Comprehensive Adult Medical Eye Evaluation PPP

Comprehensive Adult
Medical Eye Evaluation

Preferred Practice
Pattern®
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Secretary for Quality of Care
Timothy W. Olsen, MD
Academy Staff
Ali Al-Rajhi, PhD, MPH
Andre Ambrus, MLIS
Meghan Daly
Flora C. Lum, MD
Medical Editor: Susan Garratt
Approved by: Board of Trustees

September 12, 2020
Copyright © 2020 American Academy of Ophthalmology®

All rights reserved
AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are

registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of
their respective owners.
Preferred Practice Pattern® guidelines are developed by the Academy’s H. Dunbar Hoskins Jr., MD Center
for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are
volunteers and do not receive any financial compensation for their contributions to the documents. The
guidelines are externally reviewed by experts and stakeholders before publication.
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Comprehensive Adult Medical Eye Evaluation PPP
COMPREHENSIVE ADULT MEDICAL EYE

EVALUATION PREFERRED PRACTICE
PATTERN® DEVELOPMENT PROCESS AND
PARTICIPANTS
The Preferred Practice Patterns Committee members wrote the Comprehensive Adult Medical Eye
Evaluation Preferred Practice Pattern® guidelines (PPP). The committee members discussed and reviewed
successive drafts of the document, meeting in person once and conducting other review by e-mail discussion,
to develop a consensus over the final version of the document.
Preferred Practice Patterns Committee 2020

Roy S. Chuck, MD, PhD, Chair
Steven P. Dunn, MD
Christina J. Flaxel, MD
Steven J. Gedde, MD
Francis S. Mah, MD
Kevin M. Miller, MD
David K. Wallace, MD, MPH
David C. Musch, PhD, MPH, Methodologist
The Comprehensive Adult Medical Eye Evaluation PPP was then sent for review to additional internal and
external groups and individuals in June 2020. All those who returned comments were required to provide
disclosure of relevant relationships with industry to have their comments considered (indicated with an
asterisk below). Members of the Preferred Practice Patterns Committee reviewed and discussed these
comments and determined revisions to the document.
National Medical Association, Ophthalmology
Academy Reviewers Section
Board of Trustees and Committee of Secretaries* Outpatient Ophthalmic Surgery Society
Council* Women in Ophthalmology*
General Counsel* Alfred Sommer, MD, MHS*
Practicing Ophthalmologists Advisory Committee Jonathan Javitt, MD, MPH
for Education Oliver Schein, MD*
Invited Reviewers
American College of Surgeons, Advisory Council
for Ophthalmic Surgery
American Glaucoma Society
American Ophthalmological Society*
American Society of Cataract & Refractive
Surgery
American Society of Ophthalmic Plastic and
Reconstructive Surgery
American Society of Retina Specialists*
Association for Research in Vision and
Ophthalmology
Association of University Professors of
Ophthalmology
Consumer Reports Health Choices
Cornea Society
Canadian Ophthalmological Society
International Society of Refractive Surgery
North American Neuro-Ophthalmology Society*
National Eye Institute*
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FINANCIAL DISCLOSURES
In compliance with the Council of Medical Specialty Societies’ Code for Interactions with Companies
(available at https://cmss.org/code-signers-pdf/), relevant relationships with industry are listed. The Academy
has Relationship with Industry Procedures to comply with the Code (available at www.aao.org/about-
preferred-practice-patterns). A majority (75%) of the members of the Preferred Practice Patterns Committee
2020 had no related financial relationship to disclose.
Preferred Practice Patterns Committee 2020

Roy S. Chuck, MD, PhD, Chair: No financial relationships to disclose
Steven P. Dunn, MD: No financial relationships to disclose
Christina J. Flaxel, MD: No financial relationships to disclose
Steven J. Gedde, MD: No financial relationships to disclose
Francis S. Mah, MD: Alcon Laboratories Inc., Bausch + Lomb, Novartis, Alcon Pharmaceuticals—
Consultant/Advisor; Bausch + Lomb, Novartis, Alcon Pharmaceuticals—Lecture Fees
Kevin M. Miller, MD: Alcon Laboratories Inc., Johnson & Johnson Vision —Consultant/Advisor
David K. Wallace, MD, MPH: No financial relationships to disclose
David C. Musch, PhD, MPH: No financial relationships to disclose
Secretary for Quality of Care

Timothy W. Olsen, MD: No financial relationships to disclose
Academy Staff
Ali Al-Rajhi, PhD, MPH: No financial relationships to disclose
Andre Ambrus, MLIS: No financial relationships to disclose
Meghan Daly: No financial relationships to disclose
Flora C. Lum, MD: No financial relationships to disclose
Susan Garratt: No financial relationships to disclose
The disclosures of relevant relationships to industry of other reviewers of the document from January
to October 2020 are available online at www.aao.org/ppp.
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TABLE OF CONTENTS
OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES ..........................................P7

METHODS AND KEY TO RATINGS ................................................................................................P8
HIGHLIGHTED RECOMMENDATIONS FOR CARE .......................................................................P9
INTRODUCTION .............................................................................................................................P10
Patient Population ............................................................................................................................P10
Clinical Objectives ............................................................................................................................P10
BACKGROUND ...............................................................................................................................P10
Rationale for Comprehensive Medical Eye Evaluations ..................................................................P10
Ocular Diseases ...............................................................................................................................P11
Open-Angle Glaucoma ........................................................................................................................P11
Primary Angle Closure ..............................................................................................................P11
Diabetes Mellitus ......................................................................................................................P11
Age-Related Macular Degeneration .........................................................................................P14
Cataract ....................................................................................................................................P14
Other Ocular Disorders .............................................................................................................P14
Systemic Diseases and Conditions .................................................................................................P15
Socioeconomic Considerations .......................................................................................................P15
CARE PROCESS ............................................................................................................................P16
History .............................................................................................................................................P16
Ocular Examination ..........................................................................................................................P16
Diagnosis and Management ............................................................................................................P17
Category I: Patients With No Risk Factors ...............................................................................P18
Category II: Patients With Risk Factors ....................................................................................P18
Category III: Conditions That Require Intervention ..................................................................P19
Provider and Setting ........................................................................................................................P19
APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA ............. ............................P20
APPENDIX 2. LITERATURE SEARCHES FOR THIS PPP ...........................................................P22
RELATED ACADEMY MATERIALS ...............................................................................................P22
REFERENCES ................................................................................................................................P23
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Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern®
Background:
Patients may seek to undergo a comprehensive adult medical eye evaluation for a variety
of reasons. An evaluation is typically recommended for patients who have not been seen
by an ophthalmologist for an extended period of time or and for those who have never
been examined. Recommended intervals between comprehensive examinations vary with
age and risk factors. A thorough ophthalmic evaluation can detect common abnormalities
of the visual system and its related structures as well as less common yet extremely serious
issues. Such evaluations can also uncover evidence of systemic disease through its
associated ophthalmic manifestations. With appropriate and timely intervention, visually
impairing conditions such as cataract, and potentially blinding diseases such as glaucoma,
age-related macular degeneration, and diabetic retinopathy often have favorable outcomes.
Rationale for Treatment:

