Eyeworld

EW SECONDARY FEATURE 84 October 2015 by Lauren Lipuma EyeWorld Staff Writer The question is: Do they have a deep enough understanding of the underlying disease to appropriate- ly manage these patients? And do they have enough time to allocate to learning the nuances of treating retinal disease? The tip of the iceberg Performing an intravitreal injec- tion is straightforward, but treating patients with retinal disease requires knowing more than just how to give an injection. "Can people give injections? Sure, they can give injections," said Nancy Holekamp, MD, professor of clinical ophthalmology and visual sciences, Washington Universi- ty School of Medicine, St. Louis. "Should they be giving injections? That's a different question because for standard of care, state-of-the-art medicine, the giving of injections re- quires an in-depth understanding of these diseases and how they respond to these injections." "Once you inject, you assume the responsibility of having evalu- ated the patient, knowing the latest literature, knowing the treatment strategy, and managing the patient," said Pravin Dugel, MD, manag- ing partner, Retinal Consultants of Arizona, Phoenix, and clinical professor, University of Southern California Eye Institute, Keck School of Medicine, Los Angeles, "not only the complications that could potentially occur, but managing the patient when that's going on." Giving anti-VEGF injections is just the tip of the iceberg when it comes to treating retinal disease, Dr. Dugel said, just as giving a patient glaucoma drops or doing filtering surgery is just the beginning of glau- coma care. "I can do glaucoma surgery, but I don't pretend to know as much about glaucoma as a glaucoma spe- cialist," Dr. Dugel said. "It's not the act of doing glaucoma surgery, it's the act of managing the before, the during, and the after and being com- pletely up to date with the changing technology." According to the ASCRS Clinical Survey, the majority of cataract sur- geons believe they have an in-depth understanding of anti-VEGF ther- apies, but that does not mean that they fully understand the under- lying diseases and how to manage them, Dr. Holekamp said. "Giving the injection isn't the difficult part," she said. "The diffi- cult part is knowing how and when and managing these patients." What is the standard of care? It's helpful that cataract surgeons have a working knowledge of anti- VEGF therapies, but according to Dr. Holekamp, referral to a retina specialist is the standard of care for most geographic locations. Ophthalmic surgeons spend years honing their skills in a particu- lar subspecialty to be able to deliver the best care to their patients. But subspecialties change rapidly and require an enormous amount of effort to stay up to date with current treatment paradigms. Providing the best care for retina patients requires knowing the subspecialty as well as any retina specialist, Dr. Dugel said, something that is nearly impossible to do. "It's hard enough to keep up with one subspecialty; to be able to keep up with another one plus yours is an exceptionally difficult thing to do," he said. Retina in particular has been a fluid and dynamic field in recent years, and even dedicated special- ists don't always get it right. Until recently, most specialists thought that injecting patients every 4 weeks would deliver the best outcomes, Dr. Dugel said. Recent research has shown, however, that treating every 4 weeks is not only an un- manageable treatment burden, but may or may not be associated with macular atrophy, fibrosis, and loss of vision in the long run. In light of this research, retina specialists have shifted to giving each patient a more individual, customized treatment. "There's no cookie-cutter recipe for patients with macular degen- eration or diabetic macular edema or vein occlusion," Dr. Dugel said. "All of these treatments need to be customized. If you customize and individualize the treatments, you can not only decrease treatment burden, you can get as good if not better outcomes." But to be able to customize treatment requires knowledge that only comes with experience. where a specialist is not available. According to the 2015 ASCRS Clinical Survey, 18% of U.S. cataract surgeons are giving injections—but is this in the best interest of the physician and the patient? According to two prominent retina specialists, referring the pa- tient to a retina specialist—even for simple injections—is the standard of care. The question isn't whether most ophthalmologists are capa- ble of giving injections, they said. What is the standard of care for treating retinal disease? A ny competent ophthal- mologist is capable of giv- ing anti-VEGF injections to treat retinal disease. And in certain situations, it might make sense for a cataract surgeon or general ophthalmologist to do that—such as in rural areas Should cataract surgeons give anti-VEGF injections? Do you personally perform intravitreal injections for your patients with retinal disease? 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All U.S. Non U.S. Yes No Data from the 2015 ASCRS Clinical Survey showed that roughly 18% of U.S. cataract surgeons and 45% of non-U.S. cataract surgeons perform intravitreal injections. The majority of respondents believe they have an in-depth understanding of these therapies. Source: ASCRS Do you believe that you have an in-depth understanding of the anti-VEGF therapies and their impact on cataract patients? 60% 50% 40% 30% 20% 10% 0% Strongly agree Agree Neither agree or disagree Disagree Strongly disagree All U.S. Non U.S. continued on page 85

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