General Ophthalmologists and Intravitreal Injections

A simmering issue shows signs of heating up.

JERRY HELZNER, SENIOR EDITOR · LESLIE GOLDBERG, ASSOCIATE EDITOR

Thomas V. Claringbold, DO, practices general ophthalmology as part of the MidMichigan Physicians Group in the small, semi-rural town of Clare, Michigan.

His patient base includes a number of senior citizens who have retinal disease. This fact has placed him squarely on the horns of a troubling dilemma, as he explains: "From a strictly clinical standpoint — not taking into account any positive or negative effect the procedure would have on practice income — I would prefer not to have to perform intravitreal injections," he asserts. "However, in my situation, the nearest retina docs are 45 to 60 miles from Clare. And some of my patients are already traveling that far just to get to my office."

Last summer, when gas was in the $4 to $5 a gallon range, things hit a critical point. "I had patients refuse to drive to see the retina specialist. I would explain — and document bluntly — that they could go blind if they didn't see the specialist," Dr. Claringbold says. "They told me they would just have to go blind because there was no way they had the transportation/gas money to travel that far, even just for an initial consultation let alone multiple follow-ups."

His patients essentially told him that if he couldn't do it, they couldn't have it done. "I spoke with my practice manager and we were looking at courses for me to go to and refresh my technique, and we started to evaluate OCTs. Fortunately, gas prices dropped and it was not as critical, but we still decided to look at getting an OCT. I may have to start doing intravitreal injections in the future."

Dr. Claringbold says he currently works with one retina specialist in Lansing (about 90 miles from Clare) who is willing to see the patient initially and perform the injection (Avastin for example). Generally, these patients need to be re-examined in 3 to 4 days to rule out infection or IOP spikes. This examination is performed by Dr. Claringbold, who created a simple follow-up report form that he faxes to the retina specialist. He says that patients appreciate the convenience of this coordinated treatment.

THE CRITICAL ISSUES

Dr. Claringbold's situation highlights several key questions relating to general ophthalmologists, retina specialists, and intravitreal injections:

► Is the increasing incidence of retinal disease among an aging population putting pressure on general ophthalmologists to do intravitreal injections?

► Is the recent availability of advanced optical coherence tomography equipment — notably spectral-domain OCT — giving general ophthalmologists more confidence that they can get more involved in identifying, diagnosing, and treating retinal disease?

► Are there specific circumstances, especially in rural and remote areas, in which general ophthalmologists can be involved in at least some aspects of retinal care?

► Conversely, should general ophthalmologists even think about doing intravitreal injections if they are not capable of managing all aspects of diagnosis and treatment?

► Finally, is there anything that can be done to improve residency training that might mitigate potential tensions between retina specialists and general ophthalmologists?

Dr. Claringbold's situation is not unique. Though he is not swayed by the additional income he might earn from treating retinal disease, it would be naïve to think that all general ophthalmologists would be willing to pass up potential income that could be derived from a significant percentage of their existing patient base. This is especially true now, as ophthalmic technology continues to advance.

RETINA SPECIALISTS ARE STRONGLY OPPOSED

Although both the American Society of Retina Specialists and the American Academy of Ophthalmology have no formal position on general ophthalmologists and intravitreal injections, David F. Williams, MD, MBA, president of the ASRS, offered Retinal Physician a strictly personal view:

"The provision of the specific service of intravitreal injection of anti-VEGF agents for the treatment of wet age-related macular degeneration is only a small part of the overall management of patients with this disease," he notes. "While it may be possible to teach a non-retina, fellowship-trained ophthalmologist to perform an intravitreal injection, it should be understood that optimal management of these patients involves much more than simply giving the injection. AMD is a complex disease of protean manifestations and presentations, and a wide range of responses to therapy."

Dr. Williams asserts that "high-quality care of these patients requires artful synthesis of sequential careful clinical examinations of the retina, interpretation of multiple diagnostic studies, and ongoing evaluation of response to therapy."

He says that knowing when to start treatment, whether to consider combined therapy, when to stop treatment, and if and when to restart treatment requires complex judgments that can be best made by a physician highly experienced in managing AMD.

"Physicians treating AMD should also be experienced in the management of complications of the disease and its treatment as well, including endophthalmitis, vitreous hemorrhage, retinal detachment, and subretinal hemorrhage," Dr. Williams explains. "Such a wide range of experience can only be obtained through a formal retina fellowship and subsequent full-time practice evaluating and treating diseases of the retina and vitreous."

Dr. Williams concludes by noting that there are certainly situations in which patients with wet AMD may not have access to a fellowship-trained retina specialist.

"In these situations, comprehensive ophthalmologists who choose to treat the patient should do so ideally in consultation with a retina specialist and should encourage the patient to see the retina specialist when possible."

Similar views are echoed by Julia A. Haller, MD, ophthalmologist-in-chief of the Wills Eye Institute, and professor and chair of Ophthalmology at Jefferson Medical College of Thomas Jefferson University.

The notion of intravitreal injections administered by general ophthalmologists "concerns me because I want the best possible care for patients," says Dr. Haller. "Where constraints such as distance exist, I think it is possible for comprehensive ophthalmologists to do the injections if they are comfortable with the procedure, the workup, the followup, management of complications, and the liability issues. It would require very good familiarity with all the retinal issues and good retinal backup."

LIMITATIONS OF GENERAL OPHTHALMOLOGISTS

Michael Tolentino, MD, of Winter Haven, FL, sees several factors that make retina specialists uniquely suited to provide retinal care. "The field of retina and in particular the use of intravitreal injections is evolving rapidly," he says, commenting that in the last 2 years the standard of care has changed several times — making it difficult even for retina specialists to keep up with the latest standard of care. "The concepts of evaluation, monitoring, and determining efficacy are still in flux and rapidly changing. Any doctor that is not committed to keeping abreast of these changes in technology, technique, and clinical advances will be giving subpar treatment to their patients."