The rationale for performing periodic comprehensive medical eye examinations in adults
without known ocular conditions or risk factors is to detect ocular diseases, visual
dysfunction, or ophthalmic signs of systemic disease. Early recognition, counseling, and
treatment may preserve visual function or, in the case of systemic disease, prevent serious
illness or even premature death from occurring. Irreversible vision loss has been associated
with adverse effects on quality of life and mental health, and self-reported visual loss has
been found to be associated with depression. Comprehensive medical eye evaluations are
also performed to evaluate new symptoms and to monitor patients with previously
identified eye conditions or risk factors. The public health impact of eye disease is
substantial.
Care Process:
The components of a comprehensive medical eye evaluation include a history, medical eye
examination and any needed laboratory tests, diagnosis, and initiation of management. The
examination includes a careful evaluation for ophthalmic disorders; the treatment plan
addresses refractive errors and ocular disease; and referrals are initiated when systemic
disease is detected.
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OBJECTIVES OF PREFERRED PRACTICE

PATTERN® GUIDELINES
As a service to its members and the public, the American Academy of Ophthalmology has developed a series
of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care.
Appendix 1 describes the core criteria of quality eye care.
The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by
panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted
clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances,
the panels have to rely on their collective judgment and evaluation of available evidence.
These documents provide guidance for the pattern of practice, not for the care of a particular
individual. While they should generally meet the needs of most patients, they cannot possibly best meet the
needs of all patients. Adherence to these PPPs will not ensure a successful outcome in every situation. These
practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods
of care reasonably directed at obtaining the best results. It may be necessary to approach different patients’
needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a
particular patient in light of all of the circumstances presented by that patient. The American Academy of
Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of
ophthalmic practice.
Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual
situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind,
from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or
other information contained herein.
References to certain drugs, instruments, and other products are made for illustrative purposes only and are
not intended to constitute an endorsement of such. Such material may include information on applications
that are not considered community standard, that reflect indications not included in approved U.S. Food and
Drug Administration (FDA) labeling, or that are approved for use only in restricted research settings. The
FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or
device he or she wishes to use, and to use them with appropriate patient consent in compliance with
applicable law.
Innovation in medicine is essential to ensure the future health of the American public, and the Academy
encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is
essential to recognize that true medical excellence is achieved only when the patients’ needs are the foremost
consideration.
All Preferred Practice Pattern® guidelines are reviewed by their parent panel annually or earlier if
developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years
from the “approved by” date unless superseded by a revision. Preferred Practice Pattern guidelines are funded
by the Academy without commercial support. Authors and reviewers of PPPs are volunteers and do not
receive any financial compensation for their contributions to the documents. The PPPs are externally
reviewed by experts and stakeholders, including consumer representatives, before publication. The PPPs are
developed in compliance with the Council of Medical Specialty Societies’ Code for Interactions with
Companies. The Academy has Relationship with Industry Procedures (available at www.aao.org/about-
preferred-practice-patterns) to comply with the Code.
The intended users of the Comprehensive Medical Adult Eye Evaluation PPP are ophthalmologists.
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METHODS AND KEY TO RATINGS
Preferred Practice Pattern guidelines should be clinically relevant and specific enough to provide useful
information to practitioners. Where evidence exists to support a recommendation for care, the
recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these
aims, methods from the Scottish Intercollegiate Guideline Network1 (SIGN) and the Grading of
Recommendations Assessment, Development and Evaluation2 (GRADE) group are used. GRADE is a
systematic approach to grading the strength of the total body of evidence that is available to support
recommendations on a specific clinical management issue. Organizations that have adopted GRADE include
SIGN, the World Health Organization, the Agency for Healthcare Research and Policy, and the American
College of Physicians.3
 All studies used to form a recommendation for care are graded for strength of evidence individually, and
that grade is listed with the study citation.
 To rate individual studies, a scale based on SIGN1 is used. The definitions and levels of evidence to rate
individual studies are as follows:
I++ High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or
RCTs with a very low risk of bias
I+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
I- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
II++ High-quality systematic reviews of case control or cohort studies
High-quality case-control or cohort studies with a very low risk of confounding or bias and a
high probability that the relationship is causal
II+ Well-conducted case-control or cohort studies with a low risk of confounding or bias and a
moderate probability that the relationship is causal
II- Case-control or cohort studies with a high risk of confounding or bias and a significant risk that
the relationship is not causal
III Non-analytic studies (e.g., case reports, case series)
 Recommendations for care are formed based on the body of the evidence. The body of evidence quality
ratings are defined by GRADE2 as follows:
Good quality Further research is very unlikely to change our confidence in the estimate of
effect
Moderate quality Further research is likely to have an important impact on our confidence in the
estimate of effect and may change the estimate
Insufficient quality Further research is very likely to have an important impact on our confidence in
the estimate of effect and is likely to change the estimate
Any estimate of effect is very uncertain
 Key recommendations for care are defined by GRADE2 as follows:

Strong Used when the desirable effects of an intervention clearly outweigh the
recommendation undesirable effects or clearly do not
Discretionary Used when the trade-offs are less certain—either because of low quality evidence
recommendation or because evidence suggests that desirable and undesirable effects are closely
balanced
 The Highlighted Recommendations for Care section lists points determined by the PPP Committee to be
of particular importance to vision and quality of life outcomes.
 All recommendations for care in this PPP were rated using the system described above. Ratings are
embedded throughout the PPP main text in italics.
 Literature searches to update the PPP were undertaken in February 2020 and June 2020 in the PubMed
database. Complete details of the literature searches are available in Appendix 2.
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HIGHLIGHTED RECOMMENDATIONS FOR

