What components should be included in a Durable Medical Equipment (DME) examination for a veteran?

DME Examination Components for Veterans

A Disability Benefits Questionnaire (DBQ) examination for a veteran claiming diabetic macular edema (DME) must include dilated fundus examination with slit-lamp biomicroscopy, optical coherence tomography (OCT) to document retinal thickening, visual acuity testing, and assessment of diabetic retinopathy severity using standardized classification systems. 1

Essential Examination Components

Visual Function Assessment

• Visual acuity testing with current spectacles and best correction in both eyes 1
• Intraocular pressure measurement to screen for glaucoma 1
• Assessment of visual symptoms including blurred vision, distortion, and difficulty with reading or driving 1

Dilated Fundus Examination

• Dilated binocular stereoscopic ophthalmoscopy is the gold standard for detecting DME, as it allows three-dimensional assessment of retinal thickening 1
• Slit-lamp biomicroscopy through dilated pupils to evaluate for retinal thickening in the macula 1
• Systematic documentation of diabetic retinopathy severity using the International Clinical Diabetic Retinopathy Disease Severity Scale 1
• Gonioscopy when indicated to assess for neovascularization of the iris or angle in cases of severe ischemia 2

Optical Coherence Tomography (OCT)

• OCT is the most sensitive method for detecting and quantifying DME in high-resource settings 1
• Retinal map scans locate areas of retinal thickening 1
• Single line scans detail specific morphologic changes including intraretinal cysts, subretinal fluid, and vitreoretinal traction 1
• Central subfield thickness measurement determines whether DME is center-involving (within 1 mm of foveal center) or non-center-involving 1

DME Classification Documentation

The examination must classify DME severity 1:

• No DME: No retinal thickening or hard exudates in the macula
• Non-center-involving DME: Retinal thickening that does not involve the central 1 mm subfield zone
• Center-involving DME: Retinal thickening involving the central 1 mm subfield zone

Diabetic Retinopathy Severity Grading

Document concurrent diabetic retinopathy using standardized classification 1:

• No apparent DR: No abnormalities
• Mild nonproliferative DR: Microaneurysms only
• Moderate nonproliferative DR: More than microaneurysms but less than severe NPDR
• Severe nonproliferative DR: Intraretinal hemorrhages (≥20 in each quadrant), definite venous beading (in 2 quadrants), or intraretinal microvascular abnormalities (in 1 quadrant)
• Proliferative DR: Neovascularization or vitreous/preretinal hemorrhage

Medical History Components

Diabetes-Specific History

• Hemoglobin A1c levels and glycemic control status 1
• Duration of diabetes and type (Type 1 vs Type 2) 1
• Blood pressure control and history of hypertension 1
• Serum lipid levels and dyslipidemia management 1
• Renal status including history of diabetic nephropathy 1

Military Service-Related Exposures

• Comprehensive occupational and environmental exposure assessment covering chemical, physical, biological, and psychological stress exposures during military service 3
• Deployment history including number and location of deployments 3
• Military preventive health measures and any service-connected conditions 3

Systemic Medical History

• Cardiovascular disease history including myocardial infarction, arrhythmia, coronary artery disease 1
• Cerebrovascular disease including stroke or transient ischemic attacks 1
• Current medications including all prescription and over-the-counter preparations 1
• Pregnancy status in women of childbearing age, as this affects treatment planning 1

Functional Impact Assessment

Vision-Related Quality of Life

• Assessment of functional abilities including instrumental activities of daily living affected by vision loss 1
• Impact on reading, driving, and mobility 1
• Occupational limitations related to visual impairment 1

Documentation for Disability Rating

• Quantify visual acuity loss in both eyes with best correction 1
• Document central visual field defects if present from macular edema 1
• Assess need for vision rehabilitation services 1

Ancillary Testing When Indicated

Fundus Photography

• Useful for documenting disease activity and tracking progression over time 1, 2
• Provides objective documentation of vascular changes and hemorrhage patterns 2
• Feasible alternative in settings where OCT is not available 1

Fluorescein Angiography

• Not required for DME diagnosis but may guide treatment decisions 1
• Useful to evaluate macular capillary nonperfusion and microaneurysms in complex cases 1
• Can differentiate intraretinal microvascular abnormalities from neovascularization 1

Critical Pitfalls to Avoid

• Never rely on undilated examination alone, as peripheral retinal visualization and stereoscopic macular assessment are inadequate 4
• Do not use non-mydriatic cameras as the sole screening method for DME evaluation 4
• Ensure the examiner is skilled in evaluating diabetic retinopathy and DME, as subtle findings may be missed by inexperienced examiners 1
• Document both eyes separately, as severity may differ significantly between eyes 1
• Assess for other diabetic complications that may affect disability rating, including peripheral neuropathy and nephropathy 1