Are Optometrists Qualified to Manage AMD?

Effectiveness of Community Versus Hospital Eye Service Follow-up for Patients With Neovascular Age-Related Macular Degeneration With Quiescent Disease (ECHoES): A Virtual Non-inferiority Trial

Reeves BC, Scott LJ, Taylor J, et al
BMJ Open. 2016;6:e010685

"Well, quite honestly, when you go to the eye hospital, it always seems to be packed out left, right, and center."^[1] This comment, offered by a patient with neovascular age-related macular degeneration (AMD), reflects a common sentiment that care for patients with neovascular AMD is less than patient-centered, owing to long wait times and the challenges of monthly appointments for patients who are elderly and vision impaired.

These frequent visits come at a substantial cost to patients in terms of time and energy and also to society. A recent article estimated the mean annual societal cost of neovascular AMD to be nearly $40,000/patient, almost seven times more than for those without AMD.^[2] As the US population ages, the treatment of neovascular AMD will consume even more resources.

Is there a more patient-centered and cost-effective way of caring for patients with neovascular AMD? One potential solution is a greater utilization of optometrists in the management of these patients. Office wait times and fees are both substantially less for optometrists. The biggest question that remains is whether optometrists can provide the same quality of care for these patients as ophthalmologists.

Study Summary

The Effectiveness of Community Versus Hospital Eye Service Follow-up (ECHoES) trial explored whether a new model using optometrists for follow-up exams for patients with quiescent neovascular AMD was safe and effective.

This trial presented clinical vignettes consisting of fundus photographs, optical coherence tomography (OCT) images, and brief patient histories to optometrists and ophthalmologists practicing in the United Kingdom to evaluate clinical decision-making. All participants received training on the proper classification of images and were required to successfully meet performance criteria to participate in the trial. The participants were presented with baseline and follow-up images and visual acuities in each vignette and were asked to classify each case as quiescent, suspicious, or reactivated. A group of 96 clinicians consisting of an equal number of optometrists and ophthalmologists completed the training and vignettes.

The accuracy of optometrists' and ophthalmologists' decision-making was nearly identical. Optometrists and ophthalmologists classified 84.4% and 85.4% of cases correctly, respectively, which led researchers to conclude that optometrists' ability is not inferior to ophthalmologists' ability to make decisions about neovascular AMD. The number of sight-threatening errors made by optometrists and ophthalmologists was also virtually indistinguishable, with each group making such an error in approximately 6% of cases.

There were, however, some notable differences in performance between optometrists and ophthalmologists. Optometrists were significantly less confident than ophthalmologists in their choices despite achieving a similar accuracy. Nearly 60% of ophthalmologists were "very confident" in their classifications, whereas only 30% of optometrists were "very confident" with their choices. Nearly 90% of optometrists desired additional training prior to image classification, but the majority of ophthalmologists felt that the training offered was sufficient.

Optometrists also were more cautious in their assessments; they were more likely to generate false positives by classifying inactive lesions as reactivated.

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