CARE
The recommended frequency for adult comprehensive medical eye examinations for asymptomatic patients,
and for patients who do not have risk factors for eye disease, is as follows: under 40 years—every 5 to 10
years; 40 to 54 years—every 2 to 4 years; 55 to 64 years—every 1 to 3 years; and 65 years or older—every 1
to 2 years.
An increased frequency of comprehensive medical eye examinations is recommended for adults who have
risk factors for glaucoma, such as African Americans and Hispanics.
The first recommended adult comprehensive medical eye examination, and subsequent frequency of
examination for patients who have diabetes mellitus, depends on the type of diabetes and pregnancy status.
The recommendations are as follows: (1) type 1 diabetes mellitus—first examination 5 years after onset and
yearly thereafter; (2) type 2 diabetes mellitus—first examination at the time of diagnosis and yearly
thereafter; and (3) for women with type 1 or type 2 diabetes—first examination prior to conception and then
early in the first trimester of pregnancy. Interval recommendations thereafter will be based on findings at first
examination. (Note: Women who develop gestational diabetes do not require an eye examination during
pregnancy, and they do not appear to be at increased risk for developing diabetic retinopathy during
pregnancy.)
Smoking is a risk factor for many ocular diseases.
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INTRODUCTION
PATIENT POPULATION
Adults with no known ocular conditions or risk factors, adults with previously identified conditions or
risk factors, or adults with recurrent or new symptoms.
CLINICAL OBJECTIVES
 Detect and diagnose ocular abnormalities and diseases
 Identify risk factors for ocular disease
 Identify risk factors for systemic disease based on ocular findings
 Establish the presence or absence of ocular signs or symptoms of systemic disease
 Determine the refractive state and health status of the eye, visual system, and related structures
 Discuss the results and implications of the examination with the patient
 Initiate an appropriate management plan, including determination of the frequency of future visits,
further diagnostic tests, referral, or treatment
BACKGROUND
Patients may seek a comprehensive adult medical eye evaluation for a variety of reasons. It is
recommended for patients who have not been examined for an extended period of time by an
ophthalmologist or those who are being seen for the first time. Recommended intervals between
comprehensive examinations vary with age and risk factors. A thorough ophthalmic evaluation can
detect common abnormalities of the visual system and related structures as well as less common yet
extremely serious ones, such as ocular tumors. Such an evaluation can also uncover evidence of
systemic disease that has associated ophthalmic manifestations. All patients, particularly those with
risk factors for ocular disease, should be re-examined periodically to prevent or minimize vision loss
by detecting and treating the disease at an early stage. Patients in whom ophthalmic disease(s) is
identified require periodic comprehensive examinations for optimal monitoring and treatment of the
condition(s). With appropriate and timely intervention, potentially blinding diseases such as
glaucoma, cataract, age-related macular degeneration (AMD) and diabetic retinopathy often have a
more favorable outcome. Studies have indicated that up to 40% of legal blindness found among
nursing home residents,4 as well as in both urban5 and rural6 communities, could have been
prevented or ameliorated if those individuals had received timely ophthalmic screening and care. In
a population-based study, 63% of the participants who had eye disease were not aware of it.7
RATIONALE FOR COMPREHENSIVE MEDICAL EYE EVALUATIONS

The rationale for performing periodic comprehensive medical eye examinations in adults without
known ocular conditions or risk factors is to detect ocular diseases, visual dysfunction, or ophthalmic
signs of systemic disease in the adult population. Early recognition, counseling, or treatment may
preserve visual function or, in the case of systemic diseases, could prevent serious illness or even
premature death. Irreversible vision loss has been associated with adverse effects on quality of life
and mental health,8, 9 and self-reported visual loss has been found to be significantly associated with
depression.10 Comprehensive medical eye evaluations are also performed periodically to evaluate new
symptoms and monitor patients with previously identified eye conditions or risk factors.
The public health impact of eye disease is substantial, because vision affects daily functioning.11-15
Improvement in visual function that occurs as a result of treatment of ocular disorders is accompanied
by improvement in life satisfaction and mental health and by participation in home and community
activities.16-19 Vision plays a critical role in mobility and in fall prevention.20-23 Untreated visual
impairment has been associated with cognitive decline and Alzheimer‘s disease.24 A higher risk of
motor vehicle collisions was found among drivers with glaucoma who had severe visual field
defects.25 Cataract surgery in older drivers has been shown to reduce the subsequent motor vehicle
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collision rate.26 Visual impairment, AMD, and cataract have been associated with an increased risk of
mortality.27, 28 In women 65 and older, poorer visual acuity and reduced contrast sensitivity have been
associated with a higher risk of mortality.29
OCULAR DISEASES
In 2015, about 1.02 million adults 40 and older in the United States were legally blind (distance
corrected visual acuity of ≤20/200, or a visual field of ≤20 degrees in the better seeing eye), and an
additional 3.22 million were visually impaired (distance corrected visual acuity of <20/40 in the
better-seeing eye).30 The highest frequencies of visual impairment and legal blindness were found in
individuals 80 years and older and generally correlated with age.31, 32 Rates of visual impairment and
legal blindness were disproportionately higher among individuals of African descent compared with
individuals of European descent.5, 31, 33 Rates of visual impairment were higher among individuals of
Hispanic/Latino descent compared with individuals of European or African descent.31, 34
Many patients will be unaware that they have a vision-threatening ocular condition because of the
lack of early symptoms (see Table 1). These conditions include common and often treatable diseases
such as glaucoma, diabetic retinopathy, and some forms of macular degeneration.
Open-Angle Glaucoma
Primary open-angle glaucoma (POAG) is a significant public health problem.35-43 It is estimated
that 76 million people in the world have glaucoma in the year 2020.36 Glaucoma (both open-
angle and angle-closure) is the second leading cause of blindness worldwide.37 Overall, the
prevalence of POAG for adults aged 40 and older in the United States was estimated to be about
3.05% in 2013.36 Prevalence studies suggest that POAG will increase by 50% worldwide from
52.7 million in 2020 to 79.8 million in 2040 as the population ages36 and will disproportionately
affect African and Asian countries.35, 36, 38, 39 Large differences exist in the prevalence of
glaucoma among different ethnoracial groups. Overall, there appears to be a threefold higher
prevalence of open-angle glaucoma (OAG) in African Americans relative to non-Hispanic
whites in the United States.40, 41 It is also the leading cause of blindness in African Americans.41
Further, the prevalence of OAG is even higher in Afro-Caribbeans relative to African
Americans. Recent evidence on Hispanics/Latinos suggests that they have high prevalence rates
of OAG that are comparable to the prevalence rates for African Americans.42 An analysis of
claims data from a large U.S.-based managed care plan suggests that the prevalence of OAG
among Asian Americans is comparable to the prevalence among Latinos and is higher than that
of non-Hispanic white Americans.43
Primary Angle Closure Glaucoma

Considerable differences exist in the prevalence of angle closure among ethnoracial groups,
with highest rates in Inuit,44-46 Chinese,47-51 and other Asian52-60 populations; lower rates are
reported in populations of African and African-derived origin41, 61, 62 and European and
European-derived origin.63-69 In some Asian populations, primary angle-closure glaucoma
(PACG) is reported to account for nearly as many cases of glaucoma as OAG.36, 37, 52, 70, 71
Worldwide, 0.7% of people over 40 years of age are estimated to have angle-closure
glaucoma;37 in 2013, this represented 20.2 million people, with most (15.5 million) in Asia.36 In
China, PACG is estimated to cause unilateral blindness (visual acuity <20/200 or visual field
≤10⁰) in 1.5 million individuals and bilateral blindness in another 1.5 million.71
Diabetes-Related Ocular Disease

