Co-management of retinal patients can be as simple as educating them about what to expect when you refer them for an intravitreal injection of anti-vascular endothelial growth factor.
Co-management of retinal patients can be as simple as educating them about what to expect when you refer them for an intravitreal injection (IVI) of anti-vascular endothelial growth factor (VEGF), according to Steven Ferrucci, OD, FAAO, chief of optometry at the Sepulveda VA, and associate professor at the Southern California College of Optometry. "Intravitreal injections of anti-VEGF agents are increasingly common, but patients generally-and understandably- react negatively when they're told you're referring them for an injection in their eye," Dr. Ferrucci said. "This gives primary care optometrists the opportunity to co-manage these patients through education."
"The patient has a relationship with you, and is likely seeing the retinal specialist for the first time," Dr. Ferrucci said. "Retinal specialists are very busy these days giving anti-VEGF injections and don't have a lot of time to sit down and talk with patients. So I think it works out well if you're able to give your patients a little background before you refer them."
1. The bark is worse than the bite.
"One of the main things I tell patients is that it's not as bad as it sounds on the surface," Dr. Ferrucci said. "I often ask patients about their experience with the retinal specialist, and more often than not they'll say that it didn't hurt nearly as much as they would have imagined. Thinking about getting the injection was a lot worse than the actual process. That's important to explain to patients, because certainly when they hear 'needle' and 'eye' they immediately think the worst."
2. Intravitreal injections are a widely performed and generally very safe procedure.
However, like any medical procedure, there are possible side effects.
"It's fairly common for patients to come back to the clinic with subconjunctival hemorrhages following the procedure," Dr. Ferrucci said. "It's important that patients know that it's not a big deal if it happens to them, and there's generally no reason to do anything about it."
In addition to subconjunctival hemorrhages, intravitreal anti-VEGF injections may also cause tears of the retinal pigment epithelium.
"That's a relatively new complication, and a lot of people aren't familiar with it, but I keep it in the back of my mind and make sure I look for it at the follow-up visit," he said.
One of the biggest concerns is endophthalmitis. Although very rare with intavitreal injections, it is a risk factor after any injection or surgery, so we must always be diligent and look for any signs of this, such as infection, inflammation, or pain. If we suspect this, an immediate referral back to the retinal specialist is in order.
3. Many retinal specialists are now using bevacizumab (Avastin, Genentech) off-label.
Patients should be informed that this is an off-label use. Bevacizumab is not FDA approved for the treatment of any eye condition, but that doesn't mean it's not effective, Dr. Ferrucci said.
Provide enough detail
Patients should also understand the reason they're being referred. The goal for AMD patients is to stabilize their vision, which intravitreal anti-VEGF does very well, according to Dr. Ferrucci. Although vision improves in about one-third of patients, Dr. Ferrucci said he tends to downplay that.
"I just concentrate on the stabilization, preventing their AMD from getting worse," he said. "Then, if they get improvement, we're all happy. I think if you tell patients there's a one-in-three chance that they might get some improvement, all they hear is 'improvement' and they expect it. The studies show that intravitreal anti-VEGF agents are very good at stabilizing vision and preventing further loss, and I think that's the message to share with patients."
Finally, Dr. Ferrucci advised that if your practice regularly refers patients to a certain retinal specialist or group, talk with that ophthalmologist or group and understand their protocols so you can accurately explain to patients what they should expect.
Steven Ferrucci, OD, FAAO
Phone: 818/891-7711 ext. 7744
Dr. Ferrucci is a member of the speaker's bureau or advisory board for Alcon, Allergan, VSP, Macula Risk, and Eagle Eye Sciences