The Optometrist’s Role in Managing AMD: Part 2

Mark Dlugoss:

Age related macular degeneration is a leading cause of irreversible blindness in visual impairment in the world. According to recent statistics, nearly 20 million Americans have come down with some form of AMD. In recognition of February being AMD awareness month, Ophthalmology 360 wanted to sit down with a leading KOL and Optometry to discuss several points associated with AMDD and Optometry’s role in a diagnosis and treatment of AMD. Hi, this is Mark Dlugoss, senior contributing editor of Ophthalmology 360, and joining me is Dr. Mark Dunbar. Dr. Dunbar is director of Optometric Services at Baskin Palmer Eye Institute in Miami. Flora, thanks for joining us today at Dr. Dunbar.

Mark Dunbar, OD, FAAO:

It’s great to be here, Mark, thank you for having me, and I’m looking forward to a great discussion.

Mark Dlugoss:

New treatment options present new opportunities, especially for optometrists to engage more in all phases of AMD management. Can you outline some of these opportunities and how optometrists can take advantage of them to provide better patient care?

Mark Dunbar, OD, FAAO:

So again, we talked about earlier diagnosis. We don’t need to kind of rehash that. And again, the idea that if we’re using these kind of second generation anti-VEGF drugs that really will extend treatment. So they don’t need to see a retinal specialist as often. These are patients that can be seen in an optometric practice. So if you’re getting an injection every four months, let’s say, patients may want to be seen in the interim. So they may be able to be seen in at a month or two months by their optometrist, and that may be because they need a new pair of glasses. There’s a change in their prescription. So these are patients that are coming in and an opportunity to improve their vision refractively. But at the same time, again, if you’ve got the technology like OCT devices and whatnot, to be able to, let’s do an OCT and kind of see where you are in terms of the treatment, again, I think that speaks to the importance of having the necessary imaging technologies to be able to really function at that level.

Certainly without OCT, that’s, that just really wouldn’t happen. And again, I think most optometrists have recognized the importance of technology to be able to follow and diagnosed early as we kind of spoke of. So again, we talk about geographic atrophy. These are patients who are dry that traditionally we would follow or we would helplessly watch them. And now again, early diagnosis, early recognition, and then getting these patients in to see a retinal specialist, I think affords an opportunity to take better care of patients and preserve vision, preventing patients from losing independence. Like the poor lady that I saw today, 20 30, 20 40, in her only eye, the clock is ticking. And Kurt, certainly we send patients to low vision and that becomes a critical part of it. But in terms of her ability to drive and be independent and those type of things, I felt great letting her know that finally we’ve got something to offer her. And she felt, I think great knowing that there’s something coming down the pipe that might be able to help her.

Mark Dlugoss:

There’s been much of debate about optometrists in AMD detection diagnosis and referral, but it’s not about whether the optometrist can perform these duties, but whether the quality of work associated with these responsibilities, are optometrists ready to meet those responsibilities as things change in AMD treatment?

Mark Dunbar, OD, FAAO:

Well, I think absolutely. I think you’re seeing it. And again, just technology being the critical piece. We talk about spectral domain OCT, OCT angiography. These are devices that, as I said earlier, I think it’s leveled the playing field. It’s the same technology that my retinal specialist has. So I can do that type of a scan cross-sectionally with a high degree of sensitivity. We’re looking at being able to look at microns of resolution of retinal anatomy. So absolutely with that type of technology, it levels a playing field. So that diagnosis, it’s not a mystery, it’s not an occult disease. This is something that every one of us are able to make and follow with a high degree of sensitivity and specificity. The fact is we have to be able to do that, right? I mean, you look at the number of people, patients are living longer, they’re healthier, they’re more active.

And so it requires optometry to be able to step up to provide that level of care because certainly the retina community and the comprehensive ophthalmologists can’t see these people that we all have to work together. So to answer your question, in the absence of imaging technologies like OCT, I think we would all be handicapped. And again, when I started practicing in the ’80s and ’90s, you had to really rely on your clinical skills and ability. And if you thought a patient had converted, it was referring to a retinal specialist who was getting an injection.

It was doing a fluorescein angiogram, developing the film. Back then it was the dark ages, and now we’re really in a era where every optometrist and ophthalmologist has a technology to function at the level of a retinal specialist and being able to establish a diagnosis with OCT imaging technology. So I absolutely think so. And again, not say that we’re as good. I don’t want to imply that at all. For people who are, Mark Dunbar thinks these are, no, I’m not a retinal specialist. I’m a primary eye care provider. I’m an optometrist. But I think with the technologies that I have, I think all of us have all the tools to really, with a high degree of skills and ability, to establish these early diagnosis, follow these patients appropriately and closely, and get these patients into a retinal specialist in a timely manner.

Mark Dlugoss:

Are there any challenges for optometrists to increase their knowledge and competencies of AMD therapies, detection methods, genetic testing, and new retinal imaging techniques? Are there any challenges for them?