An estimated 100 million Americans aged 18 years and older have either been diagnosed with
diabetes or are prediabetic, according to a 2015 report by the Centers for Disease Control and
Prevention (CDC). As reported by the CDC, 30.3 million Americans 18 or older have diabetes
(9.4% of people in this age group),72 and about one-quarter are not aware that they have the
disease.73 An additional 79 million persons have impaired fasting blood glucose levels (based
on both fasting blood glucose levels and HbA1c levels).73 In 2015, an estimated 1.5 million new
cases of diabetes were diagnosed among people aged 18 and older.72
Rates of diagnosed diabetes increased with age: 4% of individuals 18 to 44 years old had
diabetes, as did 17% of those 45 to 64 years old and 25% of those 65 and older. Rates of
diagnosed diabetes were higher among Native Americans and Alaskan Natives (15.1%), non-
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Hispanic blacks (12.7%), and Hispanics (12.1%) compared with Asians (8.0%) and non-
Hispanic whites (7.4%).72
Rates of prediabetes (HbA1c levels between 5.7% and 6.4%) are also increasing.74 It is
estimated that 33.9% of U.S. adults 18 or older (84.1 million people) have prediabetes based on
their fasting glucose or HbA1c level. Nearly half (48.3%) of adults 65 or older had prediabetes.72
The age-adjusted incidence of diabetes was two times higher for people with less than a high
school education (10.4/1000 persons) compared with those with more than a high school
education (5.3/1000 persons) from 2013 to 2015. Rates of diabetes and prediabetes are similarly
high among children and adolescents (younger than 20).75 Compared with members of other
U.S. racial and ethnic groups, non-Hispanic whites had the highest rate of new cases of type 1
diabetes. Among children and adolescents aged 10 to 19, U.S. minority populations had higher
rates of new cases of type 2 diabetes compared with non-Hispanic whites.
The 2015 CDC report notes a higher prevalence of diabetes among American Indians/Alaska
Natives (15.1%), non-Hispanic blacks (12.7%), and people of Hispanic ethnicity (12.1%) than
among non-Hispanic whites (7.4%) and Asians (8.0%) among adults aged 18 years or older.72
Americans of African descent or Hispanic ethnicity have a disproportionately high prevalence
of diabetes compared with Americans of European descent (12.6%, 11.8%, 7.0%, respectively),
whereas Asian Americans have only a slightly higher prevalence (8.4%).73 American Indians
and Alaska Natives had an approximate diabetes prevalence of 6.4 per 1000 in 1990, which
increased to 9.3 per 1000 in 1998 (approximately 45% increase) in children and young adults
under the age of 35 years.76, 77 Other research suggests a high prevalence of diabetes in Asia.78,
79
According to a recently published study in the Lancet estimating the lifetime risk and years of
life lost due to diabetes in the United States from 1985–2011, approximately 40% of Americans
over the age of 20 years are at risk for developing diabetes during their lifetime.80 With
increasing industrialization and globalization, there is a concomitant increasing prevalence of
diabetes that is leading to a worldwide epidemic.81 An alarming increase in the frequency of
type 2 diabetes in the pediatric age group has been noted in several countries,82-87 including in
the United States, and has been associated with the increased frequency of childhood obesity.88
Diabetes is one of the most common diseases in school-aged children. Clearly, these trends
predict an increase in the number of individuals with diabetes as well as the associated
increased costs for health care and the burdens of disability associated with diabetes and its
complications. In addition, there is evidence suggesting that diabetes develops at earlier ages
and carries a higher incidence of complications among ethnic minorities.89-91
TABLE 1 PREVALENCE OF MAJOR OCULAR DISEASES AND CONDITIONS THAT MAY BE ASYMPTOMATIC
Disease or Condition Prevalence Risk Factors for Disease or Potentially Positive Findings on
Disease Progression Examinations
Choroidal nevi 5%–8%, increases with age, and White American populations and Clearly defined margins, often flat or
more common in white Americans.92 increasing age92 slightly elevated; typically stable in size.
(Note: Findings are based on 45º Over time, choroidal nevi may display
fundus images centered on the overlying drusen, retinal pigment
fovea and optic nerve.) epithelial atrophy, hyperplasia, or fibrous
metaplasia.
Open-angle glaucoma African Americans age ≥40: 3.4%40 African, Hispanic, or Latino Abnormal optic disc and nerve fiber layer
White Americans age ≥40: 1.7%40 descent,40-42, 94 increased age,40, 41, 64, defect, characteristic visual field defect,
66, 93, 94 family history of glaucoma,95, 96 elevated IOP, decreased vision (late
Individuals of Hispanic descent age elevated IOP,97, 98 thin central stages), exfoliation material on the lens
≥40: 2%93–4.7%42 cornea97, 98 capsule, signs of pigment dispersion
syndrome (including Krukenberg spindle)
Primary angle-closure 0.009%65–2.6%45 (highest rates in Hyperopia, family history of angle Narrow angles, elevated IOP, peripheral
glaucoma Inuit and Asian populations) closure, increasing age,49 female anterior synechiae
Individuals of Hispanic descent age gender,99, 100 Inuit or Asian
>40: 0.1%93 descent49, 70, 101, 102
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Diabetic retinopathy General population age ≥ 40: Increasing duration of diabetes,105, 106 Retinal microaneurysms, hemorrhages,
