The optometrist’s role in managing AMD: Part 1

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Mark Dlugoss:

Age-related macular degeneration is a leading cause of irreversible blindness in visual impairment in the world, according to recent statistics. Nearly 20 million Americans have come down with some form of AMD. In recognition of February being AMD awareness month, Ophthalmology 360 wanted to sit down with the leading KOL in optometry to discuss several points associated with AMD and optometry’s role in the diagnosis and treatment of AMD. Hi, this is Mark Dlugoss, Senior Contributing Editor of Ophthalmology 360, and joining me is Dr. Mark Dunbar. Dr. Dunbar is Director of Optometric Services at Bascom Palmer Eye Institute in Miami, Florida. Thanks for joining us today, Dr. Dunbar.

Mark Dunbar:

It’s great to be here, Mark. Thank you for having me, and I’m looking forward to a great discussion.

Mark Dlugoss:

Okay, great. Let’s just start with yourself. Could you give us a little brief bio of yourself, which includes your education, your training, clinical background, et cetera.

Mark Dunbar:

Yeah, so I grew up in northern Michigan, a small town called Onaway, Michigan. I went to the Ferris State College of Optometry, which is now the Michigan College of Optometry. More than 30 years ago, I did a residency or a fellowship in ocular disease at the Omni Eye Services of Lexington, which was one of the kind of original co-management centers in optometry in kind of the late 1980s. From there, I joined the optometric staff at the Bascom Palmer Eye Institute. It was in 1987, and I’ve been at the Bascom Palmer for really many years. And so really spent time working with really great subspecialty ophthalmologist, both in retina and cornea and glaucoma.

I did become Director of Optometric services probably 20 years ago when my mentor Charles Pappas kind of moved on, so to speak. I am in charge. We have an optometry residency program that we started in the mid-90s, I think ’94, so we’re over 20 years having postgraduate residency program. So six optometrists come. They spend a year with us and they rotate through all the different subspecialty clinics including retina, glaucoma, cornea, neuro, et cetera. We have a number of fourth year optometric externs that also spend time with us, and they’re there for anywhere from four to six months, and again, as part of their fourth year of optometric training, many of our residents come from our student externship programs.

We have four or five different schools and colleges of optometry that are represented that we have as fourth year externs. And then in addition to that, we have a staff of about 14 to 15 optometrists that have worked with us as long as 30 years and as short as really one or two years, and they provide primary eye care as well as comprehensive eye care. So we have a couple ODs who do postoperative care, refractive surgery, pre and postoperative co-management.

We have some ODs work in glaucoma and kind of work with our glaucoma faculty. We have one who works with our neuro-ophthalmologist. I do a little bit of everything in terms of comprehensive eye care. We have some optometrists who work in our emergency department, again, just because, and in the era of healthcare and eyecare where one of the themes I’m sure we’ll get into is the fact that ophthalmology and optometry really need to work together. There’s this incredible demand for eyecare, and the fact is there’s just not enough manpower to really cover the needs that really are required for patients who have eye health problems, whether it’s just simple refractive errors or patients who have ocular disease.

So I feel privileged being in the role that I am in and have been in working at really what it’s considered one of the premier eye hospitals in really the world, working with great ophthalmologists and feel I have and our staff, has really a great relationship with ophthalmology, I think work very well together. And again, the fact that we also have an optometric training program that includes students and residents, I think speaks a lot for the culture of Bascom Palmer, and really our chairman, Dr. Eddie Alfonso, and really the rest of the ophthalmology faculty.

Mark Dlugoss:

Great. Okay. Let’s start off and we’ll say optometrists play a clerical role in the initial diagnosis of patients with AMD. Could you outline some steps optometrists need and should address after confirming a diagnosis from day one through long-term management?

