Intravitreal Injections Without Access to Retinal Specialists

Some patients are turning to general ophthalmologists to perform intravitreal injections.

KAREN BLUM, CONTRIBUTING EDITOR

For years, Larry Patterson, MD, had a retina specialist visit his ophthalmology practice in rural Crossville, TN, to care for patients with retinal disease and perform intravitreal injections for wet age-related macular degeneration.

But like many other retinal specialists, the one who visited his office became too busy and unable to leave his primary practice on a regular basis. So Dr. Patterson reached out to the Memphis-based practice of well-known vitreoretinal surgeon Steve Charles, MD.

After speaking with Dr. Charles and his colleague Jorge Calzada, MD, by phone and realizing they used the same electronic health record system, Dr. Patterson visited the Charles Retina Institute in Memphis and trained in how to perform intravitreal injections himself, including how to properly bill for the services. Then he returned and set up one of his procedure rooms to accommodate injection patients.

GENERALISTS PROVIDING SPECIALIZED CARE

For nearly a year, Dr. Patterson has been performing about 20 injections per week in addition to his other duties. If he has any concerns or questions about these cases, he e-mails Dr. Calzada with the patient’s name and date of birth.

Dr. Calzada then can pull up the patient’s information, review the patient’s EHR chart, as well as OCT, fundus images and retinal angiography images, and respond with his diagnostic and treatment recommendations.

“It’s been great for us,” says Dr. Patterson, a cataract surgeon and medical director for Eye Centers of Tennessee. “I was concerned at first that patients would say, ‘You’re not the retina guy.’ Instead, we’ve found the opposite. They’re so thrilled to have their home-town guy do it.”

Dr. Patterson is not alone. From networking and conversations with colleagues, he estimates that 20% of general ophthalmologists now perform intravitreal injections for wet AMD. With the graying of the United States and injections being used for a number of conditions including diabetic retinopathy, “the numbers will just explode in the next few years,” Dr. Patterson says. “So many injections will need to be done there won’t be enough retina specialists.”

THE POLITICS OF RETINA

Dr. Calzada, the vitreoretinal surgeon and president of the Charles Retina Institute, who works with Dr. Patterson, says the relationship also works for him, and increases his exposure. However, he acknowledges that the area is “politically heated.”

“The know-how is always best with a retinal surgeon,” says Dr. Calzada, who estimates that about 1 in 10 to 1 in 15 patients receiving injections could have complications. “Even very good ophthalmologists can make some broad diagnoses but can fail or may not be up on every single treatment regimen.”

Optimally, he says, board-certified vitreoretinal surgeons should perform injections at a retinal practice with the proper equipment. “For the majority of urban patients, that’s what we should strive for,” Dr. Calzada says.

But in more remote areas, many patients who need injections have transportation difficulties, he says. They do not necessarily have the vision to drive, and some need an injection every month. “We would be kidding ourselves if we think patients are going to regularly travel 100, 200, or 300 miles for an injection,” he says.

A PROBLEM OF SCARCITY

Ideally there would be more retina specialists in remote areas, Dr. Calzada says, “but that’s not happening. Graduates are not going to rural areas.”

Dr. Calzada travels once a month to a satellite clinic in northern Mississippi where he and a retinal fellow perform injections. But when he cannot travel due to weather conditions or other issues, he asks local ophthalmologists to serve as a bridge, performing injections until his next scheduled clinic. “It’s not the gold standard, but it’s the best we can do to stop these patients from losing vision,” he says.

Other retina specialists share Dr. Calzada’s views. “Managing wet AMD is not just about the injection itself,” says Sophie Bakri, MD, a retina specialist and professor of ophthalmology at the Mayo Clinic in Rochester, MN. “It is about the decision of whether to inject, which drug, which frequency, and consideration of alternative treatments, as well as knowing when treatment is futile.”

These decisions should be made by a retina specialist, Dr. Bakri says, but in rural areas where patients need access to regular injections, they can be administered by properly trained general ophthalmologists.

