In our practice, we have prescribed the ForeseeHome AMD Monitoring Program (Notal Vision) for more than 300 patients. Our clinic was part of the HOME study¹ — which showed that patient self-testing with preferential hyperacuity perimetry (PHP) increases the likelihood of early detection of progression from dry age-related macular degeneration (AMD) to wet AMD — and we use the technology in our practice for several reasons.

First, it provides the highest possible quality of care for our intermediate dry AMD patients. Just as anti-VEGF therapy has replaced thermal laser as first-line therapy for wet AMD because it’s more effective, and retina specialists wouldn’t think of practicing without OCT, we should no longer send at-risk AMD patients home with only an Amsler grid for detecting choroidal neovascularization (CNV) when a much more effective method is available.

The second reason we prescribe the ForeseeHome AMD Monitoring Program is that it increases the likelihood that patients will be able to remain independent, maintaining their ability to read and drive, thus enjoying a better quality life. In the HOME study,¹ 94% of the patients who monitored their vision with ForeseeHome, using it at least two times per week, had a visual acuity of 20/40 or better when CNV was detected. That compares with 62% of the patients who didn’t.

And third, utilizing the ForeseeHome program gives patients a better understanding of their disease and reinforces that they’re at risk for wet AMD. In my experience, patients had a hard time understanding why they were supposed to use an Amsler grid and, as a result, compliance was low.

With ForeseeHome, they seem to gain a much better understanding of what’s at stake, and they test themselves much more frequently than they did with the Amsler grid.

Candidates for ForeseeHome

Patients enrolled in the HOME study were classified as having 3 or 4 risk factors for progression to CNV based on the AREDS scale with at least one druse 125 µm or larger, Snellen visual acuity of 20/60 or better, and no CNV, scarring, or geographic atrophy in the study eye(s). These are patients with dry AMD who are at high risk for progression to wet AMD and whose clinical characteristics may also include pigmentary abnormalities and/or advanced AMD in the fellow eye. Practically speaking, any patient who is recommended to take AREDS2 supplements is an individual that could benefit from ForeseeHome monitoring.

Tips for Easing Incorporation

I can share several other steps we took in our practice that made working the ForeseeHome program into our routine simple and effective. We educated our scribes and technicians and the rest of the staff about the program. During our participation in the HOME study, our clinical coordinator did much of this work, ensuring that everyone grasped which patients should be involved in the study and why.

When the study ended, we were able to use our training from the study to know which patients were good candidates for the program. We use discussion tools when we introduce ForeseeHome to patients, including ones provided by Notal Vision that illustrate how vision can be preserved with early detection of wet AMD (Figure 1).

Figure 1. Notal Vision provides free patient education aids pertaining to the ForeseeHome AMD Monitoring Program to prescribing doctors.

Another strategy that has been helpful is using a scribe to complete the ForeseeHome prescription form (Figure 2) while I’m talking to the patient about the program. The form is then faxed or e-mailed to Notal Vision.

Figure 2. In our practice, a scribe completes the prescription form for the ForeseeHome AMD Monitoring Program while the doctor discusses the program with the patient.

ForeseeHome Case Examples

The following cases are recent examples of my patients using the ForeseeHome AMD Monitoring Program

CASE 1: An initially noncompliant patient

This patient was first diagnosed with dry AMD in June 2014, at which time his visual acuity was 20/20. I talked with him about ForeseeHome and he agreed to use it, however, he didn’t use it often. The test sessions on his report were clustered only around office visit dates when we talked about why he should use the program. Luckily, he began to use the test again, as it turned out, 1 month before his results prompted an alert of disease progression (Figure 3). The alert was issued on Feb. 6, 2016, and the patient came into the office on Feb. 8. Although his visual acuity remained 20/20, OCT and fluorescein angiography confirmed subretinal fluid, so he received an anti-VEGF injection (Figure 4).

Figure 3. ForeseeHome report showing patient self-tested infrequently, but just in time for CNV to be detected.

Figure 4. Two days after a ForeseeHome alert, OCT and angiography confirmed CNV.

CASE 2: CNV alert from across the miles

This patient, who had baseline visual acuity of 20/40, is a university professor for whom I prescribed ForeseeHome in May 2015. Unbeknownst to me, she had moved out of state to take a position at a different university. I only learned of her move when my office received a ForeseeHome alert on April 7, 2016. We had her cell phone number on file and were able to reach her 1 day after the alert. One of my partners recommended a retina specialist she could see in her area, and she went to an appointment on April 8. That day, OCT confirmed CNV, and visual acuity was 20/40. The patient received an anti-VEGF injection. Interestingly, as Figure 5 shows, we can overlay the FA and the OCT thickness map with the metamorphopsia map from ForeseeHome testing and they match up at the problem area, which was just inferior to fixation.

Figure 5. A patient’s OCT thickness map obtained 2 days after a ForeseeHome alert overlaid with the ForeseeHome metamorphopsia map. They match up at the problem area, which was just inferior to fixation.

Subsequently, the patient began seeing a different retina specialist who happened to have been one of our former fellows. He informed me that he had given her three additional anti-VEGF injections. When he last saw her on July 7, visual acuity was 20/30. She received an anti-VEGF injection and scheduled a follow-up appointment.

CASE 3: A false alert?

This patient’s baseline visual acuity in July 2014 was 20/20. She had been using the ForeseeHome AMD Monitoring Program, and on April 6, 2016, we received an alert. However, when the patient came in for an exam, neither OCT nor fluorescein angiography detected CNV. We recommended the patient continue to self-test at home. Three months later, on July 16, we received another alert. This time, despite visual acuity being maintained at 20/20, CNV was present according to OCT and angiography. We treated the patient with an anti-VEGF injection. We continue to follow her and she’s doing well.

