Damon Dierker, OD, FAAO, the director of optometric services at Eye Surgeons of Indiana, and Ankur Shah, MD, FASRS, a retina specialist at Retina Partners MIdwest at the Midwest Eye Institute in Indianapolis, discuss the importance of developing efficient, patient-centered referral protocols for the management of geographic atrophy (GA). They emphasize the factors that influence referral decisions and the necessity of thorough patient vetting and education.
Tailoring Referrals for GA
An efficient and patient-centric referral is important when co-managing patients with GA. Referral decisions can be nuanced, especially for patients in earlier stages of GA.
A referral is an "easy decision" for patients with progressive or symptomatic GA. For patients in earlier stages of GA, the decision is more "nuanced". Factors that affect referral decisions include:
- High-risk features on optical coherence tomography (OCT)
- Functional changes, such as trouble reading or seeing in dim light
- Age and other co-morbidities
- Fellow eye status
- Overall health history
- Patient motivation to be proactive
Dr. Shah notes that it is reasonable to continue monitoring a patient in a few instances:
- They have historical imaging showing minimal to no GA progression
- GA is far from the fovea
- The patient is asymptomatic, or with mild, non-worsening metamorphopsia and no worsening scotomas
A lower referral threshold is reasonable for new patients without documentation of historical progression, as the historical progression rate is unknown. In these cases, the decision relies more on patient symptoms, such as increasing difficulty with reading or driving, or difficulty in low light.
A lower referral threshold is also appropriate for patients with juxtafoveal lesions, even if small and without documented progression, or for patients who already have compromised vision in the other eye due to conditions like wet Age-related Macular Degeneration (AMD) or advanced GA.
The Importance of Patient Vetting and Education
Vetting patients is essential for retina specialists to avoid expending time and effort on those unwilling to undergo treatment. The referring doctor should prepare the patient by explaining that a referral has been made because the doctor believes the patient needs therapy.
Patients should be informed that the current treatment involves injection therapy, which can slow the progression of the disease but does not stop it or improve vision. They must also understand that this treatment may require long-term injections every one to two months.
Additionally, the referring doctor should evaluate whether the patient's medical conditions outside GA could complicate or prevent injection therapy. Proper vetting helps prevent the retina specialist from working with patients who are not committed to treatment, saving time for patients, caretakers, and those who assist patients with transportation to appointments
Age should not be a primary determining factor in treatment decisions, as some patients in their 90s may have longer life expectancy than others in their 60s due to different medical comorbidities. It is vital to consider patients' motivation and their support system for attending regular appointments.
Finally, it is important to highlight that new treatments are positive advancements that can slow the disease, providing patients with hope and optimism rather than focusing solely on the necessity of long-term injections.
Components of an Ideal Referral
Drs. Shah and Dierker discussed the key elements of an ideal referral:
- Patient education: More patient education prior to the referral is always better for both the retina specialist and the patient.
- Notes over images: The retina specialist finds the referring doctor's notes, especially documentation of progression, to be very helpful. However, the faxed images are generally not helpful due to reduced transmission quality, and the retina specialist usually performs new baseline imaging anyway.
- Imaging Protocol: The retina specialist will get a baseline OCT on every new patient suspected of having macular disease. If a referral is for dry AMD but does not specifically mention GA, the retina specialist will still order an OCTA as well, but a baseline autofluorescence is only ordered once GA is confirmed.
- Treatment Logistics: Patients should know that treatment for GA is not an emergency and often does not start on the first visit due to logistical factors such as insurance and prior authorizations. It's important to give patients hope and emphasize that these new treatments are a positive development that can slow the disease down, rather than dwelling on the need for long-term injections.
Maintaining Co-management
A referral does not mean the patient is abandoned. The referring doctor should continue seeing the patient to reinforce expectations and manage other eye conditions, such as dry eye, glaucoma, cataracts, and refractive needs.
They can also help with patient compliance, identify signs of injection fatigue, and provide education while the retina specialist handles treatment.
It's recommended that the referring doctor schedule a follow-up in 4 to 6 months after the referral to ensure the patient has seen a retina specialist. If the patient is receiving complement inhibition treatment, the follow-up can often be extended to a year.
