Will General Ophthalmologists Care for More Retina Patients?

By Sean McKinney, Contributing Editor

Projections indicate an 18% increase in the total U.S. population by 2030 — and a 78% increase in the elderly population.¹ The challenge of caring for millions of additional patients likely will be compounded by improved diagnostic instruments, such as OCT, being used more frequently by general ophthalmologists and optometrists, which will result in uncovering more diseases and pathology. The trend is already under way, changing protocols for treatment and referral.

Mini retina fellowship?

"The aging of the baby boomers means retinal patients will appear in epidemic-like numbers in all of our practices," says Alan B. Aker, MD, a cataract surgeon in Boca Raton, Fla. "Intravitreal injections are effective for treating some retinal disorders. Because demand for this type of treatment will grow substantially, timely access to specialists will become difficult."

Dr. Aker recommends general ophthalmologists consider doing a mini-fellowship in retina, which can help them provide care for retina patients and help sustain practices in the face of ongoing reductions in reimbursement.

"You can treat many of these patients as long as you have appropriate training," he says. "Already, in our area, because treatments need to be provided on an ongoing basis, retina specialists are being challenged to handle the growing demand."

Access to care is a growing burden for AMD patients, who often struggle with near blindness and transportation issues. In outlying rural areas, many can't travel to see retina specialists.

Providing retinal care

Many generalists have already begun providing retinal care, careful to refer when patients require more advanced treatment.

"I believe injectable therapies are definitely within the realm of the general ophthalmologist," says J. Isaac Barthelow, MD, a private practitioner from Chico, Calif. Because of spectral domain OCT, he says he can diagnose wet AMD and postoperative CME in his standard exam lane, and it takes only 5 extra minutes.

"My spectral domain unit, the Cirrus HD-OCT, has improved my understanding of the pathophysiology of many retinal conditions," he says. "In the past, I would have referred these patients." However, David Boyer, MD, of Retina Vitreous Associates Medical Group, based in the Los Angeles area, cautions that a careful balancing act must be maintained to ensure optimal patient outcomes.

"We're seeing cases in which treatments for wet AMD are being done by general ophthalmologists," he acknowledges. "But you have to be very careful when reading an OCT scan and determining when to retreat."

Isaac Barthelow, MD, of Chico, Calif., is among a growing number of general ophthalmologists taking on retinal care. Here, he's counseling a 73-year-old patient with a history of wet AMD OD (undergoing treatment with bevacizumab [Avastin]) and advanced dry AMD OS.

Within limits

Michael Jacobs, MD, a general ophthalmologist from Athens, Ga., says he treats retinal conditions within limits, but is quick to refer complex cases. Practicing in an area of nearly 500,000 people, many in underserved areas, he feels a responsibility to provide a full range of care, including laser treatments for diabetic retinopathy.

"Using OCT to follow CME or diabetic retinopathy, I look at changes in the retina over time, with respect to macular thickness," he says. "With OCT, I can compare the changes and it's also very helpful to provide patients with education that improves their situations."

Reference

1. 65+ in the United States: 2005. U.S. Department of Health and Human Services. National Institutes of Health, National Institute on Aging. U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau.

Retinal Physicians Tackle Questions About the Future

By Sean McKinney, Contributing Editor

1. How should staff prepare for the influx of patients?
"Practices have to create a process to efficiently evaluate the patient," says Jason Slakter, MD, who practices at Vitreous- Retina-Macula Consultants of New York, N.Y., and is a clinical professor of ophthalmology at New York University School of Medicine. "A well-trained staff is critical to ensure maximal efficiency and output. I recommend empowering one or two people to supervise this effort."

David Boyer, MD, of Retina Vitreous Associates Medical Group, based in the Los Angeles area, agrees that efficiency will be key. "We'll continue to make sure patients are sent through for treatment faster," says Dr. Boyer.

"Unfortunately, we're becoming more like an injection clinic. But we're training our staff to work these patients into the early part of the schedule and to triage emergency cases for visits later in the day."

2. How will you redesign your office and practice to meet the needs of more patients?
Dr. Boyer says better space utilization, informed by types of visits, will be critical, and sharing costs for the purchase of equipment and practice mergers will become commonplace.

Dr. Slakter believes special rooms should be set aside for injections to reduce the impact of the high number of these procedures on the overall operation of the practice.

"Retina practices should also have high-tech imaging suites with networks that allow the efficient transfer of records and data, facilitating the most effective evaluation of patients by staff and physicians," he says.

3. Where should you perform surgery?
"The viability of surgery in the ASC will depend on the number of cases you do, how frugal you are, what ancillary equipment you use and how long you take to operate," says Dr. Boyer. "It may also depend on changing reimbursements."

Dr. Boyer prefers operating on very ill patients in the hospital, where systemic complications can be better managed. He also uses the hospital when cases require silicone oil or numerous disposables, and for difficult cases, such as complicated retinal detachments.