Watching from a Distance

The disruption caused by the pandemic, particularly to ophthalmic practices, saw an inevitable increase in (and development of) teleophthalmology practices to ensure continuity of care for patients affected by long-term conditions. Here, Jennifer Jacobs, an ophthalmologist specializing in remote AMD monitoring, speaks to The Ophthalmologist about her own research, presented at ARVO 2023, that explores how teleophthalmology can be best applied to remote monitoring for patients living with age-related macular degeneration (AMD).

What is the current state of AMD treatment?
 

When it comes to AMD treatment, there’s always research being done. We know that we have very effective treatments for wet AMD – we’ve had those for two decades or so. But we also know that macular degeneration is a leading cause of blindness in the US. Even though we have effective treatments, there’s still a diagnostic gap – one we can help meet with remote monitoring. Around 10–15 percent of patients with dry AMD will convert to the more severe, vision-threatening wet AMD. The average visual acuity at wet AMD diagnosis is around 20/83. Studies have shown that patients who receive remote monitoring in addition to their standard care are diagnosed with better visual acuity than those who do not, and in fact the average visual acuity of the monitored patient at wet AMD diagnosis is better than or equal to 20/40. The ALOFT study was a study that showed   that even  long-term, after diagnosis and treatment of wet AMD in the monitored patient, good visual acuity is maintained  because advancing disease in these patients has been caught earlier (3). We also know that the best predictor of long-term visual outcome is the visual acuity at diagnosis and start of treatment. There is definitely a need for remote monitoring that can help catch patients when they convert from dry to wet AMD as early as possible. There’s also a need in neovascular AMD for monitoring patients with home-based OCT; with this heterogeneous disease, being able to personalize treatment, to some extent, could be great for patients. Through home-based OCT, we monitor patients remotely so doctors have the ability to determine remotely  if patients are responding to anti-VEGF treatments – and if they would like to bring them  in sooner for further treatment.

What did you share at ARVO 2023?
 

The model I presented includes three basic components – one of which is the monitoring center. We wanted to assess patient compliance, patient retention, and also look at patient experience – if patients have a good experience of monitoring, they will continue with it. The performance metrics of the model have been demonstrated in peer-reviewed studies. One retrospective study looked at over 2,000 intermediate AMD patients on the ForeseeHome AMD Monitoring Program, with compliance determined by the number of tests patients performed per week. The study found that patients performed a mean of 5.2 tests per week. In looking  at longitudinal compliance over a period of 10 years, it was discovered  that patients continued to test between 4.8 to 6.9 tests per week, indicating that there isn’t really a dip in compliance over time. In terms of neovascular AMD, a study looking at patients who were monitored using the home-based OCT showed that compliance was also very good (5.7 times per week). (4)

These results show that compliance is not a problem and suggest our monitoring center model is really helping patients. We also saw this in the positive responses to a patient survey that assessed the device’s user friendliness, the patients’ experience with monitoring center service calls, and whether patients wanted to continue using the device. The monitoring center also gives out general information and education for patients about macular degeneration. When patients understand their disease process, they’re more likely to be compliant and want to take an active role in the monitoring of their condition.

How will teleophthalmology change how clinicians practice?
 

In terms of monitoring intermediate AMD patients, it certainly has made a mark in helping doctors diagnose conversion from dry to wet AMD earlier. The ForeseeHome preferential hyperacuity perimetry device is approved for patients with intermediate AMD because they are high-risk. I think it will be very helpful in terms of preserving vision, as doctors catching the conversion can do so while visual acuity is good.

I think home-based OCT on the other hand will be instrumental in how doctors manage patients on therapy. Now, doctors use in-office OCT and OCT-A to help evaluate if patients have converted, help determine whether they have subretinal or intraretinal fluid, and to assess what kind of treatment they require. Home-based OCT will also enable doctors to see if patients are responding to treatment, and if the patient has developed more fluid and regressed. With the home-based OCT, doctors can specify when they want to be alerted (based on how much fluid is in or under the retina). I don’t think it’s bold to say that it's going to better personalize medicine for wet AMD patients, which will help both the patient and the doctor.

What’s the take-home from your work?
 

The results of this model are important because patient compliance is a big issue, not just for macular degeneration or glaucoma, but across all aspects of medicine. The monitoring center makes a huge difference. We didn't have the center when we first began our monitoring program; Over years the program has been developed. Now there's a clinical partner at the monitoring center, assigned to the patient, who walks them through the monitoring process, helps them set up the equipment, and gives them testing tips.

The center certainly helps patients to understand the importance of monitoring. We didn't know that the compliance would turn out to be so great – but it is, and we’re pretty happy about that. From what we’ve seen, the model works!