CO-MANAGING ANTI-VEGF THERAPY

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Optometrists represent the patient’s primary entry into eye health and vision care and often provide secondary care in the treatment and management of many ocular diseases. We also refer for consultation and treatment when appropriate and will co-manage patients with macular degeneration with a retinal specialist once the referral decision has been made. Oftentimes, patients present with comorbidities including ocular hypertension and primary open angle glaucoma. Coordination of care with retinal specialists presents a number of challenges to practitioners. Clinical outcomes can be enhanced by preparing for and anticipating potential issues.

PATIENT COUNSELING
Counseling is a critical component of patient care and may involve recommendations to change a patient’s lifestyle, such as advising better nutrition including AREDS 2 formulation, stopping smoking, avoidance of beta carotene in smokers and UV protection in spectacle correction. Although retinal specialists may convey some or all of this information to patients, counseling by an optometrist, including written material as well as staff reinforcement, will lead to better clinical outcomes.

FOLLOW UP
Some patients fail to understand the need for follow-up treatment with the consulting retinal specialist and fail to keep follow-up appointments unless they have vision symptoms. However, a fairly large percentage of patients who have discernible vision loss will keep their appointments for retina follow-ups but fail to follow up with their primary care optometrist.

It is essential that patients in the latter group receive the proper messaging from the retinal specialist: retinal examinations and treatment, including intravitreal injections, do not replace the need for comprehensive eye exams by their optometrist

Conversely, it is critical that the treating optometrist and staff impress upon the patient the sub-specialty nature of their retinal visits and the need for follow-up with their optometric physician at appropriate intervals.

INTERPROFESSIONAL COMMUNICATIONS
In our office, receipt of co-management reports from the retinal specialist represents another opportunity for a touch point. All reports received are reviewed and initialed by the optometrist providing care in our office. We also make appropriate notes that are added as an addendum in their electronic record, and we ask our staff to be certain the patient has an appropriate appointment scheduled in our office. If no follow-up appointment has been made or a previously scheduled one needs to be changed, we make a phone call to the patient to schedule that appointment.

In the event that a patient has failed to return to us in an appropriate time interval and has not responded to either recall letters or phone calls, the doctor will call the retinal specialist and discuss the patients’ failure to return to us for needed care. In those cases, the retinal specialist makes the appropriate notes in the patient chart to have a discussion at the next visit regarding appointments with their referring optometrist.

TWO-WAY STREET
Conveying patient information is a two-way street and is not limited to us receiving reports from the treating retinal specialist. It is equally important for retinal specialists to receive reports from us including our OCT images as well as refractive information and IOPs. Remember that visual acuities are usually performed by one of their staff members and may or may not be the patient’s appropriate distance vision correction. Moreover, other than a possible pinhole test, there is usually no attempt to refract for best corrected visual acuity. Patients treated with anti-VEGF agents may have variability and/or changes in refraction and may be unaware that their vision may be corrected more fully. Patients rely on us to provide them with best corrected visual acuity, and retinal specialists rely on us to provide their offices with that important information.

GLAUCOMA
Anti-VEGF treatment by the retinal specialist does not replace the need for optometrist follow-up in patients who have co-morbidities such as glaucoma. Their tonometry readings are often performed by technicians who may be using a handheld electronic tonometer rather than a Goldman applanation tonometer. Additionally, retinal specialists rarely perform threshold visual fields on patients, nor will they typically perform OCTs of the optic nerve head or other diagnostic testing appropriate for glaucoma patients. Patients need to understand the importance of follow-up with their treating optometrist. It is also incumbent upon the treating optometrist to stress to the retinal specialist that they need to advise their patient to follow-up with their optometrist at appropriate intervals.

NEW RISKS
It has been well documented that anti-VEGF treatment may result in both short-term IOP spikes as well as long-term IOP increases. A recently published study has reported that patients receiving seven or more bevacizumab injections are associated with a statistically significant risk for the need for glaucoma surgery. This further reinforces the need for all of our patients to be scheduled for and receive appropriate care in our offices. It is even more critical that our ocular hypertensives and glaucoma patients fully understand this risk and be scheduled for follow-up diagnostic testing and treatment by the referring physician. It is especially challenging from a patient adherence perspective given that the very patients at the most risk, those receiving seven or more bevacizumab injections, will likely be the most resistant to multiple office visits from both their retinal specialist and their optometrist.

INSURANCE ISSUES
As we have all seen firsthand, patients rarely understand the difference between their medical coverage and any routine vision plan. Our patients need us to fully explain that their follow-up care in our office is medical in nature and not subject to the limitations of a vision plan covering an annual eye exam. Conversely, it is incumbent on our staff to understand the role of patient deductibles and copays to support patient adherence to our treatment plan.

Treatment and follow-up should always be at your comfort level and with mutually agreed upon clinical protocols based on patient retinal diagnosis and comorbidities. Make sure there is three-way communication between the patient, the consulting retinal specialist and the referring optometrist. Keeping the patient centered at the forefront of the treatment plan will help ensure the best possible clinical outcomes.

Randolph Brooks, OD, FAAO, is in private practice at Advanced Eyecare Associates in Ledgewood, NJ

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