Retina Specialist and Optometrist Comanagement of AMD Patients

By Jeffry Gerson, OD; Rishi P. Singh, MD

Although age-related macular degeneration (AMD) is a leading cause of vision loss for Americans 50 and older,¹ many people do not currently have the condition on their radar. When facing a diagnosis, patients often feel unsettled as a result of an overall lack of awareness of the condition. Those who are familiar with AMD typically associate it with intravitreal eye injections, usually because someone they know has an advanced stage of the disease, which leads patients to feel even more intimidated.

The most effective AMD treatment typically requires a multidisciplinary care team, which can be comprised of optometrists and retina specialists. Having a strong, collaborative relationship with all members of the team is critical not only to ease some of the understandable apprehension that patients experience after an AMD diagnosis but also to help ensure effective treatment over the patient’s lifetime. This article will present a few ways optometrists and retina specialists can work side by side to best manage and support patients with AMD.

IDENTIFYING AND CONFIRMING THE DIAGNOSIS

Age-related macular degeneration is most often detected first by optometrists because they are typically responsible for administering annual dilated eye exams. As a result, they tend to be the first to inform patients of the diagnosis as well as to explain what the diagnosis means — how it can impact their sight, and their life, now and in the future. Following the diagnosis, some optometrists might choose to refer patients to a retina specialist immediately. Others may wait until they see worsening progression.

Given that each diagnosis and situation is unique, the appropriate time to refer an AMD patient to a retina specialist varies, but sometimes optometrists refer patients too late because they are concerned about overburdening them. To ensure appropriate referrals, the optometrist should lean on AAO guidelines and communicate with the retina specialist directly to discuss at what point they would prefer or expect to see patients. Typically, there is an urgency to refer patients with suspected exudative (wet) macular degeneration, but in those with intermediate AMD or geographic atrophy, routine referral within a few weeks may be a reasonable approach.

Optometrists and retina specialists can also discuss the possibility of masquerading syndromes or other conditions that may cause retinal problems that can look like AMD, potential options for therapy depending on diagnosis and stage, or other clinical issues as they arise. Doing so collaboratively allows them to holistically determine the appropriate next step in the patient’s treatment plan.

After the diagnosis has been confirmed, retina specialists tend to lead the AMD patient’s treatment and management plan, while keeping the optometrist informed as to the patient’s progress, as appropriate. Optometrists can — and should — continue to help these patients even when undergoing treatment by providing them the best refraction, offering low-vision aids, and further educating on warning symptoms and signs to watch for.

SUCCESSFULLY COMANAGING THE CONDITION

When it comes to successfully comanaging AMD, communication across the care team and with the patient should be a top priority. Following an AMD diagnosis, optometrists should encourage patients to ask their retina specialists specific questions (once they have examined the patient and confirmed the diagnosis) and voice any concerns. Retina specialists should be prepared to answer patient inquiries and requests with the appropriate information and resources on hand. Retina specialists should also ask optometrists for the results of the patient’s vision, eye pressure, and imaging tests along with any comorbidities prior to the appointment with the patient.

Patient education should start as soon as the diagnosis is confirmed. While an optometrist will likely be the one to begin the conversation with the patient, retina specialists should continue to educate and empower patients during each appointment. This will help to mitigate the anxiety that often lingers after a diagnosis and ensure they are taking the right actions to manage their condition. Both eye care professionals should reiterate why the referral was necessary (ie, “As a specialist, I’m able to do even further testing than what your optometrist has available”) and the reasoning for the timing of the referral. The message of consistency goes a long way in sustaining patient confidence and comfort.

A FOCUS ON SLOWING THE PROGRESSION

While there is no known way to reverse AMD, there are ways patients can help slow its progression. Both optometrists and retina specialists play a large role in communicating these steps to their patients.

The National Eye Institute (NEI) AREDS2 10-year follow-on study results were recently published and they demonstrate continued efficacy in reducing the risk of moderate to advanced AMD progression with a specific eye vitamin formulation: vitamin C (500 mg), zinc (80 mg), copper (2 mg), vitamin E (180 mg), lutein (10 mg), and zeaxanthin (2 mg).² Taking these supplements may help reduce the risk of progression from intermediate to advanced AMD by about 25%, yet 64% of patients with moderate to advanced AMD are not currently taking an AREDS2 formula eye vitamin.^3,4

We have seen misconceptions in the industry that any multivitamin can have this impact, but this isn’t supported by science or rigorous clinical trials. Many AMD patients are not having proactive conversations with their optometrists or retina specialists about the benefits of the AREDS2 formulation — and getting education on the two decades of data that backs up that recommendation. In reality, many people are unaware that eye vitamin formulas even exist and the tangible impact they have been proven to have.

