CLINICAL

  POSTERIOR

PREPARE FOR RETINAL DISEASE

DO YOU HAVE THE TOOLS NEEDED TO AID IN DIAGNOSIS AND MANAGEMENT?

SHERROL A. REYNOLDS, O.D., F.A.A.O.

GOVERNMENT HEALTH entities, such as the National Eye Institute, and various studies reveal that retinal diseases, such as AMD, diabetic retinopathy and retinal vascular occlusions (RVO) are on the rise.

Given the aging of baby boomers — the second largest population behind Millennials — and the fact that 9.3% of the U.S. population has diabetes, this makes sense. What doesn’t make sense? Failing to arm your practice with the necessary equipment to aid in the diagnosis and management of this growing patient population.

With that said, here’s a list of devices to provide these patients with the best care and, therefore, increase the likelihood of binding them to your practice.

UPGRADED CONDENSING LENSES

These provide enhanced image quality, large fields of view or more magnification and have filters (i.e. yellow filters) that reduce the impact of blue light on the retina. For example, wide field lenses provide views beyond the posterior pole, even without dilation, allowing for the detection of small mid-peripheral hemorrhages that are indicative of early vascular diseases, such as diabetic retinopathy.

Three-mirror retinal evaluation provides excellent views of pathologies (i.e retinal breaks or tears). The central lens is valuable as well, especially in cases of subtle maculopathies (i.e. cystoid macular edema and central serous chorioretinopathy).

Finally, binocular indirect ophthalmoscopy has an upgraded light source that offers enhanced views of the retina. Use scleral indentation (depression) for enhanced assessment of peripheral retinal lesions (i.e., small retinal breaks or traction). (See “Slit Lamp Tips,” page 31.)

RETINAL CAMERA

Digital fundus photography captures subtle pathologies, such as exudates, drusen or retinal arteriovenous nicking, that may be missed during the routine exam. The red-free filter can highlight retinal vascular changes, like microaneurysms or a retinal nerve fiber layer defect. It is beneficial in documenting, managing and sharing information with colleagues, but most importantly, patient education.

New cameras are available in combination with OCT, while widefield imaging provides panoramic retinal assessment. Also, some cameras can adapt to smartphone technology.

AUTOMATED VISUAL FIELD TESTING

Central visual field testing is extremely valuable for assessing macular function, such as toxicity associated with hydroxychloroquine (Plaquenil, Covis Pharmaceuticals Inc.). Specifically, a 10-2 white-stimulus, which detects subtle paracentral defects in early macular toxicity, is part of the American Academy of Ophthalmology’s screening guideline.

OCT/SD-OCT

These devices have become the standard of care and, therefore, a must-have technology for the management of retinal disease. OCT has improved our ability to understand, diagnose, monitor and treat a wide range of retinal conditions. SD-OCT is necessary to aid in the diagnosis of vitreomacular adhesion or traction, and in some cases it may aid in making the initial diagnosis (i.e. stage 1 macular hole).

Recently FDA-approved OCTA, or optical coherence tomography angiography, a non-invasive test that allows for the assessment of retinal and choroidal blood vessels. OCTA uses motion contrast instead of intravenous dye, eliminating the risk of significant complications, including anaphylactic response. OCTA provides a limited field of view and does not allow for the viewing of leakage, but it can aid in the detection of choroidal neovascularization in a variety of conditions, especially in AMD, according to the “International Journal of Retina and Vitreous.”

FUNDUS AUTOFLUORESCENCE

FAF detects metabolic changes/lipofuscin at the level of the retinal pigment epithelium. It can aid in the detection of early damage in AMD, hereditary retinal disorders or toxic maculopathy. FAF can be added to cameras or an OCT system.

Currently, no CPT code exists solely for FAF imaging, but it can be billed as part of fundus photography, using CPT 99250. That said, you cannot bill for both if performed the same day. (Some imaging companies recommend providers use CPT code 92499 [unlisted ophthalmological service] to identify FAF on claims.)

MACULAR PIGMENT OPTICAL DENSITY

Macular pigment optical density, or MPOD determines AMD risk and can gauge the effects of dietary changes and supplementation by evaluating the macular pigments, lutein and zeaxanthin. MPOD testing does not have a CPT code.

MULTISPECTRAL IMAGING (MSI)

MSI is a noninvasive test that allows for the assessment of structural change in individual retinal layers and the choroid. It can aid in the detection of early diabetic retinopathy changes, such as microaneurysms, and helps differentiate AMD from conditions such as polypoidal choroidal vasculopathy.

No CPT code exists for MSI, but it can be billed as part of fundus photography, using CPT 99250 (fundus photography with interpretation and report).

ULTRASOUND IMAGING AND ELECTROPHYSIOLOGY

Ultrasound offers high-resolution diagnostic imaging that allows for the rapid assessment of retinal pathology (i.e. retinal detachment, tumors), especially in cases of dense cataract or vitreous hemorrhage. Multifocal electroretinography (mfERG) provides a detailed assessment of retinal health (i.e. inherited retinal disease, detection of early hydroxychloroquine toxicity). CPT code 92275 can be used for electroretinography with interpretation and report.

DARK ADAPTATION

Automated assessment of dark adaptation time is particularly useful in evaluating retinal conditions, such as retinitis pigmentosa, inherited retinal dystrophies and identifying early AMD.

OUR ROLE

We, as optometrists, need to be prepared to provide timely detection, prompt management and, most importantly, patient education, in order to prevent the onset and progression of retinal disease. Those who “take the plunge” and appropriately use new technology realize a sound return on their investment. OM

DR. REYNOLDS is an associate professor at the Nova Southeastern University College of Optometry and clinical preceptor/attending in the college’s diabetes and macular clinic. She is a fellow of the Optometric Retina Society and chairperson for the Florida Optometric Association Healthy Eyes Healthy People Committee. Comment at tinyurl.com/OMcomment.