Are we missing signs of early AMD? According to recent research, the answer is yes. A cross-sectional study¹ of primary eyecare practices in Birmingham, AL, focused on 644 subjects who were 60 years or older with normal macular health based on their most recent dilated comprehensive eye examination by an ophthalmologist or optometrist. Researchers found that signs of AMD were missed on a quarter of otherwise seemingly normal eye exams.

Indeed, approximately 25% of eyes identified as normal by primary eyecare physicians based on dilated eye examination were found to have macular characteristics indicating AMD by fundus photography and trained raters. Thirty percent of undiagnosed eyes ultimately had AMD with large drusen that would have been treatable with nutritional supplements had it been diagnosed, according to the study.¹

The study also discussed some of the characteristics of patients with missed diagnoses, which included older eyes, men, and those with less than a high school education. But it revealed no difference between phakia or pseudophakia or between optometrists versus ophthalmologists.

What’s interesting is that cataract status or eyecare professional education had no bearing on missed diagnoses. In addition, one would assume a primary care eye doctor would scrutinize the maculas of their older patients more closely, as these patients are at higher risk for AMD. Perhaps the mostly white, non-Hispanic population in the study had more blonde fundi, or certain subjects were very photophobic, limiting a good evaluation. Nevertheless, a 1-in-4 rate of missed diagnoses is very high.

It’s worth noting that this cohort stemmed from patients examined between 2009 and 2011. Since then, the practicality and cost of regular imaging use, such as fundus photography and OCT, has improved. It is possible that if this same cohort were examined today with more consistent use of such technology, there would be fewer missed diagnoses. OCT has been shown to be important in the diagnosis and management of AMD and is recommended by the American Academy of Ophthalmology Preferred Practice Patterns for AMD.^2,3

In addition, new clinical and technological strategies to improve early detection of macular degeneration have been developed, and, if employed, could reduce the number of missed diagnoses (See “Early AMD Detection,” page 10).

Yet, another important strategy to reduce missed AMD diagnoses, highlighted by the findings of the study,¹ is to focus on educating those at the center of the study: primary eyecare professionals and their patients. Indeed, the very real possibility that patients may not understand the importance of undergoing regular dilated eye exams, especially after age 50, and more often for those with a family history of AMD, limits the ability of primary eyecare professionals to diagnose AMD. In surveys in the U.S., Australia and Canada, only 20-30% of respondents indicated they were “very familiar” or “somewhat familiar” with AMD.^3,4 For a condition that is the leading cause of visual impairment in those over age 50 in the U.S,⁵ it is a severe shortcoming in our health education that most patients do not know this.

Thus, retina specialists, in particular, are presented with an opportunity to be at vanguard of educational efforts to help reduce missed AMD diagnoses and thereby help to prevent vision loss. Early AMD diagnosis means earlier intervention, and it’s been shown that earlier intervention leads to better outcomes in AMD treatment.⁶

COMPONENTS OF AN AMD EDUCATIONAL CAMPAIGN

Like any good messaging effort, a comprehensive AMD educational campaign addresses the key questions of who or what, where, when, how, and why, with the level of detail and clinical or scientific terminology and concepts varying depending on your audience (ophthalmologists, optometrists, general public, or the community from which you are likely to draw your patients).

In addition, the campaign must target the motivations and interests of each group, which will differ as well. Gearing your campaign’s efforts toward the interests of each group will make your message more interesting. This doesn’t mean the motivations are mutually exclusive, but emphasizing certain components over others will be helpful. Indeed, there will be many opportunities to educate at all levels.

LEVERAGE MULTIPLE PLATFORMS

Depending on how far you take it, your AMD educational campaign can — and likely should — consist of multiple parts unfolding on multiple platforms, including speaking engagements for local community groups or events, brochures, interviews for TV news broadcasts and newspaper articles, a web page on your practice website, and a social media presence.

For your patients, in particular, having a good website with plenty of educational materials on AMD and ease of making appointments will be important, as will a social media presence with Facebook, Twitter, and Instagram. While your typical AMD patient may not be very tech savvy (although you’ll be surprised how many of them are these days), younger family members who will be driving them to their appointments are likely to be active on social media. But remember: regular updates are extremely important. Even linking to a new article on AMD will be helpful if your time is too limited to regularly write new content. A website or social media account that hasn’t been updated in a year or two looks worse than not having one at all.

