Comanaging AMD

As detective and collaborator, you provide AMD patients with the highest level of care.

Kirk L. Smick, O.D. and Dr. Charles W. Ficco, O.D., Morrow, Ga.

DIAGNOSTICS
Kirk L.Smick, O.D. and Charles W. Ficco, O.D.

Your roles in the co-management of age-related macular degeneration (AMD) are detective and collaborator. You detect AMD progression via your skills and confirm your clinical observations through your diagnostic instruments. And, should the disease progress, you collaborate with a retinal specialist to determine the best course of action.

Questioning the AMD suspect

When a new patient presents, take a careful medical history. First, ask about family history, as AMD is an inherited eye disease. Then, ask about the patient's social history to determine whether he smokes, has hypertension and/or cardiovascular disease — all individual risk factors for AMD, according to the National Eye Institute's Age-Related Eye Disease study (AREDS). Also, keep in mind the patient's appearance. Female sex, obesity, light-colored eyes and light skin (Caucasian race) are deemed risk factors for AMD as well, according to AREDS. Hyperopia is another risk factor, says the same study.

Educate the patient on the purpose of your specific questions, and reinforce this education with AMD pamphlets, posters and videos. To keep abreast of the latest developments, take continuing education courses and read the various journals.

Booking and processing

If the patient's medical and social histories reveal he's a likely AMD candidate, note it in his record. Then, talk about how a yearly exam (CPT code 92014) will enable you to monitor retinal changes.

If, at the patient's next exam, our clinical observations indicate dry AMD (i.e. color changes under the retinal pigment epithelium [RPE] and fluid production under the retina), we typically do a fundus evaluation, then employ optical coherence tomography (OCT) to document any lack of sub-retinal blood. We also use the Foresee Preferential Hyperacuity Perimeter (PHP) test, from Notal Vision and MSS, to confirm our clinical observations and determine a baseline. This device generates a non-invasive test that enables the identification of RPE elevations and photoreceptor layer bowing, both of which signal the conversion from dry- to wet AMD.

We ask dry AMD patients to return four times per year for PHP testing (CPT code 92081), as we want to identify the conversion as soon as it occurs. We decided on four times a year as a compromise between the size an average lesion will grow (assuming it started growing the day after a negative exam, which comes to ~1,800 microns) and the number of times a patient would consent to the test. From a clinical standpoint, six would be better if patient, doctor and reimbursement tolerated this frequency. Thus far, we have run this test on all our AMD patients (250), and we've been able to diagnose wet AMD very early in at least 15 to 20 patients to date.

We also bill the appropriate level of office visit to the patient. (See "The Physician Quality Reporting Initiative," below.) Once we determine a likely conversion to wet AMD, we send the patient to a retinal specialist, who likely performs a Fluorescein Angiogram (FA). Prior to the last few years, we didn't refer until the patient's wet AMD was fairly well-developed (a 4- to 5mm diameter lesion). Retinal specialists had few treatment options then, so doing so didn't affect visual outcomes. With the development of new AMD therapies, however, early detection is crucial.

Collaborating on care

Let the retinal specialist know that you expect to remain an active participant in the patient's care. This is the first step to establishing on-going communication — something vital to your collaboration.

Periodically review your communication process to make sure it fairly serves everyone involved. The way we've accomplished this is by sitting down and learning each other's treatment philosophies. This puts us in a position to know exactly when the surgeon wants to see the patient. In addition, he knows how we view our involvement, as well as the type of technology on which we base our referrals.

As detective, you possess all the necessary background information to build the case for a referral. And, because of the recent developments in AMD therapies, properly timed referrals are vital to helping these patients maintain vision. Such referrals also strengthen your relationship with the retinal specialist, which secures your other role in co-managing the AMD patient — that of the collaborator. OM

Dr. Smick is co-founder of the Clayton Eye Center in Morrow, Ga. and has served as president of the Georgia Optometric Association (GOA), the Georgia State Board of Examiners in Optometry and the Southern Council of Optometrists (SCO).

Dr. Ficco practices at Clayton Eye Center in Morrow, Ga. and is a member of the GOA, SCO and the American Optometric Association (AOA).