If there’s one compelling reason why primary care optometrists should be looking for signs of geographic atrophy, it’s this: “We see 88 million comprehensive eye exams a year,” says Selina McGee, OD, FAAO, of BeSpoke Vision in Edmond, Oklahoma. “We have to be the ones on the front lines, diagnosing, educating, managing, and moving patients to new therapies.”
That philosophy took on a new urgency when the U.S. Food and Drug Administration approved two complement inhibitor therapies for the treatment of geographic atrophy, secondary to age-related macular degeneration (AMD).
Dr. McGee realized that there would be a learning curve. “I’m known for having an anterior seg focus. I know all about ocular surface disease, but still, I look at retinas all day, every day,” she says. Once she knew that there was a GA treatment option for retina specialists and that she had the technology to help make the diagnoses, she knew she needed to expand her knowledge and increase her confidence.
What she found after attending a few courses on the topic was that she was “underutilizing my technology and my skill set. This is well within our capabilities, and we can have a significant impact when we can make the diagnosis and referrals to slow disease progression.”
Dr. McGee shares her process and some strategies for optometrists who want to get started in their primary care practices.
“Don’t wait until patients are symptomatic. I want to be proactive by looking for those clinical signs that patients may not complain about,” she says. It’s crucial that multimodal imaging is part of a comprehensive exam. “Most ODs have widefield photography and access to fundus autofluorescence, and many have optical coherence tomography (OCT).”
Each of those technologies provides a piece of the puzzle, she says. “In our practice, we include fundus color and autofluorescence and OCT imaging as a wellness piece of the exam. It’s cash-pay for the patients, but we have a 96% uptake. Even if that isn’t your model, all patients who have been diagnosed with AMD should have multimodal imaging at each patient encounter to round out the complete picture.”
The tests complement each other. “Sixty-seven percent of GA patients have an extrafoveal lesion first. which is typically asymptomatic, and those can grow at a much faster rate than central lesions, which are often visually devastating,” she says. “If you’re only doing a macular OCT and not autofluorescence, or doing color photography and not OCT, it’s possible to miss lesions, drusen or a choroidal neovascular membrane (CNVM),” she says.
Similarly, doctors who look at the macula only through the slit lamp without having done an OCT image or fundus photography, “can miss drusen, pigmentary changes or CNVMs.”
When Dr. McGee purchased her OCT, “I invested in optical coherence tomography angiography (OCTA) because I wanted to be able to diagnose and monitor my patients. Otherwise, I would have been referring everyone to the retina specialist earlier–and in many cases unnecessarily,” she says.
She recalls any patient diagnosed with mild AMD every six months. “If they have extrafoveal lesions or have geographic atrophy, then we discuss the possibility of utilizing one of the recently approved GA therapies to slow progression. If I can extend a patient’s independence for longer, I want to give that patient every opportunity.”
In addition to having the technology in the office or access to it, there are other steps Dr. McGee took.
Go to classes.
“At every big optometric meeting, there are course options on retina education, OCT interpretation, and GA now. Read the journals and trade publications focused on this topic. I read everything Carolyn Majcher, OD, FAAO, presented or wrote. I talked with the medical science liaisons as well. Those resources gave me solid confidence to identify GA and utilize multimodal imaging to diagnose and monitor,” she says.
Talk to your retina specialists.
Dr. McGee advises that ODs have a conversation with the retina specialists they refer to. “You don’t want to send a patient to the retina doctor without knowing what that specialist’s treatment options are,” she says. Her quick conversation with these specialists started with these questions.
- What is your current approach with the recent approvals for GA?
- Can you walk me through the process?
- How can we best work together with this new information?
Primary care optometrists do not need to explain every step of the treatment options. But it is important to know that the retina doctor to whom you’re referring is prepared to pursue treatment if it’s indicated for the patient, she says.
Counsel all patients about ocular health.
“I do this throughout the exam, so I’m not overloading the patient with advice at the end of the exam or overwhelming myself with a lengthy discussion. I’ll talk about the importance of not smoking, eating a well-balanced diet, nutritional supplementation and wearing good ophthalmic sun lenses. This is especially important for patients with risk factors. There are opportunities for patients to help prevent or slow down the progression of ocular disease. I look for opportunities to tuck that advice in with every single patient,” she says.
One way to do so easily is during the different tests she conducts. “I’ll explain that I’m looking at their macula, what it does and how they can take care of it. Then I’ll review what I’m looking for and what that means.” I present it as a journey through their eye and build a story as we go. Not only does that help educate patients, it also helps reinforce why annual comprehensive exams are so important,” she says. “I look for ways to congratulate them on making the awesome decision to take care of themselves.”
As optometrists continue to gain a more expanded scope of practice, the responsibilities increase, too. “If we as primary care optometrists want those opportunities, we have to accept the responsibility and be ready to lead the conversations and forge the paths when new therapies are introduced,” she says.
Read other stories about how ODs are detecting and talking with patients about GA here.
This content is independent editorial sponsored by Astellas. Astellas had no input in the development of this content.