Age-Related Macular Degeneration Treatments: Determining Appropriate Use - Episode 6
Peter L. Salgo, MD: Let’s talk about treating patients, managing patients, with AMD. Let’s assume that we’ve got some plans in place and patients are getting picked up. Who’s going to take care of these folks? Is it the retina specialists or is it the ophthalmologists? Where do we even start?
Charles Wykoff, MD, PhD: In most cases, it is a retina specialist, which is an ophthalmologist with additional training. This is where it’s critical to get the entire community involved with a patient, because, as Jared pointed out, the patient often has family or friends involved in bringing them in. And it’s critical that the patient and their entire support network understand that this is a chronic disease and, as I say in my conversation with patients, is not curable. We have really good treatments for this, but it requires ongoing treatment.
Peter L. Salgo, MD: So, you’re telling me right off the bat, retina specialist. Ophthalmologist should refer everybody out. Is this getting paid for?
Jared Nielsen, MD: Yes, definitely. I think if somebody has wet AMD, they go in to see a retina specialist. We’re definitely getting paid to provide that care for patients. I think another equally important reason to enlist a retina specialist, rather than a general ophthalmologist, is that the misdiagnosis of wet AMD can have devastating impacts. First of all, if it’s missed and the patient goes untreated, there can be permanent vision loss. If somebody has a masquerade-type lesion and they end up getting put on anti-VEGF therapy over a long period of time, that’s unnecessary treatment. And Charlie and I have seen many patients who have been treated, misdiagnosed, and injected for years, perhaps, when they could benefit from seeing a retina specialist and receiving an accurate diagnosis to guide treatment.
Peter L. Salgo, MD: Just because I heard this for the very first time right now, a masquerade. What is that?
Jared Nielsen, MD: Well, any condition that certainly mimics another in medicine we call a masquerade. An important one for macular degeneration, especially wet macular degeneration, is vitelliform disease or pattern dystrophy. Sometimes, an OCT—that laser test we talked about earlier—can have a dramatic appearance, where you have fluid underneath the retina that can mimic exudative or wet AMD. Oftentimes, you look at that and you say, “I’ve got to treat this.” That’s where a retina specialist can do additional testing, fluorescein or OCT angiography, to help really pin down the diagnosis and make sure that the patient is getting the treatment that they need.
Peter L. Salgo, MD: So, before you ask these guys to shell out, you want to be sure you’re asking them to shell out for the right stuff?
Jared Nielsen, MD: Correct, yes.
Gary L. Johnson, MD, MS, MBA: And we’re happy to do that.
Jared Nielsen, MD: I think, as a payer or as a patient, I’d rather have that done with a retina specialist who has the expertise to be able to make the difficult calls in some cases.
Peter L. Salgo, MD: Does every ophthalmologist agree with you or do they think, “Ah, I can handle everything across the water”?
Charles Wykoff, MD, PhD: There are certainly general ophthalmologists who do manage retinal conditions, but in most cases in my area, retina specialists are the ones driving this.
Peter L. Salgo, MD: That does bring up the obvious question, right? There are underserved areas. There are some parts where the population density is quite low and the ophthalmologist-to-patient ratio is very poor.
Charles Wykoff, MD, PhD: Absolutely.
Jared Nielsen, MD: I think a lot of retina specialists step up in that area, and certainly in my practice, that’s the case. Our practice has a large geographic area: the whole state of Iowa. But we do go out to where the patients are in many cases. Even in the West, where the population is less dense, you’ll find that the retina specialists will often get on a plane or in a car and head out to take care of patients.
Peter L. Salgo, MD: What about telemedicine? Can you take a picture of the retina and make a diagnosis?
Jared Nielsen, MD: That’s the Holy Grail in a lot of cases, and people are certainly working on that. The only problem is that there’s not an arm on the end of that computer to administer treatment when the patient needs it.