3.4%103 high levels of glycosylated lipid exudates, intraretinal microvascular
Individuals age ≥40 with type 1 or hemoglobin,86, 107-113 high systolic anomalies, macular edema, retinal or
type 2 diabetes: 28.5%104–40.3%103 blood pressure,114, 115 elevated serum anterior segment neovascularization,
lipid levels116-118 preretinal or vitreous hemorrhage,
Individuals of Hispanic descent with tractional retinal detachment
type 1 or type 2 diabetes age ≥40:
46.9%105
Early AMD White Americans age ≥45: 4.8%119 Increasing age,122-124 bilateral soft Retinal pigment epithelial
Individuals of African descent age drusen, large drusen, confluent disturbances/atrophy, intermediate or
≥45: 2.1% 119 drusen, clumping or atrophy of retinal large drusen, geographic atrophy, or
pigment epithelium,125-127 family retinal pigmented epithelial detachments
Individuals of Hispanic descent age history, genetic polymorphisms,
≥45: 4.0%119 smoking, poor diet/nutrition
Individuals of Hispanic descent age
≥40: 7.5%120
Individuals of Asian descent
age 40–79: 6.8%121
Late AMD White Americans age ≥45: 0.6%119 Increasing age,122-124 family history, Drusen and associated retinal pigment
Individuals of African descent age smoking, bilateral soft drusen, large epithelial changes, geographic atrophy,
≥45: 0.3%119 drusen, confluent drusen, clumping or evidence of choroidal neovascularization
atrophy of retinal pigment (intra- or subretinal hemorrhage, lipid,
Individuals of Hispanic descent age epithelium,128 body mass index and intra- or subretinal fluid)
≥45: 0.2%119, 120 genetic factors129, 130
Individuals of Hispanic descent age
≥40: 0.2%120
Individuals of Asian descent age
40–79: 0.56%121
AMD = age-related macular degeneration; IOP = intraocular pressure.
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Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is a leading cause of severe vision impairment
among white Americans.131 In 2004, it was estimated that approximately 1.75 million people
aged 40 years or older in the United States have either neovascular AMD or geographic atrophy
in at least one eye and that 7.3 million have high-risk features, such as large drusen (≥125 µm),
in one or both eyes.131 A report published in JAMA Ophthalmology in 2011 notes that the
prevalence of any AMD in the 2005–2008 National Health and Nutrition Examination Survey
was 6.5%, which is lower than the 9.4% prevalence reported in the 1988–1994 Third National
Health and Nutrition Examination Survey. Overall, these estimates show a decreasing incidence
of AMD.132 The prevalence, incidence, and progression of AMD and most associated features
(e.g., large drusen) increase significantly with age.123, 124, 131 For example, the prevalence of
AMD in white females 60 to 64 is 0.3%, increasing to 16.4% in those 80 and older.131 Age-
related macular degeneration is usually asymptomatic in its early stages, although a fundus
examination is helpful in identifying patients with an increased risk of developing choroidal
neovascularization or advanced AMD.128 The Age Related Eye Disease Study (AREDS)
defined a role for nutritional supplements for slowing the progression of AMD. It is important
to identify those patients at higher risk because the AREDS2 supplement formulation (i.e.,
vitamin C, vitamin E, zinc, copper, lutein, zeaxanthin) has been shown to have preventive
efficacy in this higher-risk group.133 An estimated 8 million persons at least 55 years old in the
United States have monocular or binocular intermediate AMD or monocular advanced AMD.
They should be considered to be at high risk for progression of advanced AMD and are the
population for whom the AREDS2 formulation should be considered. If all the patients at risk
were given supplements, then more than 300,000 could delay disease progression and
associated vision loss.133
Cigarette smoking has been consistently identified in numerous studies as a risk factor for
progression of AMD, and the risk increases relative to the number of pack-years smoked.134-141
Smoking-cessation counseling may influence patients to stop smoking, reducing the risk of
AMD progression. Patients with neovascular AMD report a substantial decline in their quality
of life and have an increased need for assistance with activities of daily living that progresses as
visual acuity worsens.142 Early treatment of AMD is associated with a more favorable
prognosis.143 Anti-vascular endothelial growth factor (VEGF) treatment given within 2 years
after diagnosis of neovascular AMD in non-Hispanic white patients has been shown to reduce
legal blindness and visual impairment.144 It is important to note that since the registration trials
for the currently approved anti-VEGF medications, the standard of care is to treat neovascular
AMD as soon as diagnosis has been made. Because early symptoms may be subtle, a
comprehensive eye examination may represent a patient’s best opportunity to be diagnosed and
treated at an earlier and potentially more favorable stage.
Cataract
Cataract remains a significant cause of visual disability in the United States, accounting for
approximately 50% of low-vision cases in adults over 40.145 Cataract is the leading cause of
treatable blindness among Americans of African descent who are 40 years of age and older, and
it is the leading cause of low vision among individuals of African, Hispanic/Latino, and
European descent.31 Because smoking increases the risk of cataract progression,146, 147
informing smokers about this and other associated ocular and systemic diseases may influence
them to stop smoking.
Other Ocular Disorders

