The latest approaches to managing age-related macular degeneration and diabetic eye disease were the main topics of discussion at the fourth Global Retina Network Program, hosted in Sydney in late June.
When 200 eye health professionals from the Asia Pacific region met for the fourth Global Retina Network Program meeting in June, they were left in no doubt that patient education and support is key to achieving treatment compliance.
Alarmingly, Professor Paul Mitchell AO (Sydney West Retina) quoted a Graefes survey, which found that two thirds of people being treated for wet age related macular degeneration (wet AMD) with anti-VEGF did not realise injections would be ongoing. He said it was essential to establish realistic expectations for treatment because, “this is a relentless disease and unless you keep treating people aggressively, you lose it (their vision)”.
We know vision can be maintained for five years or longer – it’s a marathon rather than a short sprint when managing this disorder
Prof. Mitchell also spoke about the value of support services like Bayer’s SmartSight and Macular Disease Foundation Australia to complement consultations. Australia is now seeing the best results for treatment of wet AMD in the world, thanks to good access to anti-VEGF via the pharmaceutical benefits scheme. Additionally, a treat and extend protocol means on average, Australian patients with wet AMD receive more injections than wet AMD patients in other countries. Prof. Mitchell highlighted how important it is to avoid under treatment and help overcome barriers such as out of pocket costs; travel; carer burden; the overall treatment burden with co-morbidities; absence due to illness; injection fatigue and low patient education. He said when patients need injections in both eyes, bilateral same day treatment can reduce patient and carer burden particularly if there are co-morbidities involved.
ESTABLISH PATIENT EXPECTATIONS
The importance of establishing patient expectations with regard to treatment was reinforced by several presenters. Dr. Neil Bressler (John Hopkins University School of Medicine, Baltimore USA) said, “The patient will do whatever you say – as long as you can explain well… If they can’t come in as often as required we need to explain the risk – we need to tell them, ‘you are taking a chance with your vision’. Yes, we all want fewer visits and fewer treatments but at what costs – you don’t want them to lose vision.”
Dr. Jennifer Arnold (Marsden Eye Specialists) discussed research findings in relation to real world outcomes, highlighting five year outcomes from the Fight Retinal Blindness! Study, which like randomised clinical trials, show improved visual gains can be attributed to higher injection frequencies. “You need to treat people intensively: one in 20 needed injections for the first 12 months before becoming inactive (i.e. their retinas were dry and stable). Once people were inactive 38 per cent never had any reactivation out into their third and fourth year as long as treatment continued at four to 12 week intervals,” she said, adding “it is important to tell people about the risk of stopping treatment”. Dr. Andrew Chang (Sydney Eye Hospital) said having received great benefit from their first few injections, patients typically think they can stop, making ongoing patient education and support crucial to long term outcomes. He said, “We know vision can be maintained for five years or longer – it’s a marathon rather than a short sprint when managing this disorder”.
Professor Mark Gillies (Save Sight Institute) made a light-hearted point to demonstrate the importance of establishing realistic expectations. “When I see a patient with wet AMD I tell them, if you see me on the street you should run because I’m going to inject you every time I see you until one of us dies”.
TIME: THE THORN IN EVERYONE’S SIDE
Although a PRN or ‘when required’ protocol can reduce the number of injections required, it does not necessarily reduce the number of visits to an ophthalmologist, as patients still require monitoring between injections. In contrast, a ‘treat and extend’ protocol dictates that a patient will receive an injection at each visit to their ophthalmologist. As Dr. Arnold pointed out “If a patient comes in knowing they are going to get an injection, everyone is prepared – in terms of travel time, recovery time and clinic time,” she said.
Time is of course a thorn in the side of doctor, patient and carer as psychologist Dr. Carey-Ann Jackson (Calabash Solutions) highlighted. She said time spent in the waiting room ahead of an injection can significantly increase a patient’s anxiety and stress a carer who may have taken time from work to accompany the patient and be paying for expensive city parking.
Management of time was also addressed by ophthalmologist Dr. Matthew Russell (OKKO Eye Specialist Centre) who has extensively modelled and reconfigured his practice workflow to optimise time both from the patient’ and clinic’s perspective. He said an optimally laid out and resourced practice will increase the number of patients that can be seen in one clinic and significantly improve workflow.
The conference continued with presentations on diabetic eye disease, the expanding role of screening and artificial intelligence and the importance of multimodal imaging in the detection and management of retinal disease.