Dr. Tolentino sees intravitreal injections as a surgical skill that must be cultivated and honed like any other. "The more you do them, the better and safer you can administer the injections," he says. The rate of infections and complications has diminished since the procedure debuted, and he's of the opinion that it's mainly because of the attainment of experience by the retina community. "As a retina specialist, I rarely perform cataract surgeries even though I am fully trained in phacoemulsification," he explains, because the techniques and technology have progressed even since he was performing phacoemulsification. "For the best interest of the patient, it is best that their care is done by the surgeon who is the most proficient and skilled in the surgical intervention."

Dr. Tolentino also notes that medications administered by retina specialists also carry with them potential systemic effects that need to be understood and monitored. "This puts another layer of complexity to the decision-making process that is required in treating patients with retinal diseases," he asserts.

As for the potential impact of SD-OCT, Dr. Tolentino says, "I believe it will allow general ophthalmologists to detect retinal diseases more frequently and enhance the care that these patients will obtain because of early detection and early treatment by a retinal specialist."

Paul Tornambe, MD, of San Diego, past president of the ASRS, says that general ophthalmologists' management of AMD increases the risk of poorer outcomes for patients and also increases the legal risk to themselves when they assume the responsibility of providing retinal care. "The comprehensive ophthalmologist providing AMD care must also know what to do when the injections are not working, or if a complication develops such as inflammation vs infection." How knowledgeable are they, he wonders, in determining when the patient is beginning to fail therapy?

There is more evidence that PDT (and likely reduced-fluence PDT), in combination with a steroid and VEGF inhibitor injections, may be a reasonable alternative to monthly injections, Dr. Tornambe explains. "The comprehensive ophthalmologist treating AMD must be able to know when to modify therapy and appropriately commence a different therapy."

Dr. Tornambe says that the "bottom line" is that comprehensive ophthalmologists can give intravitreal injections "if they assume the ultimate responsibility of determining when the injection should be given, are able to recognize and manage complications, and be able to offer alternative treatments in a timely fashion."

He notes that from the medicolegal standpoint, once the comprehensive ophthalmologist assumes the care of a retinal condition, he/she "will likely be held to the same standard of care as a retina specialist. If they feel comfortable assuming this exposure and have acquired the skill set to manage AMD patients and keep abreast of advances in care, there is no reason they cannot manage AMD patients."

PERSPECTIVES ON RESIDENT TRAINING

Dr. Tolentino believes that "the next generation of ophthalmologists will have more retinal care integrated in their training during residency so that they are more facile with managing retinal patients, but I believe that a retinal fellowship is required to train the ophthalmologist to manage the full set of problems associated with retinal care."

Currently, almost all ophthalmology residents are exposed to a broad range of training rotations and responsibilities. Then, they may choose to narrow their focus toward a specific subspecialty.

Lauren Eckstein, MD, PhD, who is currently completing an oculoplastics fellowship at the Scheie Eye Institute of the University of Pennsylvania, relates the following experience: "Both here at Scheie as well as at Jules Stein, the residents receive instruction in intravitreal injection techniques. Whether the ubiquity of resident training in intravitreal injection equates with the intervention being part of the domain of comprehensive ophthalmologists is potentially debatable," she says. Dr. Eckstein points out that all residents are also taught PRP, but most ultimately leave this to retina specialists. "The list of procedures taught in residency but not practiced by generalists is probably quite long," she says, as they depend on a multitude of factors unique to each physician and practice, such as physician comfort, patient preference, accessibility to specialty care, marketplace influences, and other considerations.

Uday Devgan, MD, FACS, who supervises the training of residents at Jules Stein Eye Institute, offers a "big picture" view of current resident training.

"All residents learn intravitreal injections, and they all do retinal laser, cataracts, oculoplastics, pediatric strabismus cases, corneal cases, glaucoma cases, etc.," he says. Then the residents can either go into general ophthalmology practice or they can go further into a fellowship to specialize in another field such as glaucoma, pediatric ophthalmology, cornea, retina, or plastics. "The same way that all MDs learn everything during medical school — heck, I even delivered 31 babies in med school — we end up specializing in a far narrower field, like ophthalmology." All ophthalmology residents should learn the full spectrum of ophthalmology, ocular surgery, and ocular procedures, he advises, so that "they are well-positioned for either a career in general ophthalmology or for further specialization."

FUTURE DIRECTIONS

While they do not wish to be mentioned by name in this article, several respected general ophthalmologists have recently been able to identify macular issues in cataract surgery patients and make better IOL selections through the use of advanced SD-OCT technology.

One veteran general ophthalmologist who has SD-OCT told Retinal Physician that having the instrument provides him with precise information about the posterior segment that would allow him to do intravitreal injections if he were motivated to do so. "But I would prefer to leave the treatment of ARMD to the retina people," he says. If a general ophthalmologist had the motivation as well as access to SD-OCT and fluorescein angiography, "they could stay on top of all the studies being done and inject Lucentis, but I'm not sure it would be worth the effort and risk to do so. It isn't for me."

This doctor adds that he currently does intravitreal Kenalog injections on some patients but feels this is a bit different than injecting Lucentis. He says his comfort level is much higher having SD-OCT and doing Kenalog injections selectively.

It is also important to note that these general ophthalmologists who use SD-OCT say that they have great respect for the skills of retina specialists and they strongly assert that they are not looking to begin "turf wars."

However, this is an emerging issue that cannot be lightly overlooked. Retinal Physician will continue to follow this issue and report on it as new facts become clear. RP