Doctors’ of optometry AMD assessments comparable to ophthalmologists

Doctors of optometry are no less effective at identifying developments in neovascular age-related macular degeneration (AMD) than ophthalmologists, and may even be more meticulous in their assessments, concludes a new study.

Published in the peer-reviewed journal BMJ Open this past June, the study out of the United Kingdom found community doctors' of optometry ability to make neovascular, or "wet" AMD retreatment decisions were "not inferior to ophthalmologists' ability," and that "shared care with optometrists monitoring quiescent [wet AMD] lesions has the potential to reduce workload in hospitals."

In the U.K., ophthalmologists within the Hospital Eye Service (HES) typically administer AMD treatment of anti-vascular endothelial growth factor (VEGF) drugs and continue tracking patients through routine, monthly hospital visits to monitor for lesion reactivation. This can tie up doctors' time and resources. Therefore, researchers set out to determine whether 'shared care' between private practice doctors of optometry and the HES to monitor for this reactivation was feasible, considering an established model already exists for conditions such as glaucoma.

Researchers found that the 48 doctors of optometry and 48 ophthalmologists classifying lesions using virtual vignettes were 84.5% and 85.4% correct, respectively. Additionally, the study noted that doctors of optometry tended to be more cautious in their review and more likely to classify lesions as reactivated—a trait that study authors noted "may be desirable in a primary care setting."

Medical News Today cited the study, reporting: "Decisions made by ophthalmologists and optometrists were consistent and that after training, optometrists based in the community were as good as hospital-based ophthalmologists."

AMD in the USA

A leading cause of severe vision loss in adults over age 50, AMD affects up to 1.8 million Americans with another 7.3 million at substantial risk for AMD-related vision loss, according to the Centers for Disease Control and Prevention. The common eye disorder causes damage to the macula, distorting central vision. It takes two forms: wet AMD, which is caused by abnormal blood vessel growth leaking fluid beneath the retina, and dry AMD, which is the gradual breakdown of the macula's light-sensitive cells.

Early symptoms of AMD can go unnoticed, and, presently, there is no treatment for the dry form; however, wet AMD can be treated with laser therapy and injectable medications to help minimize vision loss.

Steven Ferrucci, O.D., chief of optometry at Sepulveda VA Medical Center and professor at Southern California College of Optometry at Marshall B. Ketchum University, says the current era of long-term, repetitive anti-VEGF injections keeps most retinal specialists exceedingly busy.

"[Doctors of optometry] helping to co-manage stable wet AMD patients and refer back to the retinal specialist for treatment when needed will help reduce this burden," Dr. Ferrucci says, in reviewing this U.K. study. "For years, many doctors of optometry have been co-managing a variety of conditions with various ophthalmology sub-specialists—glaucoma, cataracts, diabetic retinopathy, etc.—so adding AMD is a natural extension.

"Certainly, it is imperative that we maintain our knowledge on the associated signs to look for and stay vigilant as new technology or treatments become available."

Scope of care

In the U.S., scope of practice laws vary from state to state, granting doctors of optometry the legal authority to administer the eye injections necessary to treat AMD (read more about scope battles in the November/December 2014 edition of AOA Focus); however, research into eye drops for the disease could radically change treatment. Currently, doctors' of optometry role in disorders such as AMD is preventative, while also monitoring for disease progression and providing a crucial patient education component.

This current role could expand as advances in technology—such as optical coherence tomography (read more in the October 2015 edition of AOA Focus)—increases doctors' ability to recognize signs and symptoms of AMD, Dr. Ferrucci says.

"As treatments for AMD get better, early diagnosis becomes even more crucial, as many studies show that smaller lesion size on diagnosis is essential to treatment success," he notes. "According to this study, doctors of optometry are quite capable of recognizing these early changes and seeking out referrals for treatment in a timely fashion."

Dr. Ferrucci adds: "Interestingly, this study showed that optometrists were more cautious than the general ophthalmologist, meaning we may be even more vigilant following these types of patients and referring for additional treatment sooner if we detect suspicious lesions."

Read more about AMD care recommendations in the AOA's clinical practice guideline, Care of the Patient with Age-Related Macular Degeneration.