Other examples of high-risk conditions or diseases that necessitate a medical eye examination
include a history of ocular trauma or the presence of abnormalities of the anterior segment, such
as corneal ectasia, corneal dystrophies, or peripheral anterior synechiae. Conditions that
increase the risk of OAG (e.g., exfoliation syndrome and pigment dispersion syndrome) and
angle-closure glaucoma (narrow anterior chamber angle) should also be evaluated. High
myopia and abnormalities of the posterior segment, such as retinal tears or retinal degenerations
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(i.e., lattice degeneration or subclinical asymptomatic retinal detachments), increase the risk of
retinal detachment.
SYSTEMIC DISEASES AND CONDITIONS

Important ophthalmic manifestations associated with systemic infectious, neoplastic, autoimmune,
vascular, and nutrition-related diseases may be discovered during the ocular comprehensive
ophthalmic evaluation.
The following components of the comprehensive examination may identify signs of systemic diseases
or other serious medical conditions:
 External examination: orbital tumor, Graves’ disease, metabolic storage diseases
 Pupillary function: Horner’s syndrome, pharmacologic toxicity, midbrain tumor, aneurysm
 Ocular alignment and motility: neurological disorders (e.g., myasthenia gravis, central nervous system
defects or aneurysm, multiple sclerosis), Graves’ disease
 Visual fields by confrontation: cerebrovascular accidents, chiasmal tumors
 Anterior segment: drug or heavy-metal toxicity; immune-mediated diseases (e.g., rheumatoid
arthritis); infectious diseases; vitamin A deficiency; metabolic, endocrine, or storage diseases
 Lens: Alport syndrome, Apert syndrome, atopic disease, juvenile rheumatoid arthritis, myotonic
dystrophy, Wilson disease, homocystinuria, Marfan syndrome, Weill-Marchesani syndrome
 Posterior segment: systemic hypertension, diabetes mellitus, infectious diseases (e.g., acquired
immunodeficiency syndrome, tuberculosis, syphilis, histoplasmosis, toxoplasmosis), immune-
mediated diseases, vasculitis, primary or metastatic tumors, metabolic storage diseases,
phakomatoses, hematologic diseases, cerebrovascular disease, increased intracranial pressure, toxicity
from hydroxychloroquine, tamoxifen, or phenothiazines
SOCIOECONOMIC CONSIDERATIONS
In 2006, the societal cost of major visual disorders (AMD, cataract, diabetic retinopathy, POAG,
refractive errors) among U.S. residents 40 and older was estimated to be $35.4 billion. This total
comprised $16.2 billion in direct medical costs, $11.1 billion in other direct costs, and $8 billion in
productivity losses.148 Not included in this total are costs associated with comorbid conditions, such as
depression or injury.
In another study, U.S. residents 40 and older with blindness or visual impairment had estimated
excess medical expenditures of $5.1 billion annually.149 This estimate includes the cost of home care
and informal care for blind and visually impaired adults. The study also estimated that the total
number of quality-adjusted life years (QALY) lost for individuals with blindness or visual impairment
was 209,000. Valuing each QALY lost at $50,000 would add $10.4 billion to the estimate of the
annual economic impact of visual impairment and blindness.
In 2012, the costs of vision loss and eye disorders among the population younger than 40 years were
estimated at $27.5 billion (95% confidence interval, $21.5–$37.2 billion), including $5.9 billion for
children and $21.6 billion for adults 18 to 39 years of age in the United States. This total included
$14.5 billion in direct costs: $7.3 billion for diagnosed eye disorders, $4.9 billion in refraction
correction, and $0.5 billion for undiagnosed vision loss. The indirect costs were $13 billion, due
mainly to productivity losses. In addition, this cumulative vision loss cost society 215,000 QALYs.150
There were significant differences in the use of eye care services by adults with eye diseases in the
United States with respect to socioeconomic position, as measured by poverty-income ratio and
educational attainment.151
In Australia, researchers estimated that the economic impact and cost in 2004 was A$9.85 billion
(≈ US$9.5 billion), with vision disorders ranking seventh in the direct health care costs of various
health conditions.152 Vision loss was also the seventh leading cause of disability in Australia, with
the years of life lost to disability valued at A$4.8 billion (≈ US$4.64 billion) annually.
In 2006, the annual nonmedical costs related to visual impairment in France, Germany, Italy, and the
United Kingdom were estimated at €10,749 million (≈ US$17.439 million) in France, €9,214 million
(≈ US$14,948 million) in Germany, €12,069 million (≈ US$19,580 million) in Italy, and €15,180
million (≈ US$24,627 million) in the United Kingdom.153
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CARE PROCESS
A comprehensive medical eye evaluation includes a history, examination, diagnosis, and initiation of
management. The examination includes a careful and thorough detection and diagnosis of ophthalmic
disorders, develops a treatment plan for addressing refractive error and ocular disease, and refers detected
systemic disease to the appropriate medical care provider. The items listed are basic areas of evaluation or
investigation and are not meant to exclude additional elements when appropriate. For example, because
history taking is an interactive process, the patient's responses may guide the clinician to pursue additional
questions and evaluation.
HISTORY
In general, a thorough history may include the following items:
 Demographic data (e.g., name, date of birth, gender, and ethnicity or race)
 Patient’s other pertinent health care providers
 Chief complaint and history of present illness
 Present status of visual function (e.g., patient’s self-assessment of visual status, visual needs, any
recent or current visual symptoms, and use of eyeglasses or contact lenses)
 Ocular symptoms (e.g., eyelid swelling, diplopia, redness, photophobia)
 Ocular history (e.g., prior eye diseases, injuries, surgery, including cosmetic eyelid and refractive
surgery, or other treatments and medications)
 Systemic history: medical conditions and previous surgery
 Medications: ophthalmic and systemic medications currently used, including nutritional supplements
and other over-the-counter products
 Allergies or adverse reactions to medications
 Family history: pertinent familial ocular (e.g., glaucoma, AMD) and systemic disease
 Social history (e.g., occupation; tobacco, alcohol, illicit drug use; family and living situation, as
appropriate)
 Sexual history
 Directed review of systems
OCULAR EXAMINATION
The comprehensive eye examination consists of an evaluation of the physiological function and the
anatomical status of the eye, visual system, and its related structures. This usually includes the
following elements:
 Visual acuity with current correction (the power of the present correction recorded) at distance and,
when appropriate, at near
 Refraction when indicated
 Visual fields by confrontation
 External examination (e.g., eyelid position and character, lashes, lacrimal apparatus and tear function;
globe position; and pertinent skin and facial features)
 Pupillary function (e.g., size and response to light, relative afferent pupillary defect)
 Ocular alignment and motility (e.g., cover/uncover test, alternate cover test, ductions and versions)
 Slit-lamp biomicroscopic examination: eyelid margins and lashes; tear film; conjunctiva; sclera;
cornea; anterior chamber; and assessment of central and peripheral anterior chamber depth, iris, lens,
and anterior vitreous
 Intraocular pressure measurement, preferably using a contact applanation method (typically a
Goldmann tonometer). Contact tonometry may be deferred in the setting of suspected ocular infection
or corneal trauma.
 Fundus examination: mid and posterior vitreous, retina (including posterior pole and periphery),
vasculature, and optic nerve
 Assessment of relevant aspects of patient’s mental and physical status
Examination of anterior segment structures routinely involves gross and biomicroscopic evaluation
before and after dilation. Evaluation of structures situated posterior to the iris is best performed
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through a dilated pupil. Optimal examination of the optic nerve, macula, and peripheral retina requires
the use of an indirect ophthalmoscope or slit-lamp fundus biomicroscopy with appropriate accessory
diagnostic lenses.
Based on the patient's history and findings, additional tests or evaluations might be indicated to
evaluate further a particular structure or function. These are not routinely part of the comprehensive
medical eye clinical evaluation. Specialized clinical evaluation may include the following:
 Monocular near-vision testing
 Potential acuity testing
 Glare testing
 Contrast sensitivity testing
 Color-vision testing
 Testing of stereoacuity and fusion
 Testing of accommodation and convergence
 Central visual field testing (Amsler grid)
 Expanded evaluation of ocular motility and alignment in multiple fields of gaze at distance and near
 Exophthalmometry (e.g., Hertel)
 Tear breakup time
 Ocular surface vital dye staining
 Corneal sensation
 Gonioscopy
 Functional evaluation of the nasolacrimal system
 Indirect ophthalmoscopy with scleral indentation
 Contact lens stereoscopic biomicroscopy (e.g., Goldmann three-mirror lens)
Additional diagnostic testing may include the following:

 Keratometry (e.g., to assess surface quality and power)
 Corneal topography/tomography, including analysis
 Measurement of corneal thickness (optical and ultrasonic pachymetry)
 Corneal endothelial cell analysis
 Meibomography
 Tear osmolarity
 External, slit-lamp, or fundus photography
 Anterior and posterior segment optical coherence tomography
 Confocal microscopy
 Wavefront analysis
 Visual fields by automated and/or manual perimetry
 Biometry
 Stereophotography or computer-based image analysis of the optic disc and retinal nerve fiber layer or
macula
 Ophthalmic ultrasonography (A-scan, B-scan, ultrasound biomicroscopy)
 Fluorescein, indocyanine green, and optical coherence tomography angiography
 Electrophysiological testing
 Microbiology and cytology of ocular or periocular specimens
 In-office point-of-care testing (e.g., immunochromatography)
 Radiologic imaging
 Laboratory tests for systemic disease
DIAGNOSIS AND MANAGEMENT

The ophthalmologist evaluates and integrates the findings of the comprehensive ophthalmic
examination with all aspects of the patient's health status and social situation in determining an
appropriate course of action. Patients are considered in one of three general categories based on the
results of the evaluation: patients with no risk factors, patients with risk factors, and patients with
conditions that require intervention.
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Category I: Patients With No Risk Factors

