Improving the Standard of Care in AMD

Digital health services that complement office-based medicine are becoming the new normal in patient care. Finding ways to continue offering excellent care during the COVID pandemic was not without its challenges, and yet, there may be some valuable lessons to learn from that experience about how we can all provide improved services to patients now and in the future.

During the pandemic, each of us relied heavily on the Notal Vision Diagnostic Clinic and the ForeseeHome AMD Monitoring Program for patients being followed with intermediate age-related macular degeneration (AMD). The technology has been around the eye care field for a while, but its utility for enhancing the capability to capture conversion and initiate treatment became abundantly clear in the early stages of the pandemic. Some of our patients felt unsafe visiting the office, others could not come to the office because of logistical or health reasons, and for the most part, telemedicine proved an imperfect solution to maintain contact. At the same time, conversion to the neovascular form (nAMD) is associated with a high risk for permanent loss of visual acuity if it is not identified in time, while early identification of conversion with prompt initiation of treatment portends a more favorable long-term outcome.

By working with Notal Vision Diagnostic Clinic through the ForeseeHome AMD Monitoring Program (see Notal Vision Diagnostic Clinic—Your Practice’s Partner for Remote Patient Monitoring), we were able to capture conversions in a number of patients who were still asymptomatic, thereby initiating treatment earlier to improve the long-term vision gains. Although it may be less tangible, one of the other things we heard from patients enrolled in the Diagnostic Clinic is that they felt a sense of security, that something was being done about their eye disease—and that was no small consideration for a patient population in fear of losing vision and gripped with anxiety about COVID.

Toward a Better Normal for Following Patients With AMD

As we transition back to a more traditional model of eye care delivery with patients having returned to the clinic, the idea of using remote monitoring remains critical. For one, the recent experience during the pandemic provides an excellent example of how technology facilitates the kind of individualized care that is likely to improve outcomes. Quite literally, remote monitoring extends the doctor’s ability to care for patients between office visits; technology can help us practice better medicine.

Another thing to consider is that the option of offering digital health services is a decision being made for us as eye care providers. Digital health is already being routinely used in other fields of comprehensive care. Within the eye care field, the iCare HOME (iCare) provides the ability to track diurnal IOP through self-monitoring. For patients with diabetes, the use of continuous glucose monitoring devices is associated with improved glycemic control.¹ There is also evidence that wearable devices used to monitor heart rates and rhythm help in cardiovascular risk assessment and cardiovascular disease prevention, diagnosis, and management.² During the pandemic, contact tracing proved instrumental for early identification of people who may have become infected with the coronavirus.³ Other areas of medicine are already improving outcomes with thoughtful use of digital health, so why not eye care?

In this respect, the ForeseeHome device is ahead of the curve in demonstrating a new model for retinal care. Results from the 2014 AREDS2 HOME study were clear in showing that individuals at risk for conversion to nAMD benefited from home monitoring in addition to standard of care versus standard of care alone, which included monitoring methods as prescribed by the investigators such as Amsler grid.⁴ In fact, that trial was ended early because it was deemed that eyes at high risk for conversion could be identified better with ForeseeHome than standard of care alone. Since the time of that study, the service supporting the device has only gotten better, making it an excellent option for providers that still delivers high-quality benefit for patients.

Impact On the Practice and Patient

One of the important things to recognize about the Notal Vision Diagnostic Clinic is that there is no cost to the practice to participate. Once the referral to the Diagnostic Clinic is made, Notal does all of the work of helping patients with insurance coverage, shipping the device, training the patient on use, and troubleshooting any issues that may arise. Patients are instructed to use the device daily to perform a preferential hyperacuity perimetry test; data from the test are analyzed as soon as it is completed by the artificial intelligence-based algorithm and then transmitted to the Diagnostic Clinic via a secure health cloud. Any significant deviation from baseline signals an “alert” that is first reviewed by certified ophthalmic professionals, directed by in-house ophthalmologists, at the remote Diagnostic Clinic for quality control purposes. Should further attention be necessary, the referring doctor’s office is notified by an email that contains a direct link to the patient’s report. If a read receipt is not received, the Diagnostic Clinic will escalate the alert and call the practice directly, but at this stage the clinic will not contact the patient so as to maintain the doctor-patient line of communication.

