A healthy comanagement relationship can help ensure optimal patient outcomes while decreasing the number of necessary doctor visits. However, comanagement relationships between physicians can be difficult to maintain due to confusion regarding the roles each doctor is responsible for in the care of the patient. This results in delays in treatment, feelings of uncertainty and lack of confidence in care for the patient.

As with most relationships, the keys to a successful comanagement partnership include mutual respect, realistic expectations and maintaining open lines of communication. This starts from the first referral of the patient all the way through the treatment regimen and shared maintenance visits afterwards. 

Here, I outline the comanagement journey for retina patients and how ophthalmologists can manage this process effectively.

DIAGNOSIS AND REFERRAL  

The vast majority of new patients are referred to the retina specialist by their general ophthalmologist or optometrist. Most patients with new retinal problems do not realize the retina is the cause of their decreased vision and seek care from their ophthalmologist or occasionally the emergency room when vision issues arise. Even those who are savvy enough to suspect a retina issue may need to be referred from a primary doctor due to insurance issues. Unfortunately, this may lead to a delay in care for acute retinal problems that can provoke anxiety for both the patient and the referring physician. 

A healthy comanagement relationship requires that the retinal specialist be available and willing to take on emergent and urgent consultations but also that the general ophthalmologist does not require every consult to be seen as an emergency. For instance, in our practice, we routinely add macula-on retinal detachments, retinal tears and neovascular glaucoma emergently to our clinic schedules, but we may schedule diabetic retinopathy and vein occlusion consults within a week and dry macular degeneration and macular pucker consults within a few weeks.  

Open communication with referring chart notes and background information leads to a smooth referral process. The general ophthalmologists in our community know that they can reach my partners or me by phone, text or email if they ever have any questions about referral timing or have complicated cases that may require more explanation. We all strive to be available and try to respond as quickly as possible when questions arise, so that the general ophthalmologists feel supported and comfortable with the referral process.

Also, an important part of every new consultation is the letter back to the referring physician. This letter can answer important questions about the patient’s diagnosis, care and management that can be important when the patient returns to the ophthalmologist for routine follow-up. This is especially true of patients who ultimately have a diagnosis different than the referral diagnosis, for instance. 

COMANAGEMENT OF NON-ACUTE RETINAL DISEASES

For the patient with non-acute retinal conditions, such as an asymptomatic macular pucker, dry macular degeneration or non-proliferative diabetic retinopathy without macular edema, a consult with the retinal specialist can often provide more information and answers to questions about prognosis, future treatment and need for further monitoring. 

For instance, patients are often referred before routine cataract surgery so they have a better understanding of what to expect from their vision after surgery. Instead of monitoring these retinal conditions in the retina office every 6 months, patients with chronic, non-acute retinal conditions are often then followed every year or two by the retinal specialist. Interim follow-up with the general ophthalmologist is usually recommended, with instructions to return to the retina specialist with an urgent appointment if there is a change in retinal status from baseline. 

Patients at risk of toxic maculopathy, such as those on hydroxychloroquine, are commonly comanaged with their general ophthalmologist. Color vision and visual field testing are performed by the general ophthalmologist, while yearly retina appointments are performed with SD-OCT, autofluorescence and possible multi-focal electroretinogram testing (depending on clinical suspicion). 

Again, the key to successful comanagement is communication and sharing of data between all physicians involved in the patient’s care, including the rheumatologist. For optimal comanagement of these systemic problems, written documentation regarding retinal testing results should be provided to the referring doctors as well as documentation regarding which tests need to be performed at other offices. The follow-up interval required at each office should also be communicated between physicians, and direct telephone communication should be considered for any urgent findings or significant changes in plan.  

COMANAGEMENT OF PATIENTS AFTER RETINAL PROCEDURES

Some retinal procedures, such as subtenons Kenalog injections or intraocular dexamethasone implants for macular edema, require that patients return for an IOP check. Patients who travel long distances to a retina office often have their IOP checks comanaged with their local general ophthalmologist in-between retina appointments. 

Retina post-operative appointments can be tricky to comanage. Very few of our referring general ophthalmologists feel comfortable performing post-operative checks on eyes filled with gas or oil tamponade, especially if post-operative IOP issues require tapping of gas or oil for proper management. 

Even straightforward retinal procedures, such as membranectomy or oil removal that are less likely to have IOP spikes requiring more than medical management, can sometimes be complicated by postoperative retinal detachment. These post-vitrectomized eyes must be swiftly managed for optimal final visual results. 

General ophthalmologists who comanage these patients with retina specialists not only need to be familiar and facile with routine retinal post-operative examinations, but they also need to recognize potential post-operative complications and feel comfortable sending those patients back to the operating retina doctor in case of any doubt to ensure best outcomes. 

COMANAGEMENT OF CHRONIC RETINAL CONDITIONS

Patients who are referred to the retina specialist for treatment and management of chronic conditions such as diabetic macular edema (DME) and neovascular age-related macular degeneration (nAMD) often want to obtain a new refraction soon after commencing treatment. Retinal specialists need to counsel patients that fluctuations in retinal thickness, edema and subretinal fluid can lead to incorrect refractions. 

At the same time, it is important for retinal specialists to return these patients with chronic retinal diseases to their general ophthalmologists for routine glaucoma and cataract care.

In some geographic locations, especially for patients who must travel long distances to obtain retinal care, general ophthalmologists routinely treat patients with DME and nAMD. In those cases, referrals to a retina specialist may be made when the patient is not responsive to initial therapy or if a second opinion regarding etiology with further testing (such as fluorescein angiography) may be desired. 

Patients often make the ultimate decision as to whether care is continued in the retinal office or the referring general ophthalmologist’s office based on practical factors such as travel time and convenience, as well as emotional factors such as the trust, communication and relationship between the patient and physicians.

BACK TO THE GENERAL OPHTHALMOLOGIST AFTER SURGERY

For patients who have undergone vitrectomy, progression of cataract necessitates a return of these patients to their general ophthalmologist. However, setting proper expectations of timing of these referrals for cataract surgery is often important to allay patient anxiety. I often encourage patients to make an appointment with their general ophthalmologist during one of their first post-operative appointments with me, knowing that it can take several months for a routine cataract consultation to be scheduled. Waiting until the patient has healed from vitrectomy but has poor vision due to mature cataract can lead to unhappiness for the patient who is anxious for visual improvement. 

CONCLUSIONS

Both the general ophthalmologist and the retinal specialist are important members of the patient’s care team. Collaboration and open communication between physicians are key to ensure optimal outcomes for the patient. OM

Margaret Chang, MD, is a senior partner at Retinal Consultants Medical Group, Sacramento, Calif. She is a member of the medical leadership board of Retinal Consultants of America and is the principal investigator on multiple clinical trials. Dr. Chang received her MD and MS in biostatistics from Columbia University, where she was elected to Alpha Omega Alpha. She went on to the Wilmer Eye Institute at Johns Hopkins for both residency and fellowship, where she was awarded the Heed and Michels fellowships.