As a retina specialist, you should make a point to leverage all available channels to expand your reach. In addition to in-house and online marketing, speak at local health fairs and community centers — especially those focused on seniors and adult communities. It’s also a good idea to consider partnering with local ophthalmologists or going it alone with your own practice to present AMD awareness conferences for optometry CE credit. In addition, many hospital systems, not just universities, regularly hold grand rounds. Offering to speak at these events can get your name out to primary care physicians, while your lecture should demonstrate the necessity of stressing to patients the importance of having regular eye exams. Becoming active in your state and county medical societies can be a great way to network and present opportunities to deliver an AMD awareness lecture.

CONTENT IS KING

As discussed in the previous section, it is important to understand your target audience. Your AMD education campaign’s “what” — or specific content — will vary by audience. For example, in targeting the community, you should stress the importance of regular eye exams, educate attendees on the symptoms of AMD (such as metamorphopsia, scotoma, photopsias, and decreased vision but discuss in layman’s terms), and emphasize healthy lifestyle choices that can affect eye health. Healthy lifestyle choices include a diet rich in antioxidants with AREDS 2 vitamin supplementation, if indicated, exercise, and quitting smoking.

Content can be more complex when your audience consists of primary eyecare providers. An optometrist as part of a hospital system or a multispecialty practice versus one in solo private practice will have different incentives and business practices. Without wading into the details of scope of practice, I recommend that you keep in mind what your state allows and how that might affect your own recommendations on patient management. Speaking to an audience of ophthalmologists at a university versus multispecialty versus private practice will be different, as well.

In many ways, optometrists serve as the front line of eye care, as most patients will go to them first. This is why it is important to ensure they understand how to examine for and diagnose AMD. Remind them what clinical characteristics to look for, including how to determine intermediate drusen under difficult situations, such as a cloudy cornea/cataract with a blonde fundus. In addition, ensure that local optometrists always ask patients for an AMD family history and perform a comprehensive dilated eye exam on all patients older than 50.

As I mentioned earlier, imaging is increasingly being used for support and diagnosis. Fundus photography for baseline examination and OCT are key examples. In fact, a recent publication on automated drusen detection with en face OCT demonstrates the increasing usefulness of imaging in early detection and management.⁷ Many optometrists today have OCTs and wide-field imaging. Educating them on how to interpret their images, if applicable, could turn into a potential referral.

Speaking of which, it is critical to educate optometrists on when to refer to a retina specialist for further evaluation and treatment. Providing your audience with examples of imaging that shows early subtle neovascular changes can be helpful.

When educating optometrists, your goal should be to ensure they have all the tools they need to diagnose these patients, but also to understand when to refer and provide them the support to do so.

MESSAGING TO OPHTHALMOLOGISTS

Educating ophthalmologists can be similar to that of optometrists, but you must first determine what the referring general ophthalmologist is comfortable treating. Many younger practitioners want to do their own anti-VEGF injections, as this is a regular part of their residency education. If so, it would be beneficial to find out how they would like help in supporting their patients. In addition, educating them on the signs and symptoms of complications of AMD treatment, such as hypersensitivity reactions to anti-VEGFs and endophthalmitis, will help ensure these patients are promptly referred. Informing them about treatments coming through the pipeline will help them see you as a supportive colleague and good referral option, if needed, for certain patients.

DON’T OVERLOOK OTHER LOCAL PROVIDERS

It’s also worth reaching out to your local primary care, urgent care, and emergency care physicians. As we now know, the training we had examining the eye in medical school was limited. Holding a grand rounds lecture at the local medical school, medical society, or hospital can be a great way to let others know what to look for with a simple direct ophthalmoscopic exam in someone who fits the profile of a high-risk AMD patient. Creating awareness that AMD is the leading cause of visual impairment in those over 50 helps to catch the disease when examining a patient with visual complaints. At a minimum, it reminds them to think about referring out as well.

THE “WHEN” OF YOUR CAMPAIGN

The timing of your educational campaign will take planning. Some practices employ marketing consultants, but you can do it on your own. Either way, it’s important to map out certain events and actions over a period of 1 or 2 years in advance to ensure you don’t miss valuable opportunities to get the word out about AMD and how you can help. Knowing when certain health fairs, community events, grand rounds, CE events, and state and county society meetings and conferences occur can help you select a timeframe for your campaign and avoid missing deadlines for article or speaking submissions.

Two examples: February is “AMD Awareness Month,” and September hosts the international “AMD Awareness Week.” Many groups are receptive to having AMD talks during these times. Preparing a news release and/or using a public relations firm can help you get some traction with local television stations or publications to publicize your talk. It can increase your name recognition and may even lead to additional opportunities on TV or with national publications. Once you’ve done a good job with a few of these talks, you’ll soon develop a reputation and potentially become a “go to” person for future questions/stories about eye-related issues.

