Retinal Referrals: When to Make the Hand-off

New technology and greater confidence is yielding fewer — but better — consults for some generalists.

By Jerry Helzner, Senior Editor

To refer or not to refer to a retina specialist — that is often the question.

In many types of cases, the need for a retina referral is clear. When general ophthalmologists encounter sight-threatening problems, including retinal detachments, suspected endophthalmitis, active wet AMD, disease processes that require vitreoretinal surgery and chronic CME unresponsive to medical therapy, they do not hesitate to bring in a retina specialist.

However, with the availability of OCT, and more recently SD-OCT, many general ophthalmologists say they are now able to diagnose and treat less serious retinal issues that formerly required a subspecialist referral. How far general ophthalmologists will go in this regard depends on how much previous experience they have had in treating retinal problems, the technology at their disposal and their overall comfort level in dealing with these kinds of cases.

Don't Exceed Your Comfort Level

Uday Devgan, MD, of Los Angeles, rates physician expertise over technology as the primary determinant of when retina referrals are made.

"I think it's more of a question about the general ophthalmologist's comfort level and not the equipment," he says. "If the only requirement to treat retinal disease is an office full of fancy equipment, then even paramedical personnel would be doing so."

Michael Korenfeld, MD, of Washington, Mo., generally agrees. He offers a brief but compelling explanation of which cases should be referred to a retina specialist and which can be handled by the general ophthalmologist.

"The problems that general ophthalmologists should refer are those that he or she is not comfortable taking care of," he asserts. "There is a pretty broad spectrum of skills among general ophthalmologists. I don't administer intravitreal injections, for example, but some general ophthalmologists do."

OCT as a Diagnostic Tool

Dr. Korenfeld, who has had OCT for the past six years, says this technology has enabled him to treat postop CME and to perform focal macular laser treatments. He says these conditions would have previously required referral to retina for an angiogram. Now, with the OCT results in hand, he can use them in lieu of an angiogram to guide the planning of a focal macular laser in some instances.

Steven Silverstein, MD, of Kansas City, also sees OCT as eliminating the need for angiograms in many cases.

"We can now easily see CME on OCT," he says. "The same holds true for conditions such as macular pigment epithelial detachment, macular cyst and sometimes central serous maculopathy." These conditions do not require an investment in SD-OCT, says Dr. Silverstein, as the information derived from a standard OCT is of sufficient quality to make a diagnosis, rule out an abnormality and direct the physician toward the best method of treatment. "If the OCT is suggestive but not diagnostic of a specific pathology, fluorescein angiography is typically the gold standard in such circumstances."

Dr. Korenfeld now does a macular OCT on every patient with a macular issue requiring additional diagnosis. "Nine times out of 10 we find the problem," he says. "The OCT tells all. When I refer a patient to retina now, the patient shows up with a printout of the OCT and a diagnosis that is almost always correct."

Dr. Korenfeld says that having OCT allows him to show the patient the problem on a monitor and explain what the images are showing. "I think that lets the patient understand what they actually have," he says.

"When I refer a patient for repair of a macular hole or vitreomacular traction syndrome, the retina specialist is pretty sure he will see that same condition," notes Dr. Korenfeld. "By having patients show up at the retina doctor aware of their problem, and its likely fix, I think it helps patients be more comfortable, which helps me, the patient and my retina colleagues."

Factors That Influence Referrals

Kevin L. Waltz, MD, of Indianapolis, agrees that one of the benefits of having advanced imaging technology is that it results in more accurate and precise retina referrals.

"With OCT, we are now able to better differentiate what needs to be referred and what does not need to be referred," he notes. "This usually results in a higher quality referral and a more pleasing process for the patient."

Dr. Waltz says individual general ophthalmologists will often base their referrals on their own training, personal experience and the local availability of retina specialists.

Jay Pepose, MD, PhD, of Chesterfield, Mo., agrees.

He says that the decision to refer or not to refer depends on the training that the general ophthalmologist has in the diagnosis, management and treatment of macular degeneration or other macular conditions, as well as being competent to handle potential complications of treatment.

"In a large city where I practice, there are many retinal specialists in close proximity and so referral is generally not inconvenient for the patient and provides optimum subspecialty care," says Dr. Pepose.

He says that in rural areas, where fellowship-trained retinal subspecialist care may be hours away, the general ophthalmologist may feel that it is in the best interest of the patient to provide some aspects of retinal treatment, including intravitreal injections of anti-VEGF agents for the treatment of wet AMD.

"But this would require adequate training and adequate retina backup should a complication occur," he notes. "Similarly, some general ophthalmologists may be comfortable performing PRP or focal retinal laser treatments."

Medical vs. Surgical Retina

When Dr. Waltz started in private practice in 1993, he had experience with treating surgical and medical retina. He personally treated patients who needed vitrectomies and medical laser treatment for macular disease, DR and retinal tears.

As Dr. Waltz became busier and more expert in other areas, he did less surgical retina but continued with medical retinal treatment and diagnosis because he found it rewarding and enjoyed it. He gave up medical retina when he added a retinal partner in 1999.

"Generally, I think comprehensive ophthalmologists can decide for themselves what they are comfortable diagnosing and treating in the retina area," says Dr. Waltz. "There are two generally recognized referral points. Most comprehensive ophthalmologists do not do surgical retina such as buckles or vitrectomies, though some do medical retina such as medical laser treatments. And I think most, but not all, comprehensive ophthalmologists do not routinely do intravitreal injections."

