In primary care of the retinal disease patient, ODs must realize full scope of practice and comanage with other physicians

--- Larry J. Alexander, OD

Author and international lecturer Larry J. Alexander, OD, recently completed a 20-year career at the University of Alabama at Birmingham, School of Optometry, as chief of the ocular disease service. He served as an optometrist in the U.S. Navy for 2 years before joining the faculty at UAB. His primary interests are in glaucoma, diabetes, hypertension, macular degeneration and brain injury.

Alexander is currently associated with a multispecialty group in Indiana and Kentucky, works in the areas of managed care, refractive surgery and the integration of eye care networks, and recently released the 2nd edition of his textbook, Primary Care of the Posterior Segment.

In an interview with Primary Care Optometry News Staff Writer Susan Biro, Alexander discusses optometry's evolving role in managing retina/vitreous patients, the responsibility behind therapeutic laws, and his support of nutritional supplements in preventing age-related macular degeneration.

Primary Care Optometry News: How has optometry's role changed in managing retina/vitreous patients?

Larry J. Alexander, OD: When I graduated from optometry school optometry was in a phase where we rarely dilated patients; therefore, we rarely had an opportunity to see what was going on inside the eye. At that point, we had no need to learn about diagnosis and management of retina/vitreous disorders.

When the evolution of diagnostic pharmaceuticals began, we essentially forced our own hand. We hit that stage where we became good detectors and diagnosticians, and from that point had to evolve to figure out why the changes were occurring in the retina. The majority of changes that occur in the eye, other than retinal tears, are associated with some systemic disorder, so the next logical evolutionary step was the area of understanding systemic disease as it relates to the eye. Once we understand that, we became better managers.

Therapeutics is actually the easy part of all this. It's the diagnosis that's the real challenge as far as I'm concerned.

PCON: How do you feel about optometrists ordering special diagnostic tests such as fluorescein angiography or electrodiagnostic tests?

Alexander: If you're asking whether or not optometrists should be able to order special diagnostic tests, without a doubt the answer is yes. If you do not order and do not understand fluorescein angiography, then you do not understand diagnosis of retinal and vitreous disorders, because fluorescein angiography is going to give you the real answer to what's going on at a clinical/pathological level. It's the only way to tell if vessels are compromised, if they're leaking. It's the only way to assess the underlying retinal and choroidal anatomy.

Electrodiagnosis is good to have in your differential diagnostic testing armamentarium, but it is certainly not of the same importance as fluorescein angiography. Electrodiagnosis comes into play primarily in hereditary retinal/choroidal diseases. While it's important from an epidemiological standpoint, you're going to need fluorescein angiography more frequently.

Visual fields is a special diagnostic test, and it is highly underutilized by optometry and ophthalmology. We're thinking only about glaucoma, yet visual fields are useful in retinal disease, hereditary retinal disease, optic nerve disease and neurological disease.

More lab tests ordered

Ordering blood tests is the next big area of development in optometry. You're seeing those kinds of requests more frequently: blood glucose levels, glycated hemoglobin levels, CBCs and other laboratory tests. The important thing to realize is when you see something in the eye, you are obligated to figure out why it's there, and a laboratory diagnostic assessment is important in attaining your goal.

PCON: And optometrists should order these tests?

Alexander: Yes, it doesn't matter if I order the tests or if the primary care physician orders the tests. I often choose to get the primary care physician involved by calling and saying, "I've got Mrs. Jones here. She has a branch vein occlusion, she is a little bit hypertensive, and I would like us to consider ordering these lab tests for her," and then let the primary care physician order them. This includes everyone in the loop and lets the primary care physician know that you know what you're doing.

Be a primary care provider

If we're going to ask to be included in the primary health care delivery system, understanding laboratory testing is critical. You either control your own fate or somebody's going to control it for you. We have touted primary care optometry for a long time and it has been accepted, but now we have to carry forth with it. We've asked for therapeutics, yet we write under 5% of the therapeutic prescriptions that go out in this country.

PCON: What do you think are the reasons fewer than 5% of ODs write all the prescriptions right now?