Mark Dunbar:

So let’s just say that probably most patients with macular degeneration are initially diagnosed by an optometrist, right? So there’s 40 to 45,000 optometrists practicing. According to AOA, 85% of all eye exams are done by optometry, and there’s a number of really access points for patients. You’ve got optometrists who work in traditional standalone practices. You’ve got optometrists working with ophthalmologists. We have ODs in commercial retail settings in malls. And so there’s many different access points for patients to receive eye care by an optometrist. So it would make sense that an optometrist is going to be the first person who recognizes and sees a patient with macular degeneration.

And I think anybody who’s listening would recognize macular degeneration is a fairly simple and straightforward diagnosis to make. The clinical features of macular degeneration are readily recognizable on fundoscopy. Part of a comprehensive eye exam is dilating the pupils and really looking at the retina. And so as I said, macular degeneration is routinely seen. It’s a diagnosis that is pretty easily made.

So the first thing, of course is recognition, making that diagnosis of macular degeneration. And really in the world that we live in with imaging technologies, many optometrists will take a fundus photograph just to document the clinical findings and really to establish a baseline for that patient. Many optometrists now have OCT devices, which is optical coherence tomography, which I think has become almost the standard in eyecare. And so part of that baseline exam is doing an OCT, really establishing a baseline and kind of categorically trying to decide what level of macular degeneration this patient has.

Much like diabetic retinopathy, when you see AMD, it’s important to stage it because really that gives us a sense of what is the risk of progression, what is the risk of conversion to the wet form of the disease? The National Institute through the age-related eye disease study has done a great job in helping us really from a categorization perspective, that intermediate level AMD becomes kind of that critical time point for recommending nutritional supplements, patients with intermediate AMD, you’re going to typically see more than once a year, sometimes twice a year, maybe even three or four times a year, depending on really risk.

And of course, if they are at a point where either you’re not comfortable with what level of AMD or you’re worried about conversion to wet or what have you, then of course referring to a retinal specialist as appropriate. So number one, diagnosis, and then really helping the patient understand what’s going on. Helping them understand that they carry this diagnosis of macular degeneration.

So again, with great imaging modalities, being able to show a patient a fundus photograph of their eye, really what are some of the features that we’re seeing consistent with macular degeneration. So helping them really understand what this disease is, helping them understand risk factors including smoking, diet, genetic risks and predispositions, those type of things. So whether it’s recommending a nutritional supplement, whether it’s talking about diet, sunglasses, some of those type of things that patients at least on that front end working with their primary care optometrists need to understand.

And then being that go-between, between the patient who has early intermediate AMD to that point where you feel, uh-oh, they really need to see a retinal specialist. Long-winded answer. I’m sorry about that, Mark.

Mark Dlugoss:

No, that’s okay. It was a long-winded question in terms of from day one to long-term management. Now there have been guidelines in the past involving patient practice guidelines in terms of treating. Some of them or a lot of them are outdated and they’re being updated probably as we speak. But is there a general outline to these guidelines that optometrists should perform?

Mark Dunbar:

So it’s a tough question. The AOA guidelines were established I think in 1994, they were revised in 2004, and in really the world of eyecare has really changed in the last 19 or 20 years. You look at the adoption of OCT imaging technology in the early 2000s. Not even many ophthalmologists had it. And today, when you look in 2023, 80 to 90% of optometrists have OCT. Certainly every retinal specialist and comprehensive ophthalmologists have OCT. And so that really has become, I think, a critical tool in not only making a diagnosis, establishing what level, but really making a decision, has this patient converted to really from the dry form of the disease to the wet form of the disease?

And so at least in the AOA world, there aren’t established guidelines yet. We really look at, as we talked about earlier, what are the AREDS guidelines in terms of recommending nutritional supplements? I go to the American Academy of Ophthalmology websites as well. And again, just part of the culture that we live in, and of course we know that there’s great anti-VEGF medications available. And so we know that many patients when their diagnosis with wet macular degeneration already have suffered significant vision loss.