Dr. Waltz thinks the general category of macular problems can now be better differentiated with OCT than in the past. He says a good example is in pre- and post-cataract care. "We sometimes find CME preop that in the past we would only find postop. This might result in a referral to a retinal specialist when it would not have in the past," he says. "Likewise, when I suspect CME postop, I order an OCT and evaluate it myself. I do not refer to a retinal specialist at this point. If there is CME, then I treat it and follow it with confidence that I can document when it gets better or not. If there are problems in the process, I might involve a retinal specialist."

Dr. Waltz believes that the availability of OCT to general ophthalmologists is resulting in more difficult cases being referred to retina specialists.

"OCT has increased the acuity — or degree of difficulty — of the typical retinal specialist's case load," Dr. Waltz asserts. "But the new diagnostic tools are making the prereferral diagnosis more accurate."

Macular Issues and IOL Selection

When Steven Safran, MD, of Lawrenceville, NJ, purchased his Spectralis SD-OCT, one of his primary goals was to be able to "know what was going on with the macula in terms of cystoid macula edema and finding fluid in the retina associated with macular degeneration."

However, he soon found other applications for the instrument. For example, detecting macular issues with the Spectralis has become key in Dr. Safran's evaluation and treatment of cataract patients for premium IOLs.

"I use the Spectralis to scan every premium lens patient prior to surgery and also for every cataract we do if the macula doesn't look perfect — and even sometimes if it does but I'm just not sure," says Dr. Safran.

He says he has identified vitreomacular traction frequently, lamellar holes even more frequently, subretinal fluid, peripapillary disciform lesions with fluid leaking into the macula, subretinal nevi with subretinal neovascularization and fluid, and other issues prior to surgery that would have led to problems had he not known about them and gone ahead with the surgery.

Dr. Safran notes that today's cataract surgery patients have high expectations, and premium IOL patients higher still. He says that detecting macular issues in cataract surgery patients with the Spectralis has helped enable him to implant the appropriate premium or monofocal IOL for these patients.

For example, Figure 1 is a 52-year old −4 D myope who had a retinal detachment repair recently with buckle. "The retinal detachment went right up to the edge of the macula and although the macula looks abnormal on exam, the Spectralis shows a rather normal macula architecture in this, his dominant right eye," says Dr. Safran. "This patient did extremely well with Crystalens in this eye, ending up 20/20 and J2 uncorrected."

"The next patient (Figure 2) also had Crystalens surgery in the dominant eye and did very well despite the presence of epiretinal membrane (ERM) on exam," he notes. "The OCT shows normal macula architecture, which indicates that, despite the ERM, the patient should do very well without problems."

Figure 2. This patient had an ERM, but the image shows normal macular architecture, which allowed Dr. Safran to successfully implant the Crystalens without need for a retina referral.

The third patient (Figure 3) was a few months out from cataract surgery and although she was relatively asymptomatic, a drop in vision to 20/25 from 20/20 prompted Dr. Safran to perform an OCT scan, which demonstrated a subretinal net with fluid. She was referred to a retina practice for treatment.

Developing a Team Approach

Dr. Safran says that the issues after surgery that prompt referral include suspected or actual endophthalmitis, retina detachment, choroidal hemorrhage or dropped lens fragments. Sometimes, if he is undertaking a case where there is an extremely high risk of vitreoretinal complications, he will have the retina practice on standby, ready to come over and assist. An example of this is a cataract surgery he recently performed on a 12-year-old who had blunt trauma to the eye with a large split in the posterior capsule with lens material bulging through the split.

"It is important to have retina people who understand what your capabilities are so that they can interface properly with you in the care of your patients," asserts Dr. Safran. "I think it is important to develop this relationship to provide a better 'team' approach to care. The retina people I work with know that I do a lot of complicated anterior segment procedures and that I often use a pars plana approach in dealing with complex IOL/lens problems. They are quite comfortable with this and often refer patients to me for my expertise in dealing with these issues, just as I refer problems to them for theirs."

Dr. Silverstein notes that having an in-house retina specialist can also contribute to more of a team approach to diagnosis and treatment.

"The convenience of having someone in-house would increase the retina referrals for borderline cases, such as mild background diabetic retinopathy which may potentially benefit from having a few microaneurysms lasered but in whom observation is often recommended," Dr. Silverstein says. "In these cases, it is also critical to lower the circulating blood sugar and hemoglobin A1-C level, which in itself can lead to improvement or resolution of a mild case of this type."

Positives in New Referral Patterns

One might think that the trend toward general ophthalmologists doing more of their own diagnosis — and sometimes treatment — of retinal problems might be causing a strain in their relationships with retina specialists. However, this does not appear to be the case.

Dr. Silverstein sees the newer diagnostic technologies emerging in general ophthalmology practices serving as a screen to eliminate unnecessary referrals to already overburdened retina specialists. "The retina specialists are trying to accommodate an ever-growing population of Avastin/Lucentis patients with AMD," he says.

Dr. Waltz agrees. "I don't see any [strain]," he says. "I think the typical retinal specialist is so overwhelmed by the increase in intravitreal injections that they appreciate the lower volume of referrals, which is resulting in a higher acuity of subspecialist care."

"Having Spectralis has actually made me better at macular examination and diagnosis at the slit lamp by giving me immediate confirmation of what I am seeing on exam so that I am better able to understand what different types of subtle pathology tend to look like," says Dr. Safran. "I find I am no longer sending patients for referral based on fear of what they might have, but rather to treat what I know they do have when it is appropriate." OM