Optometry and Anti-VEGF Co-management

For this issue of mivision, I spoke to Sydney retinal ophthalmologist Dr Simon Chen about how optometrists and ophthalmologists can work together to maximise patient outcomes when managing macular degeneration. This is especially important when this chronic disease takes a turn for the worse, and anti- VEGF becomes the appropriate treatment.

patients need to be treated as soon as signs of nAMD become apparent in the disease process

Q. What does an optometrist need to know about anti-VEGF therapy?

A. Anti-VEGF therapy has beenestablished as the widely accepted standardof care for the management of neovascular macular degeneration (nAMD) in Australia. The treatment comprises an anti- VEGF agent administered into the eye via an intravitreal injection on a regular basis.

Q. What’s new about anti-VEGF therapy since it started?

A. Thanks to an ever increasing volume ofhigh quality evidence from numerous metaanalyses,prospective randomised clinical trials, and real world data registries, we now have a much greater understanding of important aspects of anti-VEGF therapy, including the pros and cons of different treatment regimens. We also understand the importance of life-long treatment for most patients, and the long term visual outcomes of therapy.

Previous treatment protocols used to consist of injections being administered only when signs of activity recurred, or else based on regular fixed intervals. There has been an increasing trend for retinal specialists to shift away from these treatment protocols towards customised ‘treat and extend’ protocols, whereby the frequency of injections is tailored to individual patients according to their own response to treatment.

Treat and extend protocols have been shown to provide equivalent visual results while reducing the number of injections needed, compared to regular fixed interval treatment protocols. This shift has helped optimise patient management by maximising visual gains while minimising the burden of treatment. This may help improve compliance with treatment.

Another learning from the accumulating evidence base is the importance of aggressive treatment of nAMD. It is now well established that patients need to be treated as soon as signs of nAMD become apparent in the disease process.

An optometrist’s ongoing educational and emotional support will help to optimise patient care

Treatment also needs to be administered frequently, especially in the early stages, when the disease is most active. We now know that for the majority of patients with nAMD, long term, potentially life long, anti-VEGF treatment is required because high rates of disease reactivation and permanent visual loss have been reported in patients that cease therapy.

We currently have three anti-VEGF agents available to choose from. Bevacizumab (Avastin) was the first anti-VEGF agent. Avastin is a full-length monoclonal antibody that inhibits all isoforms of VEGF-A. As it was originally developed for another use and was not tested for ocular use, it remains off-label.

Secondly, Ranibizumab (Lucentis) is a monoclonal antibody fragment derived from the Avastin molecule, which was designed and approved for ocular use. As with Avastin, it also inhibits all isoforms of VEGF-A.

Thirdly, Aflibercept (Eylea) is a VEGF decoy receptor that blocks all isoforms of VEGF-A and placental growth factor (PlGF). It is also approved for ocular use.

There are numerous promising anti-VEGF agents in the research pipeline and retinal specialists are optimistic that new agents (e.g. Brolucizumab) will become available within the next couple of years. Newer anti- VEGF agents have the potential to reduce the frequency of injections needed, thus reducing the treatment burden on patients.

Q.What can we tell nAMD suspects to expect when referred on?

A. nAMD suspects who are referredon can expect an initial consultation that asks their history, followed by adilated clinical examination and retinal imaging with fundus photography and optical coherence tomography (OCT) scanning. Additional retinal imaging tests, such as OCT-angiography (OCT-A), fluorescein angiography, indocyanine green angiography or fundus autofluorescence may also be performed to confirm a diagnosis of nAMD.

Once nAMD is confirmed, a decision will be made regarding whether the patient may benefit from anti-VEGF therapy. A minority of patients may not benefit if their condition is too far advanced and they have evidence of severe permanent macular scarring.

Assuming anti-VEGF therapy is indicated, treatment vs no treatment will be discussed with the patient, along with the likely need for long term therapy. The initial anti-VEGF injection should be given as soon after diagnosis as practical to avoid the potential for ongoing visual loss. Many ophthalmologists will initiate treatment at the first visit or within a few days of the initial visit.

Q. Many patients feel anxious about an injection into their eye and potential pain. What can we tell them?

A. Patients should be reassured thatthis is a very natural response andthat ophthalmologists experienced in administering anti-VEGF injections have typically performed many hundreds, if not thousands of injections, enabling them to hone their techniques to minimise pain and discomfort.

Thanks to anaesthesia, most patients experience no pain at all. In rare cases, where there is some sensation, patients report it is not significant.

Having said that, a small minority of patients experience pain associated with an injection. It is usually very brief and can be managed appropriately.

If the patient returns to the optometrist with concerns after an injection, they should be advised to inform their ophthalmologist so the injection technique can be adjusted. Optometrists can play an important, sight saving role by reminding their patient of the bigger picture – injections are important to optimise their vision, and ultimately their quality of life and independence.

Q. What is the risk of serious complication?

A. Fortunately, the risk of serious vision threatening complications with anti-VEGF injections is low. Possible sight threatening complications include:

• Endophthalmitis, which is reported tooccur at a rate between 0.019% and0.09%. (Many cases of endophthalmitis can be successfully treated, with good levels of visual acuity regained. Some cases may not respond as well, ultimately leading to permanent loss of vision),
• Retinal detachment (under 0.05%), and
• Cataract due to the needle used to injectthe anti-VEGF agent inadvertentlytouching the crystalline lens.