Alexander: I think everybody wants to be able to do it, and we are certainly trained to do it, but nobody wants the responsibility of doing it. Anytime you use a therapeutic agent, anytime you order a diagnostic test, anytime you go above and beyond what you've been doing for years, you're taking some degree of risk and responsibility.

Very often with this responsibility there's not increased income generated; therefore, there's little motivation there. It takes a lot of work and a lot of studying.

There's also X amount of expenditure involved. There are more excuses not to do it than there are to do it, but again, we've called ourselves primary care. In the managed care environment, it becomes critical. If we're certified to manage glaucoma patients and a patient who is capitated walks into our office and we choose to send him off to a higher care level, the managed care company will track that and say, "Why should I even contract with you if the tertiary-level provider can provide all of these services?" This has happened in some markets.

PCON: Addressing age-related macular degeneration (AMD), what can ODs tell patients today that they could not have told them 15 or 20 years ago?

Alexander: Unfortunately it's fairly easy to diagnose, but once AMD happens, there's not a whole lot you can do about it. In theory there are means to improve wet macular degeneration, or the choroidal neovascular membrane variety. Laser photocoagulative intervention comes to mind. The trouble is a high recurrence rate over the years with laser-treated wet AMD. There is the possibility of subfoveal surgery to remove the choroidal neovascular membrane, but that doesn't work very well in AMD. You get an anatomical success, the membrane's gone, but the patient can't see very well.

PCON: What are the important AMD issues today?

Alexander: There's been considerable hype for nutritional pharmacology or vitamin therapy in preventing macular degeneration. I have investigated and written on it, and I'm a proponent of it. But there are a lot of caveats, such as once severe AMD happens, it's difficult to reverse with nutritional therapy.

The thing that no one emphasizes is the fact that there isn't a magic-bullet solution. If you have a 350-lb. hypertensive patient in your chair and you recommend antihypertensive medication to prolong his or her life, you might give them another 20 minutes of life. If you don't modify their lifestyle it's not going to do that much good.

I think the same thing holistic approach exists with macular degeneration. The patient should take nutritional supplements in the morning and at night. You've always got to take them with meals, because lipids are what carry the nutrients to the retina. If Olestra, the new fat substitute, is approved in the United States, it will be the number-one cause of macular degeneration in the year 2020, because the patient will no longer have the necessary lipids to carry the nutrients to the retina. If you don't have fat to carry vitamins to the eye, you're going to lose all the benefits of nutritional supplements.

We as optometrists are poised to become active in the prevention of macular degeneration. We can advise our patients about nutritional pharmacology. I don't think I want us all selling vitamins in the office, but at the same time we have the responsibility to let people know about the cause of AMD and the possible preventive measures. Optometrists know the way to block the cause of macular degeneration: short-wavelength blue light and probably some UVB. We can produce glasses to block these wavelengths

PCON: So optometrists are ideally situated to perhaps change a patient's lifestyle to lessen their chance of developing AMD?

Alexander: Optometry is in an excellent position to actually contribute to the demise of macular degeneration. The most important thing is to get industry involved in order to put out a successful public campaign. It's difficult to modify Americans' lifestyles, but the cholesterol campaign seemed to do it, and they had industry support.

Optometrists can work on the prevention side of it. Also, we don't have a psychological counseling program for people who are losing their vision, and it bothers me deeply that we as a health care industry are not helping the aged population deal with the loss of vision. We need to train optometrists and ophthalmologists to give some sort of counseling, or we need to get the federal government or insurance companies to pay for it. If you lose a limb and you get a prosthesis, you're going to get psychological counseling. If you lose your sight you'll get counseling if you're young, but if you're old, you don't get counseling.

PCON: What should optometrists tell their patients about nutrition and its role in preventing AMD?

Alexander: If you don't want to get macular degeneration, one, don't get old; two, have good genetics.

If you're a woman and you're supposed to take estrogen, take it, because if you don't you've got an increased incidence of developing macular degeneration. If you're a smoker, you're in deep trouble because each cigarette burns up to 25 mg of vitamin C every time you smoke, and if you don't replace it, you're increasing the risk of macular degeneration.