And so I think everybody recognizes if we can establish that diagnosis earlier so patients understand, we can see them more regularly. And again, helping patients understand that, then that requires seeing patients on a more frequent basis. Again, maybe it’s twice a year, maybe it’s three times a year. Industry has done a great job in really working in partnership with the eyecare community. I’ll talk about really home monitoring of macular degeneration.

Notel has the ForeseeHome device. And again, full disclosure, I don’t consult with them, I don’t work with them, but I really applaud what they have done in terms of really patients, we can prescribe a device that they can take home that really utilizes today’s modern technology to help them really make an earlier diagnosis. And so instead of patients coming in with vision loss that’s worse than 20/80, using home monitoring, we can make that diagnosis much earlier. And as you know, like any disease, if we can catch it when vision’s good, the outcomes are really better with treatment.

So guidelines, as you indicated, Mark, they’re evolving. I think they need to catch up with really where we are today, that hasn’t happened yet, but at least in the AOA sense, they just redid their diabetes guidelines in 2019. I have no doubt that the AMD guidelines will evolve as well. And so in the meantime, we listen to our thought leaders, we read the journals, we go to lectures, we hear the experts. And again, I’ll put a shoutout to some of the pharmaceutical companies like Regeneron and Genentech that have been really working closely with optometry to help really get the word out on the importance of early diagnosis, early referral, and things like that.

Mark Dlugoss:

Until there is a means to prevent or cure AMD, what do optometrists need to understand regarding the clinical and medical aspects of AMD?

Mark Dunbar:

Well, I think, again, the diagnosis is a relatively simple diagnosis to make. I think, you look at this disease where we understand the genetics, we understand risk factors, we understand oxidative stress. And so in terms of understanding why patients get macular degeneration, genetic predisposition, et cetera, et cetera, I think we really kind of understand that already. And so helping patients understand it becomes important. I think with OC imaging technologies, I’ll say it’s really almost level the playing field between ophthalmology and optometry in terms of, again, establishing a diagnosis, being able to determine with a high degree of really sensitivity and specificity when patients really convert from dry to wet AMD.

So gosh, I think the technology has really done a great job of really allowing, whether it’s a retinal specialist or a comprehensive or optometrist, we all have the same technology to be able to, at a very early level, utilizing these technologies to establish a diagnosis and establish really risk factors. Now we’re looking at biomarkers for conversion from dry to wet. And again, I think we’re learning more and more as time goes on.

Mark Dlugoss:

How can optometrists improve from their perspective? How can they improve patient outcomes in relation to AMD management?

Mark Dunbar:

Well, the key is early diagnosis, as we’ve talked about. When you look at ARED study, when you look at the clinical trials that were done on the anti-VEGF drugs, the reality is when patients are diagnosed with wet AMD, they already come in with vision worse than 20/70, 20/80. And that’s because either it doesn’t get recognized or patients, again, because it happens in one eye, unless they do this, they may not be aware that they’ve got vision loss in one eye already. So it takes a village to care for patients with macular degeneration and to really educate those that are at the highest risk of developing AMD.

So yes, on a primary care level, getting patients in to see their primary eye care providers, getting that early diagnosis, helping patients understand the disease and the risk of vision loss, and then getting patients to understand, especially in that higher risk group, the intermediate AMD, that it’s not good enough to come in just once a year or once every couple years.

I see patients all the time who they’ve had cataract surgery, their vision in the distance is perfect, they see 20/20, they don’t need glasses. And so the mindset may be, oh, I see great. I’ve had cataract surgery. I don’t have a problem. I don’t need to come in on a regular basis maybe like I used to. And so again, changing that mindset. So again, I think we all have to do a better job of educating our patients regarding this disease macular degeneration that they may have earlier, intermediate, that we need to see them more regularly than once a year or once every other year. That, again, we have imaging modalities to help us make early diagnosis.

So I think to your point, it’s a frustration. And the data really shows if we can catch the disease early, when patients still have good vision, we have a much better opportunity of keeping and maintaining good vision throughout treatment with successful anti-VEGF drugs, or again, hopefully in the future with geographic atrophy drugs.

