How to Comanage Patients Who Have Retinal Disease

Serve the patient best with confidence, cooperation and communication.

ROBERT MURPHY Contributing Editor

The advent and overall success of anti-VEGF injections to treat neovascular macular degeneration — sometimes for extended periods — has swelled retina specialists’ waiting areas almost to standing-room-only.

This increasing need for retinal care has likewise placed demands on optometrists who can make the initial diagnosis and referral, and when appropriate, follow the patient in a comanagement arrangement. Bene- fits likely accrue to all parties — the patient, the retina specialist and, not least, the referring optometrist.

“I have no doubt that there are more retina specialists who are comanaging,” says Mark E. Dunbar, O.D., director of optometry at University of Miami’s Bascom-Palmer Eye Institute.

That hasn’t always been the case. Largely, it comes down to whether the surgeon is ready to place his or her trust in the referring doctor when it comes to postoperative care. This trust must be mutual for a successful comanagement arrangement, say those interviewed.

“Having practiced 25 years, I think this [comanagement] is evolving into a very unique situation,” Dr. Dunbar says. “Most retina specialists feel that there’s nobody that is trained enough… besides them, to detect some of the subtle nuances of the disease. So there’s nobody beyond them who is capable of deciding: Does the patient need to be retreated or not?”

Those perceptions are changing among many retina specialists, owing perhaps to a more accurate concept of what an optometrist provides. In short, these optometric services can foster comanagement relationships between O.D.s and retina specialists.

Establishing a relationship

Optometrists dipping their feet into these waters for the first time should establish a mutually positive and productive relationship with retina specialists in their vicinity. It helps to work periodically with perhaps three or more surgeons depending on the condition at hand. Some may be comfortable peeling an epiretinal membrane, for example, while others may not.

Then, of course, there’s the personal touch in developing a relationship with a retina specialist. Here, those interviewed recommend you reach out at least with a phone call, if not a meal or cup of coffee.

“I think probably the best way to establish a good relationship with the retina specialist is to make the capabilities of the optometrist well-understood,” says Leo P. Semes, O.D., a professor at the University of Alabama, Birmingham, School of Optometry. “So developing a good, open relationship and a good basis for professional rapport is key there.”

In the context of comanagement, vicinity may be a matter of around the corner or 200 miles away. The latter case is often typical of rural areas, where the patient may travel long distances, sometimes each month for intravitreal injections and perhaps less often for subsequent follow-up care. Distance sometimes determines whether the patient prefers to remain with the retina surgeon once the condition stabilizes, say those interviewed.

“Some of these relationships will depend on geography,” says Dr. Semes. For example, if the patient would have to travel 50 miles to the retina specialist to have an OCT, “but the optometrist is, let’s say, 10 miles away, then it would make more sense logistically for the optometrist to participate in the postoperative care,” says Dr. Semes.

The proper equipment

Also, establish with retina specialists that you have the requisite diagnostic equipment:

► Fundus camera. The lack of a fundus camera, which can monitor change through time, may disqualify an optometrist wishing to comanage with retina specialists, say those interviewed.

“The reason for fundus photos is, you look at the picture of what it [the retina] was four months ago, and you look at it now,” says Eric Schmidt, O.D., president of Omni Eye Specialists in Wilmington, N.C. “There is a change you can see in living color.”

► Spectral-domain OCT. Additionally de rigueur for optometric comanagement of retinal disease is the OCT to measure retinal thickening and detect choroidal neovascularization. Says Dr. Dunbar, “There’s nothing better than an OCT to follow these patients and determine whether they need to be treated again.”

► Dilated fundus examination. Of all the diagnostic tools available, Dr. Schmidt singles out the dilated fundus exam as the most diagnostically generative evaluation. “The best way to do that is with your own eye and a dilated fundus examination,” Dr. Schmidt says.

Fundus autofluorescence and macular pigment density provide further diagnostic data, but are not required for diagnosing and following most retinal cases, say those interviewed.

When to refer?

This, clinically, is the crux of the matter, and you must make the call: Does this patient require treatment, or can you follow him or her through time before you decide it’s time to refer to a retina specialist?

With many retinal conditions, the guidelines are rather cut-and-dry, and available from prestigious medical associations. Consider some selected scenarios and recommendations:

► Macular degeneration. “Whenever you see any subretinal bleeding at all, depending on the visual acuity, the patient needs to be sent out for an injection,” says Dr. Schmidt. “The quicker you send him/her out, the better he/she responds. And with OCTs now, there’s really no guessing as to whether he/she has a subretinal membrane. With retina, if it’s treatable, you send the patient out.”

► Diabetic macular edema. “If there’s macular thickening within a half disc diameter of the foveal avascular zone, you send the patient out for treatment, irrespective of their vision,” Dr. Schmidt explains.

► Proliferative diabetic retinopathy. “If the condition fits the definition of proliferative diabetic retinopathy — neovascularization of the disc or neovascurization elsewhere — we know the patient responds well to PRP [panretinal photocoagulation],” Dr. Schmidt says. “So there’s really no reason to wait, because the treatments are rather innocuous.”