Q. Is treatment compliance a concern for anti-VEGF therapy?

A. Recent studies in the United States indicate up to 25% of patients that start anti-VEGF treatment are eventually lost to follow up. Factors that influence this include:

• Demographics, e.g. older patients mayhave other co-morbidities and mobilityissues that make obtaining treatment more challenging,
• Socioeconomic status,
• Logistical issues, such as problemsremembering appointments or clinicaccessibility,
• Carers can find it challenging to taketime off work to accompany patientsto treatments,
• Patients may experience guilt about theon-going burden on carers, and be lesslikely to attend for treatment,
• Patients with financial difficulties maybe concerned about out of pocket costsassociated with treatment,
• Over time, some patients becomefrustrated with the ongoing need fortreatment, causing their commitment to treatment to wane, and
• Some patients may perceive a lack ofbenefit, especially if treatment has notled to improvement in their vision or their vision has continued to deteriorate despite treatment.

Q. What role do optometrists play in improving treatment compliance?

A. Optometrists have a vital role to play in optimising patients’ compliance with anti-VEGF therapy, and in doing so, maximising their visual function and quality of life.

Educating patients with early stage dry AMD about the possibility and long term risk of developing nAMD can help them accept treatment more easily, should it be required.

Educating them about why it is essential to seek treatment immediately if they experience any changes in their vision, can help prevent vision loss.

When referring a patient with nAMD, optometrists can help by emphasising the importance of attending the appointment without unnecessary delay, and highlighting the risk of permanent visual loss if their condition is not assessed and managed appropriately. Often patients do not realise that delaying a visit to the ophthalmologist can lead to progression of the neovascular process and irreversible visual loss.

Q. How will my role in co-management evolve once the patient is referred on?

A. An optometrist’s ongoing educationaland emotional support will help to optimisepatient care. Real world evidence has shown that anti-VEGF injection frequency is an important factor in achieving optimal gains in vision – and on average, patients will receive about five injections per year. In Australia, the Fight Retinal Blindness! study reported that visual acuity was maintained throughout five years of anti-VEGF treatment. Despite this, relative under-treatment is common.

Patients should be encouraged to return to their optometrist for review, even when they are having regular anti-VEGF injections, to:

• Maximise their limited vision with the best optical correction possible,
• Detect changes in their disease state and any other concurrent ocular pathology,such as cataracts,
• Assess the need, and where appropriate refer on to low vision services that will maximise their functional vision, and
• Discuss any issues of concern they may feel uncomfortable discussing with theirophthalmologist. By encouraging patients to talk to their ophthalmologist, or liaising with the ophthalmologist on their behalf, optometrists can address issues and potentially prevent the patient from becoming non-compliant with treatment or lost to follow up.

Margaret Lam is currently the National President of the Cornea and Contact Lens Society of Australia and teaches at the School of Optometry at UNSW as an Adjunct Senior Lecturer. She works as the Head of Optometry Services for George and Matilda Eyecare. 

Dr. Simon Chen MBBS, FRANZCO is an experienced cataract and retinal surgeon at Vision Eye Institute in Chatswood, Bondi Junction, and Drummoyne in Sydney. He is also Conjoint Senior Lecturer at UNSW. He has an interest in performing complex cataract surgery in patients with retinal disease or ocular trauma. 

Case Study: 85 year old Vera*

Dr Simon Chen

At 85, Vera is incredibly independent. Despite having only one seeing eye following complications with cataract surgery, she lives in her own home and spends her time reading and painting.

Had it not been for a long term association with her optometrist, this would all have changed.

Five years ago, Vera experienced rapid vision loss in her one good eye – it dropped to 6/60 within a week due to the development of nAMD.

Understandably, this was very distressing for Vera, as she was suddenly faced with being unable to read, paint, or drive. She was concerned about her ability to continue to care for herself and live in her own home.

Vera was referred to me for assessment by her optometrist of approximately 20 years. At the initial consultation, I confirmed a diagnosis of nAMD and urged her to have treatment with anti-VEGF injections the same day.

Despite my best efforts, Vera could not overcome her fear that complications could lead to further sight loss, as had happened following previous cataract surgery. She refused treatment that day but promised to return the following day, once she’d had time to collect her thoughts. However, the next day she failed to attend for treatment. Vera explained, over the phone, that she had decided to take her chances, and let nature take its course.

When I explained the situation to Vera’s optometrist, he quickly called her and managed to convince her to attend for treatment the same day. He explained that we had shared numerous patients with nAMD, and that the results had been very positive. He reiterated the potential consequences of not having treatment on her quality of life.

It was the long term rapport, built up over 20 years with her optometrist, that gave Vera the confidence to trust his advice.

Vera responded extremely well to treatment, eventually regaining a visual acuity of 6/9 which has been maintained to this day. As a result, she has been able to remain fully independent and continues to fulfil her passion for reading and painting.

At all levels of macular degeneration management, optometrists have a vital role to play in educating patients and encouraging their treatment compliance. By helping patients understand their anti-VEGF therapy, optometrists can help maintain their patients’ vision and quality of life.

*Name changed for patient privacy