Lifestyle changes needed

You need to eat a healthy, balanced diet. Excessive fats are going to create all kinds of problems within the retina. You want a high-fiber diet, but you've got to be careful with that, too, because if you eliminate all of your lipids with a high-fiber diet, you've got nothing to carry nutrients to the eye. If you're taking nutritional supplementation in the form of vitamins and are not taking it on a full stomach, you're not helping yourself, because lipids carry it to the eye. It's a complex issue, but it involves a lifestyle change.

PCON: Let's move on to diabetic retinopathy. As ODs become more involved in managed care, should they manage these patients up until surgery?

Alexander: This is a tough one. I'll give you a political answer, and then a pragmatic one. The American Optometric Association put together guidelines for care of the diabetic patient, developed by a panel that I happened to head. We came up with a series of guidelines that would stand up to any medicolegal review.

Dilate all diabetics

--- AMD in a diabetic patient: Neovascularization and exudative infiltration secondary to wet age-related macular degeneration.

Certainly, any optometrist who's managing a diabetic patient has to dilate that patient. While that seems like a no-brainer, I find I have to say it, and I don't mean that just toward optometry. I did a study reviewing how optometrists and ophthalmologists in the state of Florida manage diabetic patients. Surprisingly, only 70% of optometrists and ophthalmologists routinely dilated patients with diabetes. You can't do that. If you as an eye care practitioner aren't dilating diabetic patients, then you must send those patients to somebody who routinely dilates. That's a stance from which I will not waver.

The pragmatic answer is that optometry and ophthalmology are trained and equipped to manage the patient with diabetic retinopathy up to the point of laser or surgical intervention, assuming the patient with diabetes is routinely dilated.

PCON: What are the reasons eye care providers have for not dilating diabetic patients?

Alexander: The reasons are phenomenal. The typical answers range from "I can't figure out how to put it in my schedule," and "It would delay my patient care," to "I don't see any benefit to it," or "I'll dilate people when I see something wrong inside of the eye."

In fact, how can you see something wrong if you don't dilate? There are no good reasons; it makes no sense.

PCON: What kinds of things should optometrists look for in the retina that signal a potential problem?

Alexander: Anytime there's intrusion of edema or hard exudates into the foveal avascular zone or into the macular area, that deserves a fluorescein angiography and a retinal consult. Anytime there's neovascularization out of the disk or elsewhere, or there's iris neovascularization, that deserves a retinal consult.

--- Glaucoma patient: Fluorescein angiography shows telangiectatic leaking vasculature in the afflicted area in a glaucoma patient.

One of the things that should alarm optometrists is the appearance of a lack of oxygen. If you see signs of lack of oxygen such as cotton-wool spots, flame-shaped hemorrhages and IRMA (intraretinal microvascular abnormalities), then that deserves a fluorescein angiography. One of the other aspects of comanagement of diabetic retinopathy is working with the primary care physician.

If you've got a 35-year-old, 20-year-duration diabetic sitting in your chair and the retina looks fine, you can call the primary care physician and ask about the patient's last glycated hemoglobin level. Let's say it's 8.5%, then you can say the glycated hemoglobin level is good and you can see this patient in about 6 months. But if the primary care physician says the level is 12.0%, you should be concerned, and see the patient again in 3 months.

You've got to modify your management protocol according to what's going on with the general health of the patient. If the patient's got end-stage renal disease, but the retina looks fine, you should see him more often. If there are other complications, such as poorly controlled hypertension, then you've got to consider those factors. That becomes the difficult part of comanaging retinal patients. You've got to have a communication system built with the primary care physician. When you talk about comanagement, it involves not only a retinal specialist, but it also involves the primary care physician.

The future is being driven by outside forces. Medicolegal issues and the threat of managed care pose additional obstacles in the evolution of eye care delivery. Are lawsuits bad? Well, lawsuits are bad. Is managed care bad? Managed care is potentially bad. But the interesting thing about managed care and lawsuits is that they force us to think in a different way, to document better, and this often makes us better health care providers. Internal housekeeping through a coordinated national effort is critical.