When the initial comprehensive evaluation is normal or involves only refractive errors that
require corrective lenses, the ophthalmologist reviews the findings with the patient and renders
advice regarding an appropriate interval for re-examination. Although this is considered a low-
risk category, periodic re-examination is indicated to detect new, potentially asymptomatic, or
unrecognized ocular disease, such as glaucoma, diabetic retinopathy, and AMD, the incidence
of which increases with age.
A 5-year observational study of a nationally representative cohort of Medicare beneficiaries
showed that patients 65 and older who had more regular eye examinations experienced less
decline in vision and functional status than those who had less frequent examinations.154 For
each additional year in which a patient received an eye examination, there was an increased
likelihood of continuing to read newsprint and maintaining activities of daily living. There was
also a decreased risk of developing new limitations in activities of daily living and instrumental
activities of daily living. Instrumental activities of daily living are activities related to
independent living and include preparing meals, managing money, shopping for groceries or
personal items, performing light or heavy housework, and using a telephone.
There is little evidence in the literature to define the optimal frequency of eye examinations of
patients under 65 with no eye symptoms or signs. There is some evidence that clinically
significant fundus abnormalities in asymptomatic patients increase with age,155 but other
evidence suggests that the diagnostic yield of dilated fundus examination in asymptomatic
patients is low, particularly in younger age groups.156 In the absence of symptoms or other
indications following the initial comprehensive medical eye evaluation, periodic evaluations are
recommended at the frequency indicated in Table 2, which takes into account the relationship
between increasing age and the risk of asymptomatic or undiagnosed disease. At the time of
each comprehensive medical eye evaluation, the ophthalmologist will reassess the patient to
determine the appropriate follow-up interval. Adults with no signs or risk factors for eye disease
should have a comprehensive medical eye evaluation at age 40 if they have not previously
received one.157
Interim evaluations, such as screenings, refractions, or less extensive evaluations, are indicated
to address episodic minor problems and complaints, or for patient reassurance. Other situations
may warrant a comprehensive medical eye evaluation. The extent of the interim evaluation to
be performed is determined by the patient's condition, symptoms, and the ophthalmologist's
medical judgment.
TABLE 2 COMPREHENSIVE MEDICAL EYE EVALUATION FOR ADULTS WITH NO RISK FACTORS
Age (years) Frequency of Evaluation*
65 or older154 Every 1–2 years
55–64 Every 1–3 years
40–54 Every 2–4 years
Under 40 Every 5–10 years
* Interim eye evaluations, consisting of vision examinations (e.g., refractions, eyeglasses, contact lens evaluations), may be performed during these
periods as well.
Category II: Patients With Risk Factors

A patient is considered to be at increased risk when the evaluation reveals signs that are
suggestive of a potentially abnormal condition or when risk factors for developing ocular
disease are identified but the patient does not yet require intervention. These situations may
merit closer follow-up to monitor the patient's ocular health and to detect early signs of disease
with additional testing.
The ophthalmologist determines an appropriate follow-up interval for each patient based on the
presence of early symptoms and signs, risk factors, the onset of ocular disease, and the potential
rate of progression of a given disease. For example, individuals of African descent might
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require more frequent examinations because they are at higher risk for an earlier onset and more
rapid progression of glaucoma. It is recommended that patients with the conditions and risk
factors noted in Table 3 undergo a comprehensive medical eye evaluation at the listed intervals.
TABLE 3 COMPREHENSIVE MEDICAL EYE EVALUATION FOR PATIENTS WITH DIABETES MELLITUS OR RISK FACTORS FOR GLAUCOMA
Condition/Risk Factor* Frequency of Evaluation†
Diabetes Mellitus Recommended Time of First Examination Recommended Follow-up*
Type 1158 5 years after onset† Yearly
Type 2159 At time of diagnosis Yearly
Prior to pregnancy160-162 Prior to conception and early in the first trimester See Diabetic Retinopathy PPP163 for interval
(Type 1 or 2) recommendations based on findings at first examination
Risk Factors for Glaucoma40, 42, 93, 97, 98, Frequency of Evaluation*
164
Age 65 years or older Every 1–2 years*

Age 55–64 years Every 1–2 years
Age 40–54 years Every 1–3 years
Under 40 years Every 2–5 years
* The Center for Medicare and Medicaid Services covers glaucoma examinations by eye care professionals in the office for beneficiaries who have
diabetes mellitus, those with a family history of glaucoma, African Americans 50 years or older, and Hispanics 65 years or older.
† The ophthalmologist’s assessment of degree of risk, abnormal findings, or potential loss of visual function may dictate more frequent follow-up
examinations than listed in this table. If the patient has additional glaucoma risk factors, the Primary Open-Angle Glaucoma Suspect PPP should be
consulted.165
‡ Some patients may require refractive management during this period.
Category III: Conditions That Require Intervention

For a patient with ophthalmic or refractive abnormalities, the ophthalmologist prescribes
glasses, contact lenses, or other optical devices; treats with medications; arranges for additional
evaluation, testing, and follow-up as appropriate; and performs nonsurgical or surgical
procedures, including laser surgery when indicated.
The ophthalmologist should ensure that the patient is informed of relevant examination findings
and any need for further evaluation, testing, treatment, or follow-up. Also, relevant ophthalmic
findings should be shared with the patient's primary care physician or other specialists, as
appropriate. For a patient with systemic abnormalities, the ophthalmologist may advise further
evaluation or referral, as appropriate.
Vision rehabilitation attempts to restore as much functional ability as possible,166 and patients
with reduced visual function may be referred for vision rehabilitation and social services (see
Vision Rehabilitation PPP).167, 168 More information on vision rehabilitation, including materials
for patients, is available at www.aao.org/smart-sight-low-vision.
PROVIDER AND SETTING

Of all health care providers, the ophthalmologist, as a physician with full medical training, best
combines a thorough understanding of ocular pathology and disease processes; familiarity with
systemic disorders that have ocular manifestations; and clinical skills and experience in ocular
diagnosis, treatment, and medical decision making. This makes the ophthalmologist the most qualified
professional to perform, oversee, and interpret the results of a comprehensive medical eye evaluation.
Frequently, and appropriately, specific testing and data collection are conducted by trained personnel
working under the ophthalmologist’s supervision.
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APPENDIX 1. QUALITY OF OPHTHALMIC