► Retinal detachment. Now, you’re looking at an ocular emergency. “It doesn’t have to be [treated] the same day, but the next day for sure,” Dr. Schmidt says. “And the retina surgeon to whom you refer should be prepared for the patient, [anticipate] that he/she is going to need surgery, and make preparations for that.”

► Epiretinal membrane. Patients who require treatment for an epiretinal peel undergo a technically challenging retinal microsurgery. The call for when treatment is indicated can be similarly vexing.

“That’s more subjective,” Dr. Schmidt says. “That’s one of those [cases] in which it all depends on how much the patient is bothered by their vision. The membranes cause glare; they cause lots of distortions. It’s a surgery that works really well, and [the condition] is really responsive to the surgery.”

Consider two clinical cases of epiretinal membrane that likely call for two different indications for management:

“Take, for example, a 55-year-old male who has an epiretinal membrane,” Dr. Schmidt says. “His vision is 20/45 (-3). He’s got some distortion on his Amsler grid, vocal complaints about his vision. That’s a guy who would be very amenable to surgery. So I would give him the options, and tell him that I think he would do very well with surgery, and recommend it.”

A counter-example suggests another management pathway.

“Now, if it’s a 75-year-old female, she’s 20/35 (-2), and she’s able to read okay, that might be one who you can kind of watch and wait,” Dr. Schmidt says. “If the membrane gets denser, then perhaps you might want to consider surgery. Doctors always have to remember that they’re not just treating the eye, they’re treating a person.”

As a general rule, clinicians refer a patient when they recognize that the latter requires care that they cannot render. It all comes back to acting on behalf of the patient’s best interests, say those interviewed.

Making the referral

Okay, so you have a patient in your office who requires a referral to a retina specialist. What do you and your staff do?

First, have a staff member call to schedule a referral visit, preferably while the patient is still in your office. The urgency of the condition dictates an appropriate time frame for the appointment. That’s important to remember if a particular retina specialist cannot see the patient anytime soon.

Patient education is a pivotal component of the referral process. Describe to the patient the nature of the team approach to managing a retinal condition. Be straightforward.

“Explain that, ‘Your disease has progressed beyond what I can take care of,’” Dr. Dunbar says. “’We need the benefit of having you see a retina specialist. It’s quite possible that you might need treatment. That treatment may include surgical management, either having them work on the condition in the operating room or just doing an injection into the eye.’ Explain that the patient may need to be seen several times because the disease demands or dictates it.”

Next, write a concise case report for the retina specialist that hits upon the pertinent highlights, say those interviewed.

“Something simple like, ‘75-year-old male, dry age-related macular degeneration for five years,’” Dr. Schmidt says. “’Presented today with a complaint of decreased vision for a week. No pain, discharge or redness.’ Then give the visual acuity. ‘Slit lamp normal. Pressure 18mmHg and 14mmHg. Retina reveals fresh subretinal neovascular membrane OS.’ Include the OCTs. And I would also recommend you include, ‘reevaluate and treat as necessary.’ I would always render an opinion of what I think it is.” (See “A Tale of Two Referrals,” page 25.)

Postoperative comanagement

The course of postoperative retinal comanagement hinges on numerous factors, including the initial nature of the condition; the degree to which surgical, laser or injectable medical treatment provides a salutory outcome; the point at which the patient’s condition is stable; logistical factors, such as the patient’s travel distance; and more generally, yet importantly, the patient’s own wishes.

Don’t take for granted that the retina specialist will wish to return the patient to you for postoperative follow-up evaluation. The retina doctor may justify holding onto the patient for any number of reasons.

Those more amenable to return the patient to you will do so only after the patient’s condition has stabilized and shows little or no sign of exacerbation or relapse. Schedule these patients as frequently as their condition dictates. Send the retina specialist a summary of each visit’s findings, and include fundus photos and OCT results if the retinal physician wants them.

Finally, communicate all your services to the retinal physician. (See “Coding for Retinal Followup,” page 24.)

“If you do a lot of low vision, I don’t think there’s anything wrong with the retina specialist sending low vision patients back,” Dr. Schmidt says. “I don’t think that’s a quid pro quo thing. If you provide low vision treatment for patients, I certainly hope you would tell every retina specialist around you, and send them literature on what you can do for their patients.”

Make it work

Some key takeaway pearls? If you don’t currently possess a fundus camera or OCT, consider the investments and their potential returns, and more importantly, so that you can provide the best possible retinal diagnostic coverage. Be aware of guidelines for retinal diagnoses, along with recommendations for when referral for treatment is in order. Communicate fully with the retina surgeon regarding the case at hand.

“It may be a matter of establishing a retinal base so the retina specialist knows your quality, etc.,” Dr. Dunbar says. “It may even be visiting the retina specialist and simply saying, ‘I’ve got all the necessary tools, I’m happy to follow this patient accordingly. And we can send the patient back as needed.’” Sounds like a plan designed to work. OM