As part of Macula Month, DR JOSEPH PAUL, head of professional services at Specsavers, reveals data and insights on macular degeneration and discusses the organisation’s long-term plans to improve vision and health outcomes for patients with the condition.
Age-related macular degeneration (AMD) is one of the more potentially devastating eye conditions seen in everyday optometry – a blinding disease that affects an estimated 1.4 million1 Australians, causing irreparable damage to vision in the precious older years of one’s life.
Of the 1.4 million people, it is further estimated that more than 156,0002 are living with neovascular age-related macular degeneration (nAMD), requiring ongoing treatment to prevent progressive vision loss. Despite the risk of non-adherence to treatment leading to the development of severe vision loss or blindness3, it is estimated 20%-25%4 of patients cease the intravitrealinjection treatment required to save their sight within the first year.
As eyecare practitioners, we have a responsibility to appropriately support our patients through their treatment journey, ensuring they are armed with the information and knowledge required to make the right decisions about their eye health. We all have a role to play, both individually as eyecare practitioners, and as part of a larger whole, collaborating with the wider industry on strategies that improve outcomes for all patients.
With that in mind, Specsavers has begun sharing its key findings on AMD and formed a strategic scoping partnership with Macular Disease Foundation Australia (MDFA). In the first phase of the partnership, both organisations are collaborating with an ambition to gain a true understanding of incidence and prevalence of nAMD across Australia, with a vision to enhance support for patients diagnosed with the condition. Longer-term goals are focussed on developing a sustainable approach to achieve the best possible outcomes for nAMD patients, including minimising treatment dropout and removing barriers to access.
Though it is early in the process, it’s possible to identify some key factors influencing care for AMD patients in recent years:
- Technology changes within optometry
- Patient review periods
- The impact of COVID-19
Technology changes within optometry
With increased access to optical coherence tomography (OCT) in clinical practice, and the RANZCO-led Referral Pathway for AMD Management evolving to reflect this, optometric management of patients with AMD has transformed over the past five years.
These transformations can be clearly identified in the makeup of referrals to specialists. In 2017, 70% of patients referred to specialists were referred with early or intermediate AMD.
Since then, the percentage of patients being referred in early stages has steadily decreased (Figure 1), making up only 54% of patients referred in 2021. In contrast, the percentage of AMD referrals being made for patients with new onset nAMD has increased significantly. This is not to suggest a sudden increase in incidence of nAMD – rather, it reflects the benefits for clinical decision-making gained through the routine use of OCT for every patient.
The vastly superior clinical information afforded by OCT allows a greater level of comfort and clarity for optometrists when staging and managing early and intermediate AMD, and in detecting, classifying and appropriately referring nAMD as early as possible.
Appropriate review periods
One of the major benefits of OCT is the ability to accurately monitor changes over time. This is of most benefit when patients are being reviewed regularly, and early changes can be detected quickly. To better understand how optometrists are reviewing and managing patients with early AMD, Specsavers examined the review periods set by optometrists for patients with the condition.
It found that in the years leading up to an initial AMD referral, patients were regularly reviewed by their optometrist, with an average review period of 13 months. Following referral, the vast majority patients (68%) were recommended a follow up optometrist appointment within seven to 12 months of their AMD referral (Figure 2).
Once a tentative diagnosis of AMD was made and the patient was referred for specialist care, both the review periods set by optometrists and patient behaviour changed, with an average review period of nine months for these patients. Regular review in this way, combined with consistent OCT scans, gives optometrists the best chance of detecting progression or new onset neovascular changes and referring in a timely manner.
The impact of COVID-19
Internationally reported rates of loss to follow up for many eye conditions, including glaucoma and diabetic retinopathy, approach one in every three patients. Even in the best circumstances, this results in less than optimal outcomes for many patients.
The past two years have been far from the best circumstances, with the ever-changing restrictions, mandates and rules due to COVID-19 making them difficult and arduous for patients and optometrists alike – leading to thousands of missed appointments and a backlog of patients requiring care.5
It is very likely that restrictions on eyecare services resulted in otherwise avoidable vision loss for many patients.
Despite these challenges, the volume of patients being referred for AMD has increased since 2019, even in New South Wales and Victoria – Australia’s most locked down states. While this is a positive outcome, the volume of referrals did drop in 2019. With fewer patients attending optometric services, fewer patients were referred for specialist care.
While more patients were referred for specialist care in 2021, many of these may have been patients who did not attend for care in 2020, and potentially have had their referral for specialist care delayed by COVID-19 restrictions (Figure 3).
Limited access to eyecare services had a negative impact on patients with AMD and Specsavers will continue to monitor the trends as it navigates the years ahead. It is incumbent upon us all as eyecare practitioners to ensure we are doing everything possible to minimise avoidable blindness, and to fully support all our patients through their diagnosis and treatment journeys.
AMD clinical benchmarking project pilot
Macular Disease Foundation Australia and Specsavers have announced a strategic scoping partnership, aiming to overcome preventable vision loss for patients with nAMD by improving appointment attendance and treatment adherence rates.
The project has begun in a pilot phase with 16 Specsavers practices from around the country currently involved.
MDFA and Specsavers agree their shared vision for the project is that the successful measures determined will be shared with the entire industry to further impact the nation’s eye health.
While the project may take several years to test and slowly grow, key trends and data will be shared as it emerges from the pilot phase. Insight will follow the project and report on key milestones and data as it is shared.
References
- Deloitte Access Economics and Macular Degeneration Foundation (2011). Eyes on the future – A clear outlook on age-related macular degeneration. Accessed at https://mdfa-s3fs-prod. s3-ap-southeast-2.amazonaws.com/s3fs-public/Deloitte_Eyes_on_the_Future_Report_web.pdf
- Deloitte Access Economics and Macular Degeneration Foundation (2011). Eyes on the future – A clear outlook on age-related macular degeneration. Accessed at https://mdfa-s3fs-prod. s3-ap-southeast-2.amazonaws.com/s3fs-public/Deloitte_Eyes_on_the_Future_Report_web. pdf. (2022 prevalence estimates are derived from a straight-line extrapolation between 2020 and 2025 estimates in this report.)
- Wong T et al. (2007). The natural history and prognosis of neovascular age-related macular degeneration: a systematic review of the literature and meta-analysis. Ophthalmology. 2008 Jan;115(1):116-26. doi: 10.1016/j.ophtha.2007.03.008. Accessed at https://pubmed.ncbi.nlm. nih.gov/17675159/.
- Obeid A et al (2018). Loss to follow-up among patients with neovascular age-related macular degeneration who received intravitreal anti-vascular endothelial growth factor injections. JAMA Ophthalmol. 2018;136(11):1251-1259.
- COVID-19 and Australia’s eye health. Accessed at https://healthhub-anz.com/understanding the-impact-of-covid-19-on-australian-eye-health/
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