists should arrange face-to-face meetings, whether in-office or at local events, to understand their subspecialty and explain what a co-management relationship could look like.
- Building rapport: Good rapport requires trust and respect and takes time to build. Continually be reliable, professional, kind, respectful, and courteous. Personal connections will go a long way.
- Fostering multidisciplinary cooperation: Openly prioritize patient-centered care. Initiate contact with any relevant providers of shared patients to coordinate care and maintain consistent written communication after every patient encounter.
Conclusion
Today’s optometrists perform well over 80% of all comprehensive eye exams.11 It is crucial that eyecare providers are familiar with the ocular manifestations of the myriad systemic diseases patients may present with. It is also important to develop a network of healthcare professionals to refer and co-manage patients.
By collaborating with other healthcare providers, optometrists are able to provide quality healthcare and improve treatment outcomes for sight and potentially life-threatening conditions.
