Prescribing VEGF Inhibitors for Macular Edema

W. Lloyd Clark, MD: Let’s move into some of the more real-world discussions about treatment and various treatment options. Ehsan, first to you, talk to us about the initial patient evaluation. You see a new patient who appears to be a candidate for anti-VEGF therapy, either for age-related macular degeneration [AMD] or a non-AMD indication, such as diabetes or retinal vein occlusion. What’s your initial evaluation look like, and what’s the conversation, how does that go in terms of introducing this chronic therapy for patients with potential for severe vision loss?

Ehsan Rahimy, MD: That’s a great question. I am sure we all have our own little tips and tricks on how we initially counsel these patients when they are being sent to us for the first time. At the end of the day, we are all very busy retina specialists. We have a limited amount of time that we can spend with each patient, but especially when it’s a new patient who’s being sent to me for potential therapy, I try to educate them as best I can in as little time as possible about what the disease process is. I try to impart to them that we have great treatment for it, especially for patients with macular degeneration. Oftentimes they recall a family member, a neighbor, a friend, someone who went blind from this, so you can already sense there is a lot of fear about them potentially going blind and losing vision, and at least I can reassure them that outcome may not be the same here because we have great treatment to offer them. I do believe this process is very different depending on what type of disease we are talking about. Somebody with macular degeneration, wet AMD, being referred to us, oftentimes they are fairly symptomatic. They recognize that they have had a substantial drop in vision. They may be much more willing already to accept that they need therapy and want to have therapy because they can see the direct impact of it on their visual acuity.

Some of them with DME [diabetic macular edema] or DR [diabetic retinopathy] may not necessarily be noticing any vision changes. They could have been referred in from their optometrist and may be more reticent to want to pursue long-term therapy. So the way we approach the education is actually slightly different. With DME and DR, I rely very heavily on imaging. We have it already set up in the room. I have OCT [optical coherence tomography scans], widefield photos, FAs [fluorescein angiography images] of normal eyes and then that patient, so I can help guide them through what’s going on with the underlying diabetic retinopathy process. Them being able to see that is worth a lot, rather than I am sitting here telling someone they have severe NPDR [nonproliferative diabetic retinopathy] and may progress to proliferative disease, and they have 20/20 vision. They are not necessarily buying that because they don’t understand that they don’t have to experience vision loss to be at risk for significant vision loss at some point. So, this conversation is slightly different.

Obviously, the age groups are slightly different. Our patients with diabetes are working class, they often are taking time off work to be there, so I want to be mindful of that with our discussions about need for treatment and duration for treatment. I try to impart on them that we are going to try to get this under control and try to rapidly extend them out, so they don’t have to come in as often. Our AMD population oftentimes may be accompanied by family member who is bringing them in. I like to see signs of that, that there is some social support or family support around them. They are going to be a key component of this treatment process as well. I feel more comfortable when I see family members there because they will often encourage the patient to continue to come for their treatment. I don’t know if the others have anything else to add to that.

W. Lloyd Clark, MD: Joe, you have a very busy diabetic eye disease practice. Do you approach patients who need anti-VEGF therapy with diabetic retinopathy or diabetic macular edema any differently? Is there anything specifically related to them, or can you bring all these patients into similar profiles?

Joseph M. Coney, MD: I do approach my patients with diabetes differently. Historically, most people have sight-threatening problems and other hormonal problems because they’ve been noncompliant with their sugar control. When I see these patients, my initial approach is to buy equity into what’s going on systemically and how that can affect the eye. If they need eye treatment, I try to lay out maybe a 6-month or a year program to understand why they need to come to see me on a continued basis. I’ve had people where they had maybe severe disease, didn’t follow up for 9 months, and they come back with tractional detachments because they’ve got an infection in their eye that rapidly worsens. I’m very cautious about these patients. I think, as I said before, ancillary tests are really important. To buy into that process, I think showing them what their eyes look like; I use words like dead tissue instead of ischemia. I use the words bleeding, blocked vessels, so they can understand this is a very important disease.

The OCTs are also very helpful. From our standpoint, it’s important to show them what’s going on, but also to share in their wins. When they have therapy, and the OCT gets better, you want to show how they improved. This also gets them excited about keeping their appointments because they can see the process in them. I also take time to send letters to the physicians. I normally don’t do that for my patients with AMD from a medical standpoint. They need to understand that this is an end-stage problem, and that their A1C [glycated hemoglobin], their blood pressure, their cholesterol, diet and exercise, increased activity are all important for the long-term outlook for that patient.

It’s also important that the doctors understand this because I think in this country, we’re still not seeing patients early enough. We just had an update from the United States Preventive Services Task Force that screening has now gone from the age of 40 to 35, so I’m hoping what that means is that we’ll be seeing patients before the disease starts. We may be seeing more people without retinopathy as well, but clearly, we can start having that discussion. If we start sending more letters, physicians will understand that, “I’ve been seeing this patient for 10 to 15 years. I didn’t tell Mrs. Johnson to go have an eye exam.” So hopefully, next time they have a patient with diabetes, we can get them in earlier, so it serves as a 2-way prong, both for the physician and the patient.

W. Lloyd Clark, MD: To our audience, thank you very much for watching this HCPLive® Peer Exchange. If you enjoyed this content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.

Transcript edited for clarity.