I would argue that providing exceptional care to the AMD patient is comprised of three steps: (1) diagnosing the disease and explaining the condition to the patient; (2) monitoring progression and prescribing based on modifiable risk factors, e.g., an ocular nutritional supplement, UV protection, smoking cessation, etc; and (3) educating patients on what they can expect when we refer them to a retinal specialist. This third, perhaps, more frequently overlooked step, is the focus of this article.

I have found that prepping our wet AMD patients for what they can expect is paramount to achieving a compliant patient, who, therefore, has an increased likelihood of a satisfactory outcome. Here, I discuss how.

PROVIDE EDUCATION AND REASSURANCE

Patients who are previously diagnosed with wet AMD or those who have just converted from the dry to the wet form are, understandably, apprehensive about what’s next in their care.

To start, optometrists should explain to dry AMD patients early on in the observation process that a referral to a retinal specialist is a possibility down the road. I have found that doing so goes a long way in helping these patients to mentally prepare for this encounter vs. being surprised and, therefore, anxious:

“Mrs. Jones, the reason it is so important for us to monitor your AMD every few months is so that we can confirm that no new blood vessels have grown. These weak blood vessels are not healthy, and they leak, causing scarring and vision loss.”

When it’s time for the referral, we can provide calm by saying something along these lines:

“Mrs. Jones, unfortunately it appears you do have a change that indicates the growth of new, leaky blood vessels that can lead to permanent vision loss, if not addressed right away.

The retinal specialist I’m referring you to is highly skilled in examining and treating patients who have wet AMD, which is why I’m sending you to her.”

GIVE SPECIFICS

After providing reassurance, optometrists should give specifics about what these patients can expect during their first visit to the retinal specialist:

“Mrs. Jones, when you see Dr. ________, she will perform her own testing to determine the treatment course she believes will produce the best outcome. One of these tests may be fluorescein angiography. During this test, an IV in your arm is used to inject dye into the blood stream. This allows the doctor to see the blood vessels in your retina that may indicate the severity and exact location of your AMD.”

EDUCATE ON POSSIBLE TREATMENTS

O.D.s should, to the best of their ability, anticipate the tertiary care that will be provided, so they can explain possible treatments these patients may undergo while in the care of the retinal specialist. It helps for the optometrist to know his/her retinal specialist well, along with his/her typical decision pattern for treatments. (For guidance on maintaining collaborative care relationships, see the April issue of the magazine, online at bit.ly/2RCZiuo .)

“Mrs. Jones, Dr. ________ is going to provide treatment that he/she feels your AMD will best respond to. Most patients benefit from a periodic injection into the eye, while others may need laser therapy.”

The mainstay of treatment for wet AMD is an intravitreal anti-VEGF agent. While other therapies are FDA approved for the treatment of wet AMD (e.g. focal laser, photodynamic therapy), these are not used as often, given the success of the injectables:

“Mrs. Jones, anti-VEGF therapy inhibits the growth of the leaky blood vessels in your eye, and therefore can prevent vision loss. After a numbing medicine is applied, this therapy is given via injection into your eye. The procedure should not be painful and takes just a few minutes. Depending on the drug the retinal specialist uses, the effect lasts for a month or more, and typically will require ongoing injections to stave off vision loss.”

I don’t spend a ton of time discussing the risk factors associated with multiple injections of anti-VEGF medications, because published research shows the benefits so greatly outweigh the risks for these patients. That said, I do explain to these patients that this therapy can cause an increase in eye pressure, which causes glaucoma, so I must monitor for this. Additionally, I discuss the prevalence of subconjunctival hemorrhage, secondary to injections simply to let them know in advance that this is relatively common and without danger — saving everyone an unnecessary phone call or visit.

One other item I discuss with these patients is to ask the surgeon to give anti-VEGF injections while the patient is reclined. My reasoning: My practice had a patient once suffer syncope upon receiving an injection. As the patient slumped forward, the needle pierced the optic nerve, and the patient lost all functional vision in that eye: not a commonly reported adverse event, but clearly a preventable one.

DISCUSS APPOINTMENT COMPLIANCE

After providing education on what these patients can expect from the retinal specialist, I end the conversation by stressing the importance of maintaining their scheduled appointments and not delaying care:

“Mrs. Jones: AMD is a sight-threatening disease, so it’s crucial you adhere to all your appointments, so that myself and the retinal specialist can do everything possible to prevent vision loss. Did you know that recent studies show that AMD patients who consistently adhered to their appointment schedules had better vision than those who skipped their appointments?” (See “Low Vision Discussion” below.)

There is equal importance in helping the patient to understand the need to continue with his/her visits with the O.D. as well as the retinal specialist. Patients can be lost to follow up in the “black hole” of retina, in my experience. While these patients are receiving excellent expert care for their AMD, they may not realize other aspects of ocular health and vision continue to be need attending to.

TRUSTED GATEKEEPERS

As America’s primary eye care providers, optometry has always been positioned to be the gatekeepers in the diagnosis and management of AMD. The number of cases will continue to rise as America grays. Optometry must meet the challenge of this potentially debilitating disease by actively diagnosing it, monitoring it using the latest devices, prescribing ocular nutritional supplements, UV protection and lifestyle changes, where indicated and, yes, providing education on what patients can expect in the care of the retinal specialist. OM

DR. PATE is in a private group practice in Auburn, Ala., and was named the 2014 AOA Young Optometrist of the Year. You can email him at robpate@ymail.com.