When I was in my residency in the mid-1990s, the AREDS2 results weren’t available to inform our decision-making about intermediate stage AMD, and no anti-VEGF treatments for wet AMD existed. OCT was still only used at research institutions. To a large extent, the only tool we had to monitor AMD patients was our own eyes—and theirs. Patients were typically followed with an Amsler grid, and we referred them to a retina specialist if something changed. Even then, very little could be done to improve their vision if they developed exudation. Likewise for patients with signs of diabetic retinopathy—we sent them off.
But today, innovative diagnostic testing and breakthrough therapies allow optometrists to focus on retinal disease as a key aspect of our practices. And it works best when the optometrist takes the role of quarterback.
Quarterbacks make sure every player is prepared for the next play; likewise, optometrists are tasked with updating the primary care provider or endocrinologist on the status of their patient’s ocular health. Most importantly, optometrists make sure all members of the health care team are working in concert and at the top of their game, which ultimately benefits the patient.
Better managing patients with retinal disease begins with establishing a relationship with a retina specialty practice. Clinicians should observe the specialist in clinic and surgery to gauge the skills and demeanor of the specialist caring for your patients. With the right team in place, optometrists can be confident when taking the next step—early diagnosis.
Early Diagnosis for the Win
Newer technologies have upped our game when it comes to diagnosing early retinal disease. For example, optometrists who are equipped with OCT, OCT-A and ultra-widefield imaging can often make a relatively clear diagnosis—even before we sit down with the patient.
For dry AMD, clinicians can now diagnose this condition prior to seeing signs (or with only early minimal signs) through dark adaptation testing with AdaptDx (Maculogix). The test takes about six minutes and has over 90% sensitivity and specificity for a diagnosis of early AMD. Genetic testing will also play a significant role in both the diagnosis and potential treatment options in the future.
In cases of diabetes, technology can help identify the million or more cases of diabetic macular edema (DME) that go undiagnosed or untreated in the United States. Widefield photography, OCT and OCT-A can play a critical role in helping us monitor for retinal changes in moderate to severe nonproliferative diabetic retinopathy, increase the frequency of follow up and discuss the importance of systemic control, smoking cessation and nutrition. All of this further helps us make timely referrals for patients at risk for vision loss due to DME or proliferative disease.
The best part of being on the retina team is the expanded playbook. Everything from anti-VEGF therapy to small-gauge surgery allows most patients to have normal vision and lives. Early AMD interventions—such as UV-blocking sunglasses, high-energy visible light-blocking lenses and vitamins with carotenoids (lutein, zeaxanthin, mesozeaxanthin)—can positively impact patients early in the course. AREDS2 supplements may reduce risks for those with more advanced disease. Future therapies directed at previously untreatable causes of vision loss, such as lampalizumab for geographic atrophy, may come to fruition. For end-stage cases, we can refer for an Implantable Miniature Telescope procedure or turn to our own optometric specialists in low vision to provide tangible quality of life benefits.
The features in this month’s Annual Retina Report show just how far optometry has come. We now take charge of the early identification of posterior segment disease and educate patients on anti-VEGF therapy, then comanage with our retina specialists—exactly the sort of teamwork a good quarterback creates.
The health care system will continue to be stressed over the next decade, but with optometry’s higher level of participation in retinal disease, we can make a difference. Optometrists can help slow disease progression and appropriately monitor and refer patients to a multitude of specialists—including those within our own ranks.