What’s interesting about this case is when we look at the report corresponding to the two alerts (Figure 6), we can’t help but wonder whether the first alert was actually false. After that time, the test results never quite improved to a point where we felt reassured that there wasn’t a problem. What if the presence of nonexudative CNV, perhaps leaking intermittently or somehow disturbing hyperacuity, was the cause of the alert? There have been some papers published recently indicating that this phenomenon can be detected by the cutting-edge technology of OCT angiography, which will be a fascinating area of continued study.

Figure 6. It’s interesting to wonder whether it’s possible that this patient’s first ForeseeHome alert, when no CNV was detected by OCT or fluorescein angiography, was actually caused by nonexudative CNV that OCT angiography may be capable of detecting.

In addition, patients receive materials explaining that Notal Vision will call them to verify Medicare or other insurance coverage, complete enrollment, and arrange for delivery of the ForeseeHome monitor. The materials also ensure patients that the company will provide live support during the setup process and that support is available at any time for any questions they may have about the ForeseeHome program.

We’ve made a few other smart moves in relation to ForeseeHome, and we’ve also made a few mistakes that we had to correct.

Smart Moves

• Prescribe the program liberally for appropriate patients. Patients care about their disease and want to do everything they can to help themselves. Age alone isn’t a contraindication. I have patients in their 90s who self-test regularly.

• Develop an “elevator story.” To explain the program to patients in the time an elevator ride would take, I borrowed Dr. Michael Elman’s explanation. I liken the ForeseeHome monitor to a smoke detector. We all have smoke detectors in our homes. In the unlikely event that we have a fire, the smoke detector alerts us before the fire spreads and damages too much of the house. In the same way, ForeseeHome testing alerts us to disease progression so we can minimize its effect on vision.

Early Mistakes

Early on, I prescribed the ForeseeHome program to a few patients without educating the referring doctor. The patients called their general ophthalmologists with questions they weren’t prepared to answer. We quickly remedied the situation by educating doctors in our community, including speaking at symposia for optometrists and ophthalmologists.

At first, I prescribed the program to a couple of very anxious patients, who were testing themselves more than seven times per week. They complained to their general ophthalmologist about the frequency, yet couldn’t seem to use the test less. Although they didn’t want us to, we had to have them discontinue the program. We know these patients are rare, and we also know they’re not good candidates. Now, I wait until the visit after a patient has been diagnosed with AMD to see whether they’re visibly upset to learn they have dry AMD, which is more than the typical reaction.

I’ve also erred by prescribing the program for patients who aren’t familiar with a computer mouse or have a cognitive or physical ailment that prevents them from using the test. These types of issues disqualify approximately 20% of potential users, so now we make sure we’re identifying them.

As I mentioned previously, we’ve learned in our practice that AMD patients care about their disease and really want to do everything they can to save their sight. I saw this firsthand, too, with my own family. My mother has been using the ForeseeHome program for quite some time, and she has a sister-in-law who has dry AMD but didn’t get the prescription until much more recently. When the sister-in-law asked me why it took so long, I said perhaps her doctor wanted to wait until Medicare coverage was approved so she wouldn’t have to pay out of pocket. Her response: “But Richard, it’s my vision.” That conversation was a crucial reminder that we shouldn’t decide for our patients whether they would want to use the program because it’s not necessarily the same decision they’d make for themselves. We had quite a few patients who used ForeseeHome before it was covered by insurance, although most patients have no trouble getting coverage today.

I also recommend that doctors familiarize themselves with the monthly ForeseeHome test reports they receive. They tell us a great deal about our patients. On rare occasions, I’ve detected progression to CNV before the ForeseeHome device issued an alert because trending patient test scores on the report prompted me to perform imaging beyond OCT during a scheduled office visit. Furthermore, it’s interesting that we think we know which patients are compliant with our recommendations, but the reports include how many times per week a patient actually self-tested with ForeseeHome. (See “ForeseeHome Case Examples,” below.)

The reports are also valuable patient education tools, especially for those who feel their vision is getting worse but their visual acuity hasn’t changed. That’s frustrating for them, but the report can sometimes alleviate the frustration because it includes scotoma and metamorphopsia maps that help explain how the intermediate AMD component might be responsible, and that something, although not CNV, is actually changing.

Finally, I recommend that doctors demo the ForeseeHome test prior to prescribing it for patients. This makes it easier to answer questions, such as what they should do when they see two distorted lines on the screen at once. When you’ve tried the test, you know what’s happening. One line may be the simulated distortion and one line may be a real distortion. They should just do the best they can and click on both lines if they need to.

A Timely Technologic Advancement

The availability of the ForeseeHome program is an extremely important development for our AMD patients. As Dr. Heier explained in his article, we now know that maximizing the effectiveness of anti-VEGF therapy depends on our knowing that patients need treatment while their CNV lesions are small and before their visual acuity deteriorates. ForeseeHome is exactly what we need to provide us with that knowledge. ■

Reference

1. AREDS2-HOME Study Research Group, Chew EY, Clemons TE, Bressler SB, et al. Randomized trial of a home monitoring system for early detection of choroidal neovascularization - Home Monitoring of the Eye (HOME) study. Ophthalmology. 2014;121(2):535-544.

Dr. Garfinkel practices with Retina Group of Washington in Chevy Chase, MD. He is a clinical assistant professor at Georgetown University Hospital in Washington, D.C. Dr. Garfinkel is a consultant for Notal Vision and was a HOME Study principal investigator.