THE “HOW” OF YOUR CAMPAIGN

As a new retinal specialist, who is likely dealing with many other issues of growing your practice, how do you find the time and resources to plan, launch, and carry out such an ambitious campaign aimed at reducing missed AMD diagnoses? It can be challenging. But chances are you know a fellow retina colleague who can help. Networking is invaluable; attending the various retina meetings throughout the year can build upon the contacts you made through training. I recommend the American Society of Retina Specialists (ASRS) Business of Retina meeting that occurs every Spring, as this is a meeting focused purely on the practice management side of retina. It attracts nearly 500 managing retina practice physicians and administrators. You can also partner with local referring doctors or medical societies to share the burden of developing resources for a campaign. This has the side benefit of strengthening your relationship with these fellow colleagues.

Practice consultants and marketing specialists who work specifically with ophthalmology practices can also provide you with direction and expertise. Again, conferences like the ASRS Business of Retina meeting are invaluable for learning about these contacts. If you have the benefit of working near a university, hiring a marketing graduate student can be helpful. Obviously, this person may not know the clinical details, but he or she will know how to devise a plan and connect you with the technical expertise to develop the social media and technology aspects of the campaign.

The pharma rep whose company has an interest in AMD may also be a resource, able to supply you with educational materials and perhaps even sponsor a dinner or conference to help you educate local ophthalmologists and optometrists. These companies also may have grants available that can be used to help you develop an AMD educational program.

Other organizations have printed materials that can be shared. The ASRS, for example, has retina physician-authored material that can be printed free of charge and shared with your patients. The American Academy of Ophthalmology has AMD educational videos that can be purchased and played for patients in your office waiting room; the videos can even be custom-recorded with your own voice.

Ultimately, the depth of your AMD educational effort depends on you. They can consist of a one-time push over the course of AMD Awareness Month, with just a few presentations to the local community and your referral base, or they can comprise a full-time, ongoing dedication to make your local practice an “AMD Center of Excellence,” with a large campaign conducted together with a pharma/medical device company — complete with brochures, a web page, social media management, and press releases.

In either case, a good way to measure the effectiveness of your campaign is to track the number of referrals over time from each doctor or lecture. You should survey every new patient with questions such as, “Where did you hear about us?” or “Who referred you?” Other good ways to measure effectiveness are to track website hits and social media views or new followers.

WHY EDUCATE ABOUT AMD?

Better education could very well mean increased patient caseloads for the eyecare professionals in your community, including you. Importantly, you’ll be helping to create better informed patients, optometrists, and ophthalmologists, and increasing awareness about the leading cause of visual impairment in people older than age 50 in developed countries. You’re also building your practice’s reputation.

But the best answer to the question of why is simply to help prevent vision loss. Earlier AMD diagnosis means earlier intervention, and earlier intervention leads to better outcomes. It doesn’t get any clearer than that. NRP

REFERENCES

1. Neely DC, Bray KJ, Huisingh CE, Clark ME, McGwin G, Owsley C. Prevalence of undiagnosed age-related macular degeneration in primary eye care. JAMA Ophthalmol. 2017;135(6):570-575.
2. McDonald HR, Williams GA, Scott IU, et al. Laser scanning imaging for macular disease: a report by the American Academy of Ophthalmology. Ophthalmology. 2007; 114(6):1221-1228.
3. Kandula S, Lamkin JC, Albanese T, Edward DP. Patients’ knowledge and perspectives on wet age-related macular degeneration and its treatment. Clin Ophthalmol. 2010;4:375-381.
4. Woo JH, Au Eong KG. Don’t lose sight of age-related macular degeneration: the need for increased awareness in Singapore. Singapore Med J. 2008;49(11):850-853.
5. Age-Related Macular Degeneration. American Society of Retina Specialists website. Available at https://bit.ly/2nzAvru ; last accessed Aug. 3, 2018.
6. Ho AC, Albini TA, Brown DM, Boyer DS, Regillo CD, Heier JS. The potential importance of detection of neovascular age-related macular degeneration when visual acuity is relatively good. JAMA Ophthalmol. 2017;135(3):268-273.
7. Zhao R, Camino A, Wang J, et al. Automated drusen detection in dry age-related macular degeneration by multiple-depth, en face optical coherence tomography. Biomed Opt Express. 2017;8(11):5049-5064.

Dr. Hau is a Vitreoretinal Specialist and Vice-Chair of Research at the Kaiser Permanente Riverside Medical Center, part of the Southern California Permanente Group