The world of retina care continues to move at a rapid rate; staying on top of these advances can enhance our ability to practice fully, provide vision, prevent blindness and give hope to those looking for the next potential treatment. I had the incredible experience of completing a preceptorship at Retina Associates of Kentucky and saw patients for more than three years, which provided much insight into optometry’s current opportunity.

New Approaches to Wet AMD

Two key advances in drug therapy are Vabysmo (faricimab-svoa, Genentech) and Eylea HD (aflibercept, Regeneron Pharmaceuticals). The big advantage of these new drugs is that they require far less frequent injections. While the standard was to treat monthly and then extend the interval judiciously, many patients receiving Vabysmo or Eylea HD are down to about three injections per year. 

Hope for GA

The new complement inhibitor intravitreal drugs—Syfovre (pegcetacoplan, Apellis) and Izervay (avacincaptad pegol, Iveric Bio)—are showing success in delaying progression of geographic atrophy (GA). 

Before recommending a retina consult to consider these medications, first identify appropriate GA patients via OCT; the pattern to look for is that of a “barcode” hypertransmission through lost RPE. Once the “barcode” is identified, refer to a retina specialist. Autofluorescence, especially with technologies that better define the lesion, such as confocal retinal imaging using the Eidon TrueColor Widefield Confocal Scanner (iCare), can further refine ideal candidates. Patients whose GA spares the fovea are some of the best candidates, but keep in mind that this pattern will progress faster.

Next, discuss the “needle in the eye.” Although it sounds daunting, I tell patients that between eight and 10 million retinal injections are performed each year and, although there are risks (endophthalmitis, occlusive vasculitis), they are extremely low. Consequently, not treating GA will result in the inevitable progression to central vision loss.

I also explain how these drugs work. Injecting medications in the eye inhibits a key component in the inflammatory cascade leading to cell loss, thus slowing the progression of devitalized (damaged) RPE cells. This should maintain the vision they have for longer, but the great hope is in long-term therapy. Recent data suggests it may be possible that complement inhibitor drugs can further slow (and hopefully halt) the progression of healthy RPE cells from becoming devitalized and then eventually to atrophy.

Separate Yourself

Based on a great discussion with world-renowned retina specialist John Kitchens, MD, the following actions separate the top ODs in this field:

Contact the retina specialist early. Even if you are not sure if a referral is warranted, reach out to describe the patient’s retinal findings to the specialist and send imaging such as the OCT or retinal photography. If you believe the condition requires prompt scheduling, text the retina specialist. Certainly, some conditions, like a macula-on retinal detachment, require same-day scheduling, but others—like wet AMD—have more time (two weeks) with little consequence to visual outcome.

Make a follow-up appointment in your clinic, even if you are referring them; this way they stay in your system. These patients require regular exams, monitoring of the optic nerve for glaucoma, dry eye management and more.

Treat the retinal conditions you can treat; refer the ones you can’t. A good example is post-cataract cystoid macular edema. Prescribe Durezol (difluprednate ophthalmic emulsion 0.05%) QID and possibly a topical NSAID such as Prolensa (bromfenac ophthalmic solution 0.07%) QD for three weeks. At that point, if improvement is noted you can discontinue the NSAID but slowly taper the steroid to TID for two to three weeks, then BID for two to three weeks, and then QD for two to three weeks, all while regularly monitoring intraocular pressure.

No longer is this clinical acumen only valuable to the retina specialist. Without optometry’s knowledge in this space, there would be a significant drop in patients being seen in retina practices, as well as a significant permanent vision loss in patients.

Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.