Focus on Retina

Who should perform intravitreal injections?

General ophthalmologists are doing more, but co-management with a retinal physician seems the best approach.

By Karen Blum

The day after the FDA approved Macugen (pegaptanib, Valeant Ophthalmics) for treatment of neovascular AMD in 2004, comprehensive ophthalmologist David Gossage, DO, started offering the anti-VEGF injection to patients at his Hillsdale, Mich., practice.

At the time, only physicians who participated in the original VISION study were trained to perform the injections of Macugen, says Dr. Gossage, clinical associate professor of ophthalmology at Michigan State University, so other ophthalmologists had to teach themselves. Now, he uses intravitreal injections about 30 to 40 times a month.

The role of retina subspecialists and comprehensive ophthalmologists in performing intravitreal anti-VEGF injections has evolved.

Since then, the role of ophthalmologists — both retina specialists and comprehensive ophthalmologists — in performing intravitreal anti-VEGF injections has evolved. Once the domain of retinal physicians, more general ophthalmologists have started offering this therapy as the ranks of patients with AMD have grown.

NON-SPECIALISTS GET ON BOARD

The opportunity exists

Despite some beliefs that only retina specialists are qualified to do anti-VEGF injections, Dr. Gossage says it makes sense for comprehensive ophthalmologists to perform them, especially in regions like his where the closest retina specialist is an hour away.

“Early on, many patients we did share (with retina specialists),” he says. “But many patients want to stay close to home. They don’t want to travel; they’ve already come to you for their eye care and they feel confident with you.” Because he can also perform laser photocoagulation, he can also can offer patients injections in combination with that procedure if needed.

In addition, the use of injectable medications is expanding beyond macular degeneration to include diabetic macular edema, proliferative diabetic retinopathy and retinal vein occlusions, says Dr. Gossage. The aging US population is a mitigating factor, he notes. “The number of people needing anti-VEGF therapy will be a real burden for many retina specialists,” Dr. Gossage says. “Many ophthalmology residency programs are now training residents in the care of patients requiring anti-VEGF therapy and learning the injection techniques.”

Limitations of few specialists

In remote regions, many patients who need injections have transportation difficulties, says Larry Patterson, MD, of Crossville, Tenn., who performs about 20 injections per week. (Dr. Patterson is chief medical editor of Ophthalmology Management.) They do not necessarily have the vision to drive, and some need an injection every month. “We would be kidding ourselves if we think patients are going to regularly travel 100, 200 or 300 miles for an injection,” he says.

Ideally more retina specialists would be in remote areas, notes Jorge Calzada, MD, president of the Charles Retina Institute in Memphis. “But that’s not happening,” he says. “Graduates are not going to rural areas.”

David Lane, MD, a general ophthalmologist in Lindsay, Ontario, about 82 miles northeast of Toronto, says the travel is too much for some of his patients. “In a rural setting, there are no retina specialists — often you’re the only person,” says Dr. Lane, who performs about 50 to 60 injections weekly. “Access to care is inextricably linked to quality of care, and if you don’t (give injections), people will go blind.”

In Ontario, a province of 12.8 million people spread over 415,600 square miles (by comparison, Texas has 26.4 million over 268,600 square miles), general ophthalmologists performed about one third of all intravitreal injections in 2011 — 28,000 of 81,000, according to Ontario Ministry of Health data. Many of Dr. Lane’s patients are older, live in nursing homes or may not have assistance from family members, he says. “Just getting across town is a big deal. The idea of going to Toronto for an injection? Forget it. They just wouldn’t go,” he says.

STICKING WITH RETINAL SPECIALISTS

Fear of complications

Vitreoretinal surgeons like Dr. Calzada are cautious. “The know-how is always best with a retinal surgeon,” Dr. Calzada says. He estimates that one in 10 to 15 patients receiving injections could have complications. “Even very good ophthalmologists can make some broad diagnoses but can fail or may not be up on every single treatment regimen,” he says.

Optimally, he says, board-certified vitreoretinal surgeons should perform injections at a retinal practice with the proper equipment. “For the majority of urban patients, that’s what we should strive for,” Dr. Calzada says.

Other retina specialists share Dr. Calzada’s views. “Managing wet AMD is not just about the injection itself,” says Sophie Bakri, MD, a retina specialist and professor at the Mayo Clinic in Rochester, Minn. “It is about the decision of whether to inject, which drug, which frequency, and consideration of alternative treatments, as well as knowing when treatment is futile.”

THE CASE FOR CO-MANAGEMENT

A win-win?

A retina specialist should make the decisions on who should perform the injection, which can be administered by properly-trained general ophthalmologists in rural areas where patients need access to regular injections, says Dr. Bakri, who performs up to 50 injections each half-day along with her retina specialist colleagues.

“However,” she says, “systems need to be put in place that allow easy and frequent communication between the retina specialist and general ophthalmologist for the plan of care, as well as systems that allow the patient to schedule the injections and make follow-up appointments with the retina specialist after the series of injections.” Also, Dr. Bakri suggests standardizing and updating these protocols when needed.

Retina specialist Alan Berger, MD, chief ophthalmologist for St. Michael’s Hospital in Toronto, agrees. “General ophthalmologists are qualified to do the procedure, technically, but co-managing with a retina specialist is critical,” he says. Dr. Berger estimates he performs 100 injections a week.

The AAO does not have a formal policy on general ophthalmologists performing these injections. However, Paul Sternberg Jr., MD, past AAO president, advises that optimal medical care for AMD “not only requires skill in the proper injection technique, but also complex decision-making based on deep knowledge of vitreoretinal pathology, experience in patient selection and the complex management and treatment of complications of the disease as well as up-to-date knowledge of the evolving data on AMD treatments.”

Adds Dr. Sternberg, a retina specialist and professor and chair at Vanderbilt Eye Institute in Nashville, “Comprehensive ophthalmologists who choose to treat these patients should do so ideally in consultation with a retina specialist and should encourage patients to see a retina specialist when possible.”

Dr. Lane refers some patients to retina specialists but only if there is any uncertainty of the diagnosis or he sees something unusual during the exam. “I know there are several people in my practice every day who would permanently lose vision if I didn’t do (the injections),” he says.

Technology enables consultation

“My concern with general ophthalmologists is that most spend half a day a week doing this vs. retina specialists who do this five days a week,” Dr. Berger says. “Most are competent but not highly trained. I’ve seen cases where patients have been treated with injections and they may not have needed them at all.”

Dr. Berger says he supports general ophthalmologists performing the injections in remote areas, but concedes they should consult with retina specialists, even if they use telemedicine once every six months or once a year. Co-management can be as easy as sending a copy of an OCT report or retinal photograph.

“Ten to 20 years ago it was much harder to co-manage patients,” Dr. Berger says. “We didn’t have all the technology.”

Canada’s publicly funded health system covers the costs of injections, he notes. “It’s not like I want to take anyone’s patients — we’re all busy,” Dr. Berger says. “But if a patient is getting $25,000 of drug a year for free, for them to make one trip of 200 to 300 miles once a year (to a retina specialist) is not too much.”

WHAT’S THE VERDICT?

Who should perform the injections? It often comes down to geography. In urban or suburban areas where retinal specialists are plentiful, referrals and co-management may be the way to go. In more remote areas, comprehensive ophthalmologists who learn proper technique can perform the injections, say those interviewed. However, patients with complicated retinal conditions should be referred to or co-managed with a retina specialists. OM