CARE CORE CRITERIA
Providing quality care

is the physician's foremost ethical obligation, and is
the basis of public trust in physicians.
AMA Board of Trustees, 1986
Quality ophthalmic care is provided in a manner and with the skill that is consistent with the best interests of
the patient. The discussion that follows characterizes the core elements of such care.
The ophthalmologist is first and foremost a physician. As such, the ophthalmologist demonstrates
compassion and concern for the individual, and utilizes the science and art of medicine to help alleviate
patient fear and suffering. The ophthalmologist strives to develop and maintain clinical skills at the highest
feasible level, consistent with the needs of patients, through training and continuing education. The
ophthalmologist evaluates those skills and medical knowledge in relation to the needs of the patient and
responds accordingly. The ophthalmologist also ensures that needy patients receive necessary care directly or
through referral to appropriate persons and facilities that will provide such care, and he or she supports
activities that promote health and prevent disease and disability.
The ophthalmologist recognizes that disease places patients in a disadvantaged, dependent state. The
ophthalmologist respects the dignity and integrity of his or her patients and does not exploit their
vulnerability.
Quality ophthalmic care has the following optimal attributes, among others.
 The essence of quality care is a meaningful partnership relationship between patient and physician. The
ophthalmologist strives to communicate effectively with his or her patients, listening carefully to their
needs and concerns. In turn, the ophthalmologist educates his or her patients about the nature and
prognosis of their condition and about proper and appropriate therapeutic modalities. This is to ensure
their meaningful participation (appropriate to their unique physical, intellectual, and emotional state) in
decisions affecting their management and care, to improve their motivation and compliance with the
agreed plan of treatment, and to help alleviate their fears and concerns.
 The ophthalmologist uses his or her best judgment in choosing and timing appropriate diagnostic and
therapeutic modalities as well as the frequency of evaluation and follow-up, with due regard to the
urgency and nature of the patient's condition and unique needs and desires.
 The ophthalmologist carries out only those procedures for which he or she is adequately trained,
experienced, and competent, or, when necessary, is assisted by someone who is, depending on the
urgency of the problem and availability and accessibility of alternative providers.
 Patients are assured access to, and continuity of, needed and appropriate ophthalmic care, which can be
described as follows.
 The ophthalmologist treats patients with due regard to timeliness, appropriateness, and his or her own
ability to provide such care.
 The operating ophthalmologist makes adequate provision for appropriate pre- and postoperative
patient care.
 When the ophthalmologist is unavailable for his or her patient, he or she provides appropriate alternate
ophthalmic care, with adequate mechanisms for informing patients of the existence of such care and
procedures for obtaining it.
 The ophthalmologist refers patients to other ophthalmologists and eye care providers based on the
timeliness and appropriateness of such referral, the patient's needs, the competence and qualifications
of the person to whom the referral is made, and access and availability.
 The ophthalmologist seeks appropriate consultation with due regard to the nature of the ocular or other
medical or surgical problem. Consultants are suggested for their skill, competence, and accessibility.
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They receive as complete and accurate an accounting of the problem as necessary to provide efficient
and effective advice or intervention, and in turn they respond in an adequate and timely manner. The
ophthalmologist maintains complete and accurate medical records.
 On appropriate request, the ophthalmologist provides a full and accurate rendering of the patient's
records in his or her possession.
 The ophthalmologist reviews the results of consultations and laboratory tests in a timely and effective
manner and takes appropriate actions.
 The ophthalmologist and those who assist in providing care identify themselves and their profession.
 For patients whose conditions fail to respond to treatment and for whom further treatment is
unavailable, the ophthalmologist provides proper professional support, counseling, rehabilitative and
social services, and referral as appropriate and accessible.
 Prior to therapeutic or invasive diagnostic procedures, the ophthalmologist becomes appropriately
conversant with the patient's condition by collecting pertinent historical information and performing
relevant preoperative examinations. Additionally, he or she enables the patient to reach a fully informed
decision by providing an accurate and truthful explanation of the diagnosis; the nature, purpose, risks,
benefits, and probability of success of the proposed treatment and of alternative treatment; and the risks
and benefits of no treatment.
 The ophthalmologist adopts new technology (e.g., drugs, devices, surgical techniques) in judicious
fashion, appropriate to the cost and potential benefit relative to existing alternatives and to its
demonstrated safety and efficacy.
 The ophthalmologist enhances the quality of care he or she provides by periodically reviewing and
assessing his or her personal performance in relation to established standards, and by revising or altering
his or her practices and techniques appropriately.
 The ophthalmologist improves ophthalmic care by communicating to colleagues, through appropriate
professional channels, knowledge gained through clinical research and practice. This includes alerting
colleagues of instances of unusual or unexpected rates of complications and problems related to new
drugs, devices, or procedures.
 The ophthalmologist provides care in suitably staffed and equipped facilities adequate to deal with
potential ocular and systemic complications requiring immediate attention.
 The ophthalmologist also provides ophthalmic care in a manner that is cost effective without
unacceptably compromising accepted standards of quality.
Reviewed by: Council

Approved by: Board of Trustees
October 12, 1988
2nd Printing: January 1991
3rd Printing: August 2001
4th Printing: July 2005
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APPENDIX 2. LITERATURE SEARCHES

FOR THIS PPP
Literature searches of the PubMed and Cochrane databases were conducted in March 2020; the search strategies
were as follows. Specific limited update searches were conducted after June 2020.
"activities of daily living"[mh] AND ("vision disorders"[mh] OR "visual acuity"[mh] OR "visual fields"[mh] OR
"visually impaired persons"[mh])
"quality of life"[mh] AND ("vision disorders"[mh] OR "visual acuity"[mh] OR "visual fields"[mh] OR "visually
impaired persons"[mh])
"diagnosis"[mh] AND "vision disorders"[mh]
RELATED ACADEMY MATERIALS
Basic and Clinical Science Course

Fundamentals and Principles of Ophthalmology (Section 2, 2019–2020)
Clinical Education
Practical Ophthalmology: A Manual for Beginning Residents, 7th ed. (2015)
Ophthalmic Procedures in the Office and Clinic, Fourth Edition (2017)
To order any of these products, except for the free materials, please contact the Academy’s Customer Service
at 866.561.8558 (U.S. only) or 415.561.8540 or www.aao.org/store.
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Comprehensive Adult

Medical Eye Evaluation

Medical Editor: Susan Garratt

Approved by: Board of Trustees

Copyright © 2020 American Academy of Ophthalmology®

AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are

COMPREHENSIVE ADULT MEDICAL EYE

Preferred Practice Patterns Committee 2020

Preferred Practice Patterns Committee 2020

Secretary for Quality of Care

OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES ..........................................P7

Comprehensive Adult Medical Eye Evaluation Preferred Practice Pattern®

Rationale for Treatment:

OBJECTIVES OF PREFERRED PRACTICE

METHODS AND KEY TO RATINGS

 Key recommendations for care are defined by GRADE2 as follows:

HIGHLIGHTED RECOMMENDATIONS FOR

Smoking is a risk factor for many ocular diseases.

RATIONALE FOR COMPREHENSIVE MEDICAL EYE EVALUATIONS

Primary Angle Closure Glaucoma

Diabetes-Related Ocular Disease

AMD = age-related macular degeneration; IOP = intraocular pressure.

Age-Related Macular Degeneration

Other Ocular Disorders

SYSTEMIC DISEASES AND CONDITIONS

Additional diagnostic testing may include the following:

DIAGNOSIS AND MANAGEMENT

Category I: Patients With No Risk Factors

65 or older154 Every 1–2 years

55–64 Every 1–3 years

40–54 Every 2–4 years

Under 40 Every 5–10 years

Category II: Patients With Risk Factors

Type 2159 At time of diagnosis Yearly

Age 65 years or older Every 1–2 years*

Category III: Conditions That Require Intervention

PROVIDER AND SETTING

APPENDIX 1. QUALITY OF OPHTHALMIC

Providing quality care

Reviewed by: Council

APPENDIX 2. LITERATURE SEARCHES

"diagnosis"[mh] AND "vision disorders"[mh]

RELATED ACADEMY MATERIALS

Basic and Clinical Science Course

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