“However,” she says, “systems need to be put in place that allow easy and frequent communication between the retina specialist and general ophthalmologist for the plan of care, as well as systems that allow the patient to schedule the injections and make follow-up appointments with the retina specialist after the series of injections.” There also needs to be attention to standardizing and updating protocols when needed, she adds.

Mayo has an injection-only clinic through which Dr. Bakri and her retina specialist colleagues perform up to 50 injections each half-day.

COMANAGEMENT IS KEY

Retina specialist Alan Berger, MD, chief ophthalmologist for St. Michael’s Hospital in Toronto, Canada, agrees: “General ophthalmologists are qualified to do the procedure technically but comanaging with a retina specialist is critical.

“My concern with general ophthalmologists is that most spend half a day a week doing this, versus retina specialists, who do this five days a week,” adds Dr. Berger, who performs an estimated 100 injections a week. “Most are competent but not highly trained. I’ve seen cases where patients have been treated and treated with injections and they may not have needed them at all.”

In more remote areas, he says, “I’m all for general ophthalmologists being the ones performing the injections” but they should consult with retina specialists, “even if they just use telemedicine once every six months or once a year. Ten to 20 years ago, it was much harder to comanage patients. We didn’t have all the technology.”

Now, to send a copy of an OCT report or retinal photograph is easier and a “good way to comanage.” More and more conditions will need injections, he says. “It’s hard to keep up, and we want patients to get the best care,” he says.

Canada’s publicly funded health system covers the costs of injections, he notes. “It’s not like I want to take anyone’s patients, we’re all busy. But if a patient is getting $25,000 of drug a year for free, for them to make one trip of 200 to 300 miles once a year (to a retina specialist) is not too much.”

DEMOGRAPHIC CONCERNS

But David Lane, MD, a general ophthalmologist in rural Lindsay, Ontario in Canada, about 82 miles northeast of Toronto, says for some of his patients, that is too much. “In a rural setting there are no retina specialists — often you’re the only guy,” he says. “Access to care is inextricably linked to quality of care, and if you don’t (give injections), people will go blind.”

Ontario Ministry of Health 2011 physician reimbursement data show that of 81,000 intravitreal injections, 28,000 were performed in rural areas by general ophthalmologists, says Dr. Lane, who performs about 50 to 60 injections weekly.

Many of his patients are older, may live in nursing homes and may not have assistance from family members, he says: “Just getting across town is a big deal. The idea of going to Toronto for an injection? Forget it. They just wouldn’t go.”

Dr. Lane does refer some patients to retina specialists but only if any uncertainty of the diagnosis exists, or he sees something unusual during the exam. “I know there are several people in my practice every day who would permanently lose vision if I didn’t do (the injections),” he says.

A LACK OF GUIDELINES

The AAO does not have a formal policy on general ophthalmologists performing these injections. However, Paul Sternberg, Jr., MD, the AAO’s past president, a retina specialist, and professor and chair of ophthalmology at the Vanderbilt Eye Institute in Nashville, TN, advises that optimal medical care for AMD “not only requires skill in the proper injection technique, but also complex decision-making based on deep knowledge of vitreoretinal pathology, experience in patient selection and the complex management and treatment of complications of the disease as well as up-to-date knowledge of the evolving data on AMD treatments.

“This experience is best gained through a formal fellowship and subsequent full-time practice evaluating and treating retina and vitreous diseases,” Dr. Steinberg says.

In rural or under served areas where patients may not have access to retina specialists, “comprehensive ophthalmologists who choose to treat these patients should do so ideally in consultation with a retina specialist and should encourage patients to see a retina specialist when possible,” he adds.

The Joint Commission on Allied Health Personnel in Ophthalmology neither certifies nor sanctions its technicians to perform the injections, but it does train them to conduct preliminary patient examinations, provide patient education, and serve as surgical assistants, says CEO Lynn Anderson, PhD.

CONCLUSION

Overseas, some patients in the United Kingdom and Denmark have been evaluated by retina specialists and injected by nurse practitioners properly trained in injection and aseptic technique, Dr. Bakri notes, with regular audits to assess the rate of endophthalmitis and other complications.

“From what I have heard, this model has been successful in these countries, where there is a relative shortage of retina specialists and ophthalmologists,” she says. RP