Low Vision
AMD:Treatment & Rehabilitation
The realm of AMD is changing. Others are starting to take notice of the importance of AMD education and treatment, are you? Here are some points to consider.
BY BRUCE P. ROSENTHAL, O.D., F.A.A.O., New York, N.Y.

We regularly face many challenging and exciting reasons to incorporate and build low vision into a well-established eyecare practice. But the increasing number of patients developing age-related macular degeneration (AMD) is perhaps the most compelling reason to make these patients, as well as their families, part of your existing practice setting. I'll explain how doing so can benefit your practice and these patients.

A look at legal issues

The lack of Medicare reimbursement for low vision rehabilitation services has often deterred many clinicians from incorporating low vision into their practices. But Medicare's role is changing, especially with the recent ruling by the Centers for Medicare and Medicaid Services (CMS), as detailed in the program memorandum issued on May 29, 2002, for state access to low vision rehabilitation.

Representative Michael Capuano (D-MA) and Senator John Kerry (D-MA) have also been pursuing coverage for vision rehabilitation services (H.R. 2484 and S. 1967) with the Medicare Vision Rehabilitation Services Act. To date, nearly 140 congressional legislators have signed on as co-sponsors. If passed, the bill, which also has the support of the American Optometric Association (AOA), will expand Medicare coverage for vision rehabilitation services outside of the office.

New recognition emerges

The AOA has made "Medicare coverage for low vision rehabilitative services one of its six federal level legislative priorities for 2002." Another major change is the recognition that low vision encompasses the expertise of many disciplines.

In response to this, the AOA's House of Delegates passed a resolution on June 30, 2002 changing the name of the Low Vision Section to the Low Vision Rehabilitation Section. This name change is indicative of the recognition that successful low vision therapy requires a multidisciplinary approach to the successful rehabilitation of individuals who are visually impaired.

The team is generally comprised of optometrists and ophthalmologists specializing in low vision, as well as the other members of the vision rehabilitation team. They may include the orientation and mobility training specialist, the vision rehabilitation teacher, social worker, educator or occupational therapists.

These events have contributed to a greater public awareness and an O.D. awareness of individuals who have AMD.

This chart clearly demonstrates that the number of patients who have AMD will "explode" as the population ages. Almost 14% of the white female population have AMD by age 85.

Enter the information highway

What's happened to the awareness of AMD in the last few years? Through my own groundwork for an article on the subject, I found that less than 2% of the U.S. population is aware of AMD. There's been a greater awareness of help for AMD in the past 3 years because of a number of factors, which I'll explain.

Patients seeking information. The first factor that has contributed to the change of awareness is the rapid dissemination of information through the Internet, as well as the media's thirst for "the latest" in medical advances. Patients and their families no longer accept that doctors can't do anything for their condition and so they surf every search engine available.

My low vision patients and their families and friends come in armed with the latest reports of clinical trials that they've received from others from health Web sites and the Internet.

Patients and their families want to know what we can do for the patient now. Take advantage of this interest in AMD and use it to build your practice by becoming the expert on AMD in your solo, group, hospital or other practice setting.

Preserving functional vision. Some exciting recent medical developments and findings from clinical trials indicate that we do have the ability to preserve functional vision. Let's take a look at some of the most recent statistics that the National Eye Institute and Prevent Blindness America presented at the recent conference, "Vision Problems in the U.S," (www.preventblindness.org/vpus/vp.html) held in Washington, D.C. this year.

One hundred and nineteen million Americans are presently at risk for age-related eye disease and visual impairment. What's more disturbing is that experts expect this number to double in the next 3 decades.

Now let's look at the group who have AMD. Approximately 1.6 million Americans age 50 or over have the late form of AMD. That includes those who have geographic atrophy as well as those who have neovascularization (wet or exudative AMD) [See Table above]. Not included in these statistics is the numbers of individuals who have the early and the moderate stages of AMD.

