Improving patient outcomes: role of the primary care optometrist in the early diagnosis and management of age-related macular degeneration

Abstract

Not long ago, the management of age-related macular degeneration (AMD) was confined to rehabilitating whatever vision had not been damaged by the disease. The recent successes of the anti-vascular endothelial growth factor agents and the antioxidant clinical trials have revolutionized AMD treatment. For the first time, there is realistic hope that the progression of AMD can be slowed down or stopped and near normal vision can be preserved. Developments in new vision tests, imaging modalities, and genetic testing have greatly improved the chance of detecting the onset of AMD and choroidal neovascularization. However, because the current treatments still cannot revive degenerated retinal cells, the best patient outcome that can be achieved is early detection of the disease and application of the appropriate treatment before too much retinal damage has occurred. The opportunities and challenges offered by the new treatment options and disease detection methods have redefined the role of primary care optometrists in AMD management. This review of literature and practice guidelines demonstrates that, in addition to the traditional roles of refraction and visual rehabilitation, the unique position of optometrists as the first-line eye-care providers has allowed them to play an important role in the early detection of AMD, patient education, lifestyle-change counseling, disease monitoring and referral, and nutrition supplement counseling. The active participation of primary care optometrists in the shared care of AMD management is likely to result in great improvement in patient outcomes. Optometrists also need to improve their competence in these areas to meet the new challenges. Although primary care optometrists have always managed patients with AMD, their role in managing this sight-threatening disease has not been adequately documented. In light of the recent game-changing developments in AMD treatment, it is important to review what primary care optometrists are doing, what they can do, and what they should do to improve patient outcomes in the new era of AMD management. Keywords: detection, patient education, lifestyle-change counseling, disease monitoring, disease referral, nutrition supplement counseling Age-related macular degenerationAge-related macular degeneration (AMD) is an acquired degenerative disease of the macular area of the retina that, in its final stage, can cause severe visual impairment. AMD affects mainly older people and its prevalence increases with age. The prevalence of any AMD and late AMD (geographic atrophy [GA] or choroidal neovascularization [CNV]) in persons aged 40 years and older is between 5.2% and 14.3%, and between 0.3% and 2.6%, respectively, depending on race and ethnicity.1 AMD results in centrally located scotomas; reduced visual acuity, contrast sensitivity, color vision, and depth perception; and poor control of eye movements. AMD is one of the leading causes of severe visual impairment in Dovepress submit your manuscript | www.dovepress.com

The geographic distribution of eye care providers in the United States: Implications for a national strategy to improve vision health

“…This indicates that public health interventions that are effective in a context of limited local eye care provider availability or that are able to leverage optometrist availability effectively in areas with limited ophthalmologist availability could be of widespread use in the US as a part of VHI's national vision health strategy. Previous research suggests that public health strategies to increase access to eye care providers through the use of telemedicine and the implementation of "shared care" models of eye care, where eye care is managed jointly by ophthalmologists and optometrists, may hold promise for increasing the use of eye care services in these areas (Au and Gupta, 2011;Banes et al, 2006;Hanson et al, 2008;Kelly et al, 2011;Lee et al, 2007aLee et al, , 2007bLiu and Swanson, 2013;O'Connor et al, 2012;Rein et al, 2011;Taylor et al, 2007;US Department of Health and Human Services, 2010). In order to improve the ability of public health initiatives to respond to the local availability of eye care providers effectively, more research is needed to determine the optimal division of labor between ophthalmologists, optometrists, and other health care providers in the delivery of care that leads to the prevention, early detection, and timely treatment of vision conditions (US Department of Health and Human Services, 2010).…”

Screening for macular disorders: the optometrist's perspective

“…Late AMD is neovascular AMD and/or any geographic atrophy (GA). Exudation in AMD can take many forms: cystoid macular edema, diffuse macular edema, and pigment epithelial detachment can all be found with AMD, along with the usually extensive lesions found in retinal vascular anomalous complex or retinal angiomatous proliferation 69,70 and polypoidal neovascularization (Figure 3). These clinical entities should be considered also as late AMD, being exudative even if new vessels cannot be visualized.…”

“…At present, the treatments for early AMD are not yet proven, and therefore screening with genetics or for treatments has not been advised. 70 Using modern scanning and confocal en face imaging, particularly with near-infrared light, far more and a larger extent of drusen, exudation, and related tissue damage are seen than with color fundus photography. [71][72][73] Hyperpigmentation, which is a key variable in the international classification, is well visualized in near-infrared and red wavelengths.…”

“…Among the many potential tests, ones involving flicker have high sensitivity because of the lack of stimulus degradation by the scattered light from the anterior segment of older eyes. 70,96,97 Dark adaptation has been suggested, but does not fit the requirements for screening tests, because it needs a considerable amount of test time and adaptation of the patient to constant illumination, plus control of room illumination. 70 Macular function tests that vary in spatial content include well-known measures, such as VA, Amsler grid, contrast sensitivity, SKILL cards, and others.…”

Using Technology, Bioinformatics and Health Informatics Approaches to Improve Learning Experiences in Optometry Education, Research and Practice

“…Optometry is a fast-growing profession that addresses diagnosing and treating visual problems, prescribing eyeglasses or contact lenses and managing diseases, injuries, and other disorders of the eyes [3]. More recently, the scope of practice for optometrists is widening with newer regulations in different countries and as such there is a greater need for students to learn examining and make appropriate recommendations not only for eyes but also for ocular manifestations of potential systemic issues [4,5]. …”