Mark Dunbar, OD, FAAO:

Well, of course. Things have changed so quickly over the last four or five years with treat and extend and some of these newer treatments coming down the pipe. We talked about geographic atrophy. So where do you get that information? It’s listening to webinars. We’ve got great web-based media to be able to learn. It’s going to the different congresses and meetings. It’s picking up journals. And again, fortunately we’re an era where we are bombarded with information and you look at the pharmaceutical companies that have a marketing side.

So there’s constantly, we’re barrage with emails and opportunities to listen on web-based programs. I’ve done a number of them with retinal specialists. So yes, I think it’s like all of us that have graduated for a while and in practice in an area where there’s a fairly rapid turnover and new information coming down the pipe. How do you keep up? And that’s kind of the goal that the challenge we all face in healthcare is personalized medicine. It’s keeping up with what’s new and current. And again, just those are the challenges we all have, but I think we have many tools at our disposal to really help us to be able to do that.

Mark Dlugoss:

Do you see any challenges for the schools and colleges of optometry as well as the optometric associations to enhance DTAC instruction, clinical teaching, continuing education, and AMD management? What needs to be accomplished or updated in that area?

Mark Dunbar, OD, FAAO:

Well, I think the schools do really a very good job mean macular degeneration and other diseases are part of the curriculum. Those classes are taught, all these schools have advanced technology, so they’ve got really experts talking about ocular disease, macular degeneration. The students and externs are able to use OCT devices, OCT angiography devices. And I absolutely think that happens. You look at people, lecturers at some of these national meetings. These are people that are at the schools that go back and really teach their students. The students, all of them go on fourth year externships where they’re getting clinical training and with ophthalmology. So I think it happens. Many of them do postgraduate residencies, as I said, we have six residents, we have seven or eight students. And so I think that is being taught. And again, by being in these settings, I think they’re able to probably better than the person who’s been out four or five years being aware of some of these newer treatments.

Mark Dlugoss:

Now, equipment innovation for diagnosis and management of AMD have come a long way over the last 10 years. What are your impressions of these advancements and what innovations have impressed you the most?

Mark Dunbar, OD, FAAO:

Well, no question. I mean, OCT imaging technology has been the biggest game changer since Helm Holes invented the ophthalmoscope. There’s nothing that has come along like OCT technology to be able to really help us provide a living optical biopsy. I was privileged enough to, when I started Dr. Gas, who was really considered one of the greatest retinal specialists of the 20th century. So we would go in and look through his teaching scope, and he was a legend in great, and I think the world of Dr. Gas, right? But there were things that he spent his life trying to understand macular holes, the role of the vitreous, the role it plays in vitro macular traction or macular holes. And OCT comes along. And it wasn’t certainly simple, but it really became a game changer and it still is. We see that technology continue to evolve. Broader scans, wider scans it’s really become, I think, the most important technology of really certainly the last 25 years.

Mark Dlugoss:

One recent innovation in terms of eyecare has been the workflow systems in the clinic. Are you utilizing a workflow system in your clinic to manage patient data?

Mark Dunbar, OD, FAAO:

So we obviously have an integrated electronic health record. I think probably by now almost every eyecare provider does. We do have an image software system that’s integrated into our electronic health record. We have both the forum and we have optos. So I don’t use the retina workspace as much as I do in the glaucoma side just because the scans in terms of recognition, documenting progression, again, there are workflow software programs that are helpful. I think in optometry and primary eye care, they’re a little bit less essential, but certainly as I said, they are integrated into our electronic health record. So you can just toggle back and forth and to be able to look and compare clinically. What’s happening with these scans really has become a way we all practice today. I think about I can walk in a room and we have two computer monitors on one monitor is the image of what I want to look at and the other one is obviously the electronic health record.

And so when you’re going to look at a patient, you know, already have a sensor and idea of what you need to look at and focus on, and again, in our retinal retinal specialist, same thing. They got a fund photo on one screen, they got an OCT on the other, and we’re at a point, again, we’re looking at microns of resolution. And so yeah, it’s become a critical part of being able to take care of patients. And again, on the ophthalmology side, in the retina community, you’re looking at these guys seeing 70, 80 plus patients a day. And you can’t do that unless you have really an integrated electronic health record with an imaging image management system. In optometry, we don’t see those kind of numbers. So it’s a little less critical than on the ophthalmology side. But I think you get the point.

Mark Dlugoss:

Can you discuss how these workflow systems have helped you make your job easier as a clinician?

Mark Dunbar, OD, FAAO:

Like anything, right, you want early baseline, data and then follow patients over time to be able to recognize has this patient gotten worse, are they progressing? So especially in macular degeneration, many of the OCT software have progression analysis software. So you can look at the level of the RPE, there’s drusen analysis, there’s geographic atrophy analysis. So again, in a very objective measure, comparing change over time. And that’s really the value. Again, I think it’s a little less critical in retina side because again, I think you can see and recognize those scans that change just comparing scans. I think on the glaucoma side it’s a little more important and does a better job, or I should say it’s a little more critical in glaucoma than it is on the retina side. But again, that technology is available. We certainly utilize it, whatever image management, whatever software, I think there’s a lot of choices that providers can choose which one they want to use. I think they all do a great job.