Preserving functional vision

Thermal laser photocoagulation has been around since the early l970's. Mittra, Singermanii and others feel that traditional thermal laser procedures for wet AMD are still indicated for patients who have "well-defined extrafoveal or juxtafoveal macular lesions and is a suitable treatment for 13% to 26% of patients who have neovascular AMD.

However, photodynamic therapy (cold laser) with Verteporfin (Visudyne by Norvartis AG), which was approved by the FDA in April 2000, has become the preferred treatment for patients who have predominantly classic subfoveal CNV. This treatment is generally involves approximately 3 treatments in the first year and 2 to 3 treatments in the second.

AMD and your practice

How does this translate into more patients for your practice? Study results indicate that patients who have photodynamic therapy retain more visual acuity and contrast sensitivity function after 24 to 36 months.

As a clinician, I can explain to patients the benefits of retaining functional vision, and especially the importance of maintaining contrast sensitivity function. Photodynamic therapy also affords me the opportunity to be more successful in the prescription and application of optical and electronic low vision devices.

In addition, numerous phase II and phase III clinical trials will likely prolong useful functional vision. These investigational treatments include the use of:

• anti-angiogenic drugs
• retinoids
• corticosteroids
• triamcinolone acetonide
• submacular surgery
• radiation therapy
• macular translocation
• pigment epithelial transplantation
• intraocular telescopes
• studies of the pathogenesis of CNV
• vascular endothelial growth factor
• transforming growth factor-beta
• platelet-derived growth factor
• basic fibroblast growth factor.

It's important to remember that patients who have AMD still need vision rehabilitation, even with the most up-to-date medical treatments available. Be part of the revolution by working with patients and their families in understanding how to overcome vision impairment.

The AREDS Study

The Age-Related Eye Disease Study (AREDS) report released in October 2001 also has a big impact on useable visual function in individuals who have AMD. The study reported on 3,640 participants enrolled in the trial. Individuals were given:

• antioxidants + zinc
• antioxidants (no zinc)
• zinc (no antioxidants)
• placebo.

The study findings for patients who have extensive intermediate drusen, large drusen, or nonconcentric geographic atrophy, showed a reduction in the risk of progression to advanced AMD. Researchers recommend that persons without contraindications, such as smokers, should consider taking a supplement of antioxidants plus zinc.

Again, the major finding is the possible reduction in significant vision loss progressing to the late stages of AMD. This translates into more patients who may benefit from the prescription of low vision devices.

Educational opportunities

Attend the courses presented at the annual meetings of the American Optometric Association, the American Academy of Optometry, the Vision Expos and the Lighthouse International Center for Education.

They all provide excellent opportunities to learn how to develop or expand an existing low vision practice and to help you learn more about managing AMD. The Lighthouse International Center, in fact, recognizing the increasing importance of macular degeneration education, has added "Low Vision Management of AMD: A Practical Approach" to their syllabus.

Words of encouragement

It's been more than 25 years since I started working with low vision patients. Since then, I've practiced low vision in multiple settings (e.g., a University low vision clinic; a faculty practice; numerous nursing homes; a hospital; and a low vision private practice).

I'm seeing more patients than ever and I'm now chief of the Low Vision Programs at the Lighthouse. My colleagues will tell you that I've never lost my enthusiasm or energy to work with my patients, or their families, to teach interns and residents, as well as write about the subject. Every patient is different and yes, in many instances, challenging. And at the end of each day I'm often exhausted, but before passing out on the train on the way home, I know that I've made a difference.

You definitely have an opportunity to make a difference in someone's life. Why not start now?

References are available upon request.

Dr. Rosenthal is the chief of the Low Vision Programs at Lighthouse International, chair of the AMD Alliance International and is a Diplomate in the Low Vision Section of the American Academy of Optometry. He's also an adjunct professor at Mt. Sinai Hospital and is a distinguished adjunct professor at SUNY College of Optometry. His most recent book, "Living Well With Macular Degeneration," is published by NAL (Penguin/Putnam) books.