Remote AMD monitoring leads to more personalized care
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Age-related macular degeneration is a condition that requires regular monitoring in order to preserve vision and detect any changes in the eye.
Recent technology advancements have made it possible for patients to monitor their condition from home using tools that can detect slight changes and communicate with their ophthalmologists.
Healio spoke to Jeffrey S. Heier, MD, director of retina service and retina research at Ophthalmic Consultants of Boston, about how at-home AMD monitoring works, its benefits for patients and the future of the technology.
Healio: Which devices are currently available for remote monitoring?
Heier: Remote monitoring technologies for retinal applications available today include the Home Vision Monitor, formerly myVisiontrack (Roche-Genentech); the King-Devick Variable Color Contrast Sensitivity Chart, Alleye (Oculocare); and OdySight (Novartis).
These modalities are designed for patients to easily monitor their AMD more consistently with a potentially higher sensitivity for detecting any possible changes to neovascular AMD. The underlying science behind these monitoring systems are more advanced than the standard Amsler Grid, but they do rely on the patient’s compliance with the need to use them daily.
The Notal Vision Monitoring Center provides digital health services for remote monitoring of patients with AMD. Its ForeseeHome AMD Monitoring Program supports the early detection of conversion from dry to neovascular AMD. Following a physician referral, the monitoring center provides the patient with a preferential hyperacuity perimetry (PHP) device that detects changes in metamorphopsia often seen in conversion to nAMD. These changes are identified by an artificial intelligence algorithm that analyzes data from thousands of patients every day.
Healio: What are the benefits of remote monitoring? What are the drawbacks?
Heier: Remote patient monitoring is most relevant in diseases with acute onset or worsening that require prompt treatment.
Office visits only give us snapshots of disease progression. An asymptomatic acute event can remain unnoticed by the patient for months. Specialized home monitoring services may help to close the gap in care and allow physicians to be notified when a patient needs to be seen in the office for further diagnostic testing and potential treatment.
Physicians partnering with a monitoring center require implementation of a communication workflow between the providers. Referrals require HIPAA-compliant exchange of patient information, but that’s easily done via secure online portals. A point of contact in the practice needs to be identified so notifications from the monitoring center are reliably relayed to the managing physician, if the physician is not indicated as the point of contact. Remote monitoring makes patient care more responsive and requires more flexibility in patient scheduling. The highly sensitive functional PHP test sometimes brings patients to the office that show unspecific changes in metamorphopsia. Patients experience these types of changes on average only once every 3.5 years and are typically relieved when no exudation was confirmed in the office.
Healio: What do the data say?
Heier: Real-world data collected on almost 9,000 patients participating in the ForeseeHome program showed that 81% of neovascular AMD conversions were detected at a visual acuity of 20/40 or better.
These patients enter anti-VEGF treatment with a good prognosis of maintaining functional vision, as an analysis of IRIS registry data has shown. When choosing a care plan for an intermediate dry AMD patient, we need to always remind ourselves that visual acuity at baseline is the strongest predictor for adherence to therapy and long-term outcomes.
Healio: How is remote monitoring used in clinical practice? Are there certain patients for whom remote monitoring would be particularly beneficial?
Heier: Physicians partnering with a remote monitoring center can easily implement the services into their practice in an efficient manner and with zero overhead. Medicare covers the FDA-cleared ForeseeHome program for eyes with intermediate dry AMD with a visual acuity of 20/60 or better.
In a medical retina practice, these are not only bilateral cases but also fellow eyes of patients we treat with anti-VEGF. Fellow eye conversions in patients with long extension intervals are of particular concern.
Remote monitoring extends our care to the home of these patients whose long-term visual performance very much depends on the fellow eye. Long-acting drugs and slow drug release solutions will increase the need for remote monitoring because we will not see our patients as frequently and offer them the accustomed in-office diagnostic safety net.
Healio: Are there any other devices or monitoring systems in development? Are there other studies in the works?
Heier: An exciting continuation of the remote patient monitoring paradigm into exudative retinal diseases is a home-based OCT. We recently conducted, in collaboration with Nancy Holekamp at Pepose Vision Institute, a feasibility study with an investigational tele-connected patient self-operated OCT device (Notal Vision Home OCT) in neovascular AMD patients (Figure 1).
At the American Academy of Retina Specialists’ annual meeting, we reported that over a 3-month follow-up period, patients successfully completed 96% of scan attempts with a median weekly frequency of 5.7 times per week.
We were pleased to see that it only took patients 40 seconds to self-align their eyes to the OCT scanner with the visual feedback guidance system of the home use device.
Following automatic image transmission to the secure cloud, operated by a monitoring center, an AI algorithm identified and quantified fluid in the retina. Intra- and subretinal fluid volume trajectories with high temporal granularity gave us new insights in disease dynamics and treatment response. I expect that in the future, fluid alerts that are based on eye-specific physician-set threshold criteria will help us reduce the days of retinal fluid exposure we saw in some of our patients under the standard of care treat and extend management in this study (Figure 2).
Healio: Do you have a take-home message for readers?
Heier: Remote patient monitoring allows us to better personalize our care and be more responsive in our interventions. Patient self-operated, AI-enabled diagnostic devices offered by specialist providers in eye care have begun to allow us to embrace digital health care in our field as well. The professional component of the newly established remote OCT codes as well as the 2021 E/M code recognition of the time spent to refer patients and review data from remote monitoring providers supports these new care models.
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