In 2019 I completed a full preceptorship at Retina Associates of Kentucky, one of the top 20 retina practices in the country. This reinvigorated my love for this area of practice. I’ve always felt that our profession can do so much in retina—and now we have to, since it’s such a common finding in clinical practice. Let’s look at some opportunities discussed in detail in this month’s issue.
Inherited retinal diseases are the next frontier. We’ve already seen treatments for rare hereditary retinal dystrophy, and many potential conditions ranging from Leber’s congenital amaurosis to retinitis pigmentosa are in the near future. What we can do today is begin to determine the role genetic diagnostics play and identify disease risk early. While most patients know it’s important to eat healthy, exercise, avoid excess blue light and take vitamins/carotenoids, knowing they have a gene that predisposes them to macular degeneration would most likely change their motivation to get healthier prior to developing symptoms. Millions of people use the DNA testing kit 23andMe to see what potential diseases they are prone to; a similar version for ocular diseases would have the same success.
Conversion from Dry to Wet AMD
Research shows that the entering visual acuity is the best determinant of success post-anti-VEGF therapy, meaning that a patient who is diagnosed with 20/200 vision is not likely to achieve 20/20 after therapy. On the other hand, an early diagnosis of wet AMD, also known as chorodial neovascularization, may allow your patient to achieve 20/20 vision.
Look for signs of fluid on the OCT, including subretinal fluid, intraretinal fluid and subretinal hyperreflective material. Even then, it can be difficult to discern and you may have to rely on traditional examination for exudates or hemorrhages in the macular region or apply newer technologies such as dark adaptation, OCT-A or refer the patient for fluorescein angiography.
Age-Related Eye Disease Study 2
The results of AREDS2 confirm the value of nutritional treatment for AMD. I commonly see patients who have nothing more than a family history of AMD on AREDS2 formulations—this was not a group that was studied to show a decreased progression of disease. The patients you should recommend this formulation are those with intermediate stage AMD or greater. That is, patients who have at least one large drusen in the macula (large is defined as at the diameter of a blood vessel leaving the optic disc).
Patients with GA in one eye also showed decreased progression of AMD in the good eye with AREDS2 formulations. Everyone else, including those with early AMD or a family history of AMD, should be prescribed carotenoid or other nutritional formulations that are available. For example, Preser-Vision (Bausch + Lomb) for those that meet the AREDS2 criteria and Ocuvite (Bausch + Lomb) or your supplement of choice for those that do not.
Geographic Atrophy (GA)
With two new potential medications on the horizon, pegcetacoplan (Apellis Pharmaceuticals) and Zimura (Iveric Bio), now’s a good time for an update on GA in macular degeneration. Since these will be the first therapeutics shown to slow GA progression, it’s important to start identifying these patients now. The key to success is to identify non-center involved GA with your OCT and refer to a retina specialist when these therapeutics become available. The grayscale OCT showing RPE loss will be key to GA diagnosis.
Diabetic Retinopathy (DR)
When a patient with proliferative DR (PDR) should be referred to a retina specialist is quite simple. Besides signs of PDR or diabetic macular edema (DME), if all four quadrants show signs of retinopathy (e.g., dot or blot hemorrhages, exudates) that’s the time to get a retina specialist involved. This will allow them to help care for the patient at an appropriate time and determine treatment. They can also assess for subtle DME and other treatable DR signs.
The vast majority of patients with dry AMD (particularly GA) and those with prediabetes or early diabetes primarily reside in optometry offices. Knowing how to manage these patients and doing so effectively is an ideal scenario for successful practice.
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.