Importantly, the referring doctor always maintains 24/7 access to daily testing data via an online portal, meaning the eye care team can track results as often as desired. There are also options to receive monthly summaries, which may be useful for interpreting early changes detected on a patient’s imaging studies.
All of these aspects have been specifically designed to complement the already established routines that eye care providers already use in following patients with intermediate AMD. That is to say that at-home monitoring is not intended to replace or replicate in-clinic monitoring, but instead, it is designed to extend patient monitoring between in-office visits.

The bottom line is that the Notal Vision Diagnostic Clinic and ForeseeHome device are really two components of the same concept. The device on its own is impressive and the data clearly support it as a new standard of care for patients with intermediate AMD. But because it has a concierge service behind it, and because it is so seamless for the the staff and the patient, it becomes that much more useful of a device when working with intermediate AMD patients. In truth, if the device was something that was given out to patients and then the data had to be analyzed by the clinician, it might be too cumbersome to be of any real value. As it is, though, the Notal Vision Diagnostic Clinic and ForeseeHome device are a valuable safety net for our patients without creating extra work for the care team.

Recent Data

Data from two recent studies demonstrate that the concept of at-home monitoring has proven benefits in real-world settings.

A retrospective review of 162,902 eyes enrolled in the American Academy of Ophthalmology’s IRIS Registry diagnosed with nAMD in one or both eyes found that eyes presenting with at least 20/40 VA maintained that same acuity after 1 and 2 years of anti-VEGF therapy, whereas eyes that presented for treatment with less than 20/40 VA did not reach 20/40 VA at 1 or 2 years.⁵ Although the study was designed to investigate a link between baseline visual acuity and long-term outcomes, another data point in the study underscores the urgency in detecting conversion early: only 34% of eyes in the study presented with 20/40 or better VA, meaning that 66% of patients in real-world practice were unlikely to ever return to 20/40 VA even after 2 years of anti-VEGF therapy.

A 2021 study examined data compiled by the Notal Vision Diagnostic Clinic from patients with at least 20/60 VA and monitored for disease progression by both the device and by in-person examination conducted routinely or when symptoms presented (Table).⁶ A total of 306 patients converted to nAMD during the study period, with 69% of conversions detected by the ForeseeHome platform. Median baseline VA for all patients in the study was 20/25-2, and by the time nAMD was detected, median VA was 20/32-1. Among the 109 patients with at least 20/40 VA at baseline who converted to nAMD, 81% retained at least 20/40 VA when disease activity was detected (Figure). These data compare favorably to the aforementioned IRIS registry study (ie, 34% presenting with 20/40 or better VA) and to historical studies suggesting that only about 13% to 35% are diagnosed and begin anti-VEGF treatment when VA is 20/40 or better.^7-10

Table. Data from a real-world study of patients enrolled in Notal Vision Diagnostic Clinic suggest clinically meaningful differences in the method of detection of conversion to nAMD, with slightly better outcomes among eyes where conversion was detected with the ForeseeHome device.

Implications for Referral Relationships

An additional aspect of utilizing Notal Vision Diagnostic Clinic and the ForeseeHome AMD Monitoring Program that is not reflected in study data but which we can both attest to is how the program facilitates relationships between optometric and retinal care providers. Because of the extra safety net provided by the Diagnostic Clinic and ForeseeHome monitoring program, our optometric partners can feel more secure following intermediate AMD patients in the community before the time of referral while also being assured that conversion can be captured and patients referred at an appropriate time for initiation of treatment. One immediate outgrowth from that is increased efficiency for the retinal provider, but also a greater sense of teamwork between members of a patients’ care team.

From the perspective of a retina provider (Dr. Schechet), the ForeseeHome device and associated Diagnostic Clinic has proven a valuable conversation starter with the referral network. We have something tangible to educate about, not only about the device and program itself, but also more generally about AMD, the various stages, and the implications of conversion. The aspects of using ForeseeHome and the Diagnostic Clinic as a network builder are really additive to the value it provides in elevating patient care.

Click on the link below to learn more about how the Notal Vision Diagnostic Clinic can help you maintain your AMD patients’ functional vision.

https://modernod.com/articles/2021-july-aug-insert4/notal-vision-diagnostic-clinic-your-practices-partner-for-remote-patient-monitoring-1