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OCT, communication are keys for comanaging AMD patients
When it comes to comanaging age-related macular degeneration patients with a retinal surgeon, one thing is certain: A clear protocol does not exist. However, recent developments in technology and science have ushered in a new treatment paradigm, one in which optometrists can play a key role.
“Retina has been the classic black hole,” Larry J. Alexander, OD, a practitioner at the John Kenyon American Eye Institute in Louisville, Ky., told Primary Care Optometry News in an interview. “You would send the patient off to the retina doctor and never see him again. I have never, in my 37 years of practice, seen as much variation in the management of retinal patients. It’s all over the board.”
Part of the issue is that, most of the time, the treatment is unique to each patient, and the outcomes of such treatments are unpredictable.
However, if retinal surgeons’ decisions to retreat are based on criteria rather than duration – an abnormal ocular coherence tomography or fluorescein angiogram, for example – optometrists may be able to “plug back in” to the treatment, Jeffry D. Gerson, OD, FAAO, a fellow of the Optometric Retina Society who works at West Glen Eyecare in Shawnee, Kansas, told PCON.
Dr. Gerson said ODs who know and understand the criteria the surgeon uses and have the technology to look for that criteria, position themselves as true partners in the follow-up and management. “It’s important that we realize treatment doesn’t stop with medicine and surgery,” Dr. Gerson said.
Education, communication
Michael J. Tolentino, MD, a retina specialist and researcher with the Center for Retina and Macular Disease in central Florida, helped develop current AMD treatments and believes wholeheartedly in expanding optometrists’ educational opportunities in that realm.
“Right now so many novel things are happening to our AMD patients,” Dr. Tolentino said in an interview. “The protocols for treating these patients are fluid. The key is for ODs to constantly be updated in what’s happening, so they understand. We feel as a group that we need to manage these patients with our optometric colleagues.”
To that end, Dr. Tolentino’s center has established the Florida Retina Symposium, an annual event in Orlando where retina specialists educate optometrists on identifying early AMD and other retinal pathologies. Optometrists and ophthalmologists can and should work together, Dr. Tolentino stressed.
“The only people who get hurt when you become territorial are the patients,” he said. “If our optometrists aren’t educated in terms of picking up the disease and knowing how it will be managed, our patients won’t be either. It’s important to get these patients in early because we have all these new treatments to offer them.”
The clinicians who spoke to PCON said communication, via phone, e-mail or letter, between the retinal surgeon and comanaging optometrist is vital. “Call the retina surgeon and document what they expect in this comanagement situation,” Dr. Alexander said.
Early detection
Intravitreal injections with Avastin (bevacizumab, Genentech) and Lucentis (ranibizumab, Genentech) have revolutionized the treatment of AMD. The sooner the disease is detected and treated, the better the outcome, according to Shaun K. Coombs, OD, who is in practice at Pacific Cataract and Laser Institute in Chehalis, Wash.
“Early detection is critical for the successful optometric comanagement of AMD patients, because success with the latest treatment modalities such as photodynamic therapy and the anti-VEGF agents is maximized when applied early in the conversion from dry to wet AMD,” Dr. Coombs said. “Closely monitoring the patient for progression is another key, because recurrence of subretinal neovascularization and involvement of the fellow eye is unfortunately common.”
OCT is crucial
Optical coherence tomography is quickly becoming the technology of choice for optometrists and ophthalmologists who identify and manage retinal edema.
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“The one absolute in all of this is, if you are going to comanage any retinal patient you have to have some sort of OCT device,” Dr. Alexander stressed. “You need something that’s going to image the retina because the majority of things we are talking about here, you can’t clinically see.”
William Jones, OD, FAAO, a member of the PCON Editorial Board, agreed. “The Amsler grid is not up to the rigors of new technology,” he told PCON. “For the retinal surgeon to feel comfortable sending patients back to you, he or she would want to see some type of technology in the office for you to provide adequate follow-up.”
Mark T. Dunbar, OD, FAAO, of Bascom Palmer Eye Institute, Miami, said an OCT device would be especially beneficial for optometrists in rural settings. “You can imagine what a burden it is to have to come back to the ophthalmologist every month,” Dr. Dunbar told PCON. “If you don’t have an OCT, it is a little more difficult to have the trust from a retinal specialist and to even be able to accurately assess these patients.”
Drs. Jones and Tolentino touted the benefits of using preferential hyperacuity perimetry (Foresee PHP, Notal Vision/MSS, Bloomington, Minn.) exam, which helps clinicians detect the presence of elevations in a patient’s outer retinal layer. Patients identify humps in a dotted line they view on a computer screen, which, in turn determines the bowing of the photoreceptor layer.
“The PHP is a useful technology because it will catch the patient before he or she has lost any vision,” Dr. Tolentino said. “If we can see those patients before they have lost any vision, we know we can preserve their vision.”
Maximizing vision
Although a retina surgeon can save a patient from losing vision entirely, an optometrist can still take steps to maximize that sight.
Dr. Alexander said patients can benefit from visual rehabilitation. “It’s not just the physical or anatomical repair, it’s the subsequent follow-up care that’s necessary,” he said.
Steps may be as simple as fine-tuning a patient’s spectacle prescription, prescribing drops for dry eye or introducing a patient to low vision devices.
“A patient with relatively good vision might not be bothered by dry eye. If you reduce their vision to 20/60, a small issue like that becomes hypercritical,” Dr. Alexander said.
Patients also may benefit from an optometrist’s counseling expertise, especially on smoking cessation and nutrition, he added. “The majority of the time the retina surgeon will take care of the anatomical issue, but they don’t carry it one step further and take care of these other issues patients may have,” Dr. Alexander said. “That is where we, as family practice people, come in. The actual comanagement is probably more related to advice to the patient and rehabilitation of vision than it is for watching for the recurrence or evolution of the procedure.”
Dr. Tolentino added that optometrists should prescribe vitamins based on the Age-Related Eye Disease Study (AREDS) formula. For patients who receive intraocular injections, periodic monitoring for the development of cataracts, glaucoma or, in rare cases, endophthalmitis also is necessary.
For more information:
- Larry J. Alexander, OD, can be reached at 6907 Bridgepointe Blvd., Prospect, KY 40059; (502) 727-6568; e-mail: larryalexander@insightbb.com.
- Jeffry D. Gerson, OD, FAAO, can be reached at 12409 Howe Dr., Shawnee, KS 66217; fax: (913) 962-2013; e-mail jgerson@hotmail.com.
- Michael J. Tolentino, MD, can be reached at the Center for Retina and Macular Diseases, 250 Avenue K SW, Winter Haven, FL 33880; (863) 297-5400; fax: (863) 293-9780; e-mail: miket@crmd.net. Dr. Tolentino is a paid consultant for MSS.
- Shaun K. Coombs, OD, can be reached at 2517 Kresky Ave., Chehalis, WA 98532; (800) 888-9903; fax: (360) 748-3869; e-mail: shaun.coombs@pcli.com.
- William Jones, OD, FAAO, can be reached at 1828 Conestoga Dr. SE, Albuquerque, NM 87123; (505) 293-7347; fax: (505) 247-2153; e-mail: wjones556654@comcast.net. Dr. Jones is a paid consultant for MSS.
- Mark T. Dunbar, OD, FAAO, can be reached at Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, 900 NW 17th St., Miami, FL 33136; (800) 329-7000, ext. 4042; fax: (305) 326-6585; e-mail: mdunbar@med.miami.edu. Dr. Dunbar is a member of the Zeiss Speakers Bureau. Drs. Alexander, Gerson and Coombs have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.