Mark Dlugoss:

Let’s move on to the co-management relationship. How can optometrists and retina specialists improve their respective roles in the co-management relationship in AMD?

Mark Dunbar, OD, FAAO:

Well, I think it’s a-

Mark Dlugoss:

Entire MD I should say.

Mark Dunbar, OD, FAAO:

Yeah. Well again, you look at the two common causes of vision loss that we deal with, right? Macular degeneration being one, I would say diabetic retinopathy being the other. And you look at retinal specialists, I think their practices are probably fairly equally divided between seeing patients losing vision from diabetes and macular degeneration. And again, optometry is really on the front lines of both of those diseases. So I would say every optometrist should have a relationship with a couple of their retinal specialists in the community. And many of the optometrists that I know around the country that are in private practice have on their smartphones, they have the retinal specialist cell phone number and they have a relationship where they can just text the retinal specialist or “Listen, I’ve got this patient, do you need to see this patient today or tomorrow? So I’ve taken a picture,” they will text images to.

So I think this is the generation that we’re in. I think you need to have that type of relationship with your retinal specialist where you feel comfortable communicating, texting them, asking them, “Is this somebody you need to see today? It’s a Friday, they’ve got a retinal tear. I think this patient is converted to wet. Can it be seen on Monday or Tuesday?” So again, I think that’s critical in the success of, again, the theme of what we talked about, caring for patients with macular degeneration and making sure they’re able to preserve vision for a lifetime so they can be independent. So, absolutely.

And I’m sure that doesn’t happen 100 of the time, but it’s happening more and more a as time goes on, because again, most optometrists have OCT devices. Retinal specialists understand that the referral patterns of a lot of these patients with these diseases come through optometry. So they have established those type of relationships and I think that’s a great thing. I know I have them at Baskin Palmer. I work closely with several retinal specialists and I can text them and ask them, “Listen, is this somebody you want to see today?”

Mark Dlugoss:

Yeah. Well since you practice at Baskin Palmer. What are the retina specialists expectations of optometrists in the co-management relationship? And are those expectations higher or lower than say, retina specialists in a private practice?

Mark Dunbar, OD, FAAO:

What, obviously I’m not in private practice. It’s hard for me to say, but I do have a private practice within an academic university setting. My advantage is I’ve got a retinal specialist down the hall. So if there’s a question on symptomatic PVED or can you look at this OCT? I think this patient is converted from dry to wet, like the patient I just saw earlier today. So I would think it’s the same, right? I think retinal specialists would like to see you have technology to be able to establish early diagnosis. I think retinal specialists want to make sure that you’re referring that patient when it’s appropriate. Again, the focus is on AMD, but as we talked about, diabetes is the same. There’s a critical window that patients need to get in to be seen, and we don’t want it to be too late.

Certainly it can be earlier than maybe you would. There’s individual variability and comfort levels among optometrists of when they diagnosis, what they’re comfortable following. And again, that threshold is different where I might refer a patient later, somebody who is in a certain practice setting, they may feel not comfortable following the patient. They may refer that patient earlier. And I think all that is appropriate. So I think where retinal specialists have issues is when that patient is referred too late. And again, in an AMD setting where patients come in at all different stages of the disease, including the patient I saw today, she comes in, she’s got vision loss, fortunately she’s 20 50.

So this is a patient that I can refer within the next few days or next week to see the retinal specialist. And he will be glad I’ve done the front lines work, I already had did an OCT on the patient and so he may want to repeat it. But when that patient comes in, their patient’s automatically ready to be treated, I’ve kind of set the table that let the patient understand their disease, let them know that there is a treatment for this condition. It’s likely that your retinal specialist is going to want to treat that treatment, may involve an intravitreal injection really setting the stage. So by the time the patient comes in to see the retinal specialist, the heavy lifting if you will, has been done.

Mark Dlugoss:

We present a lot of information about AMD today. And are there any clinical pearls you’d like to share with optometrists about the points we’ve discussed today?

Mark Dunbar, OD, FAAO:

Again, as I said, I think optometrists are well versed in the diagnosis of macular degeneration. I think we recognize when the indications for referral, that conversion from dry to wet. I think most ODs have OCT to be able to help them answer that question. I think that the new thing that we’ve alluded to is really detection of geographic atrophy. Look at [inaudible 00:18:54] data and according to their tenure data, GA is more common than conversion to wet macular degeneration. And so I think that’s not something that is well recognized or understood. So I think, you talk about a clinical pearl. I think there’s a lot of work that needs to be done to educate optometry, primary eye care providers on recognition, early detection of geographic atrophy, and then when is going to be the time that these patients need to be seen by a retinal specialist for treatment. So that’s early detection of geographic atrophy I think is kind of the new area of education that we’re going to need to work on and really understanding referral patterns and when these patients need to be referred to a retinal specialist.

Mark Dlugoss:

Okay, great. Thank you for joining us today, Dr. Dunbar. I really appreciate your time and expertise in the area.

Mark Dunbar, OD, FAAO:

Thank you. I appreciate you having. Take care.