Mark Dlugoss:

Now, since there aren’t really any guidelines per se from the academies, is there certain protocols that optometrists should look at in managing their AMD patients, especially when a management requires an ongoing or a long-term care situation?

Mark Dunbar:

The protocols, as we’ve talked about, I think have evolved, right? It’s that intermediate level AMD where it becomes kind of the trigger point of recommending a nutritional supplement. And again, I think that’s well established from the age-related eye disease study. So every optometrist I know recognizes, uh-oh, this patient has intermediate AMD, they need to understand the disease. We need to prescribe an AREDs supplement that they need to know and understand. And whether it’s a commercial one that you can find in a grocery store or some practices sell, there’s so many different ones that are available.

But just getting a patient on a nutritional supplement and then seeing that patient at least twice a year with intermediate level AMD. Again, early AMD, I think there’s some latitude. Again, those guidelines though not well established, I think we recognize early AMD can be seen on an annual basis once a year. And again, I think that was guidelines that were established from the age-related eye disease study, both one and two.

So again, that intermediate becomes a critical level. And again, there’s individual worries or concerns on is this a patient who has a greater risk? If they’ve got a lot of drusen or a lot of RPE modeling, maybe I’m going to see this patient three times a year. Or maybe that’s a patient that you say, you know what, I’m not comfortable managing these patients because again, there’s individual variability. Maybe you’re in a commercial setting and you don’t have an OCT.

And so that optometrist may refer the patient to a retinal specialist much earlier than somebody who really has the ability based on some of their clinical imaging technologies to follow that patient. There’s a burden. The retinal specialists are busy, and so you don’t want burden them with patients who don’t necessarily need to be seen. But on the other hand, every retinal specialist will tell you if you’re not comfortable, I’m happy to see the patient even in early AMD and certainly intermediate AMD.

So I think the guidelines have evolved. I think they’re not entrenched in. It’s not like the 10 Commandments, but I think people understand and have pretty good protocols.

Mark Dlugoss:

Now, you mentioned evolution in terms of treatments and therapy options. What are the latest treatment and therapy options that for AMD that the optometrists should be aware of?

Mark Dunbar:

We’ve had these first generation anti-VEGF drugs, the Lucentis, the Avastin, Eylea. Those were really game changers in terms of for the first time being able to dry up the macula, really preserved vision in these patients. And they were so critical, important. And the downside, of course, was durability. These were drugs, though they worked, they didn’t last a long time, and so would’ve patients needing injections every month. We tried to extend them out, and some patients were successful doing that, some patients not.

And so you look at this second generation anti-VEGF drugs, beginning with Beovu, which was Novartis’s drug, again, the idea that they would last longer and ultimately require a less number of injections and patients would need to not be seen as regularly as they would. Of course, Genentech has developed the port delivery system, which is a surgical procedure to put the port in. It’s a slow release over time, but patients could go up to six months or even nine months without needing to either be seen or really need a re-treatment.

And then you’ve got faricimab which is the kind of the multi-mechanism, has anti-VEGF characteristics and works on a different pathway as well. So the point being, these are drugs that work longer, they’re more durable. And so it just means patients aren’t going to need 12 injections over 12 months. They may only need two or three or four after a loading dose. And so that becomes important. Again, of course we know the story with the Novartis drug Beovu because of some of the inflammation issues. It’s not used as much, but the other two I think are gaining steam. And there’s probably others that are really being studied.

So the point being, these are patients who won’t need to be seen as regularly, and these are patients that may be able to be followed in optometric practices in that interval with OCT imaging and those type of things. So patients will have better visual outcomes, they’ll end up in their primary eye care, their optometrist practice for glasses, and while they’re doing that, let’s do an OCT and just kind of make sure that your macula is dry, that you’re heading in the right direction in terms of the disease being controlled. Where before, again, they just didn’t have that opportunity because patients were coming in every month, every six weeks for another injection.