A Survey on the Current Status of Ophthalmological Consultations in Patients With Diabetes Undergoing Maintenance Hemodialysis and the Effectiveness of Education on Consultation Behavior –Experience of a Single Hemodialysis Clinic in Japan

**Background:** End-stage renal disease (ESRD) patients with diabetes undergoing maintenance hemodialysis (MHD) are at high risk for ocular diseases such as diabetic retinopathy, cataract, and retinal detachment, which can lead to blindness. Regular ophthalmologic examinations are critical for early detection and management. Despite Japan having a large MHD population with high survival rates, many diabetic patients do not receive regular eye exams. The diabetic eye notebook (DEN) was introduced in 2002 to facilitate collaboration between physicians and ophthalmologists, but its use among MHD patients is poorly documented. This study aimed to assess the current status of ophthalmology consultations and DEN use in a single Japanese hemodialysis clinic and evaluate the impact of a nurse-led educational intervention.

**Methods:** This descriptive pre-post study included 38 diabetic MHD patients (25 male, 13 female; mean age 68.7 years; mean dialysis duration 7.2 years) from the Sechi Clinic in Isehara, Japan, who were followed from March 2018 to March 2019. In March 2018, hemodialysis care unit nurses (HCUNs) conducted a baseline survey asking patients whether they had consulted an ophthalmologist and whether they used the DEN. Subsequently, HCUNs provided verbal education on the three major complications of diabetes, emphasized the importance of regular eye exams even during MHD, and recommended using the third edition of the DEN (which records ophthalmologist name, consultation dates, corrected vision, and consultation notes). In March 2019, a follow-up survey reassessed ophthalmology consultation rates and DEN use. Medical records were also reviewed for ocular disease diagnoses at the time of MHD initiation.

**Key Results:** At baseline (March 2018), 22 of 38 patients (58%) reported having regular ophthalmology consultations. Only 1 of those 22 patients (5%) used the DEN. After the one-year educational intervention, the consultation rate increased to 27 of 38 patients (71%), and DEN use among those consulting rose to 19 of 27 patients (70%). Among the 38 patients, 32 had documented ocular disease at MHD initiation (most commonly diabetic retinopathy in 19 patients and cataract in 17 patients), yet 11 of those 32 (34%) were not seeing an ophthalmologist at baseline. The mean HbA1c was 5.9%, and 6 patients were on diet therapy alone.

**Clinical Implications:** This study demonstrates that a simple, low-cost educational intervention by hemodialysis nurses can significantly improve ophthalmology consultation rates and DEN use in diabetic MHD patients. The increase from 58% to 71% in consultations and from 5% to 70% in DEN use highlights the potential for healthcare professionals to enhance patient engagement and self-care. However, 30% of patients still did not consult an ophthalmologist after the intervention, and 30% of those who did consult did not use the DEN, indicating persistent barriers. The authors suggest that closer collaboration between dialysis physicians, primary care doctors, and ophthalmologists—facilitated by tools like an improved DEN that includes comprehensive patient data (e.g., weight, blood glucose, lipid profile, renal function)—could further increase consultation rates. They also emphasize the need for multidisciplinary self-care education both before and after dialysis initiation. Limitations include the single-center design, small sample size, and lack of a control group, which limit generalizability. Nonetheless, the findings support the value of patient involvement and team-based care in preventing vision loss in this vulnerable population.