One of the most essential recommendations retina specialists should provide to their patients with moderate to advanced AMD is a twice-daily AREDS2 formula eye vitamin. The AREDS2 eye vitamin formulation recommendation that has been studied and proven by the NEI to work simply cannot be obtained from diet alone. This specific eye vitamin formula should be taken in addition to any other multivitamins or supplements a patient is currently taking.

Although patients with mild AMD were not a part of the AREDS and AREDS2 clinical studies, many professionals recommend an eye vitamin formula that includes lutein, zeaxanthin, and other antioxidants for eye health.

ENCOURAGING HEALTHY LIFESTYLE CHANGES

Given that AMD is a condition patients will have for life, both eye care professionals can encourage ongoing healthy lifestyle changes in patients at every appointment to help reduce their risk of AMD progression. Optometrists and retina specialists should be aligned in terms of what they are sharing with patients during follow-up visits so there is message consistency. It is important to reiterate the steps patients can take every day to help reduce their risk of progression, such as taking an AREDS2 formula eye vitamin and adopting a healthy lifestyle.

Two European studies found participants with AMD who closely followed a Mediterranean diet rich in fruits, vegetables, fish, whole grains, legumes, and olive oil were 41% less likely to develop advanced AMD compared to those who did not.⁵ Daily exercises can also help reduce the risk of progression. If your patient is not currently active, you can recommend that they ease into aerobic activity with things like swimming, cycling, brisk walking, or even yard work.

Lastly, it is extremely important that a patient’s care team is clear about the benefits of smoking cessation. A smoker likely already knows the associated risks of tobacco use, but it is important for optometrists and retina specialists to reiterate the benefits that quitting has on eye health. People who smoke have up to 4 times the risk of developing AMD compared with people who do not.⁴ Take the time to have a thoughtful discussion with patients about these specific lifestyle changes they can make to help slow AMD progression and make sure these conversations are consistently happening throughout their care.

In addition to these lifestyle recommendations, providing patients with the tools they need to track AMD progression on their own also gives them the opportunity to take an active role at home by taking charge of monitoring their eye health. Take-home materials like an Amsler grid should be provided to patients after a diagnosis as part of their initial visit. We recommend writing this down so patients can refer back to their take-home materials that explain key AMD terminology and outline the suggested lifestyle changes and supplements they can take to help protect their vision.

Many patients will continue to see their optometrist and retina specialist, as both perform different functions and routine follow-ups with both are important to properly track progression. Follow-up appointments allow the care team to reiterate the healthy lifestyle recommendations and the benefits of taking an AREDS2 formula eye vitamin. Even with routine follow-ups scheduled, any reported changes in vision between appointments warrants a visit to either eye care professional in case there is a new occurrence of wet AMD.

Retina specialists can also inform patients of online resources like the Macular Degeneration Association website (macularhope.org ), or groups like sightmatters.com  that offer AMD patients a sense of community that they can lean on for support and to learn about the journeys of other patients.

CONCLUSION

Many optometrists see their patients for years and have built long-term, trusting relationships and it’s important that retina specialists continue that supportive momentum. While an AMD diagnosis can lead to uncertainty among patients, an open, collaborative partnership between optometrists and retina specialists can alleviate some of the fear patients have about AMD and help patients feel more confident about their AMD journey. RP

REFERENCES

1. Centers For Disease Control and Prevention. Learn about age-related macular degeneration. Accessed September 27, 2022. https://www.cdc.gov/visionhealth/resources/features/macular-degeneration.html#:~:text=AMD%20is%20a%20major%20cause,vision%20needed%20to%20see%20clearly 
2. Chew EY, Clemons TE, Agrón E, et al. Long-term outcomes of adding lutein/zeaxanthin and ω-3 fatty acids to the areds supplements on age-related macular degeneration progression: AREDS2 Report 28. JAMA Ophthalmol. 2022;140(7):692-698. doi:10.1001/jamaophthalmol.2022.1640
3. AMD, age-related macular degeneration; AREDS, Age-related Eye Disease Study. Data on File at Bausch + Lomb.
4. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8 [published correction appears in Arch Ophthalmol. 2008 Sep;126(9):1251]. Arch Ophthalmol. 2001;119(10):1417-1436. doi:10.1001/archopht.119.10.1417
5. Merle BMJ, Colijn JM, Cougnard-Grégoire A, et al. Mediterranean diet and incidence of advanced age-related macular degeneration: The EYE-RISK consortium. Ophthalmology. 2019;126(3):381-390. doi:10.1016/j.ophtha.2018.08.006

Permission to use this article was granted by Jeffry Gerson, OD, FAAO