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Eric Newcott, Hayley Westwood, Sanjiv Banerjee; Doc Hologram and Nurse Needle Fight Wet AMD in Time of Austerity. Invest. Ophthalmol. Vis. Sci. 2017;58(8):2333.
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Increased numbers of wet age-related macular degeneration patients (AMD), a lack of ophthalmologists, and limited healthcare funds has driven the need for alternative care models. We report on a retrospective audit of a novel wet AMD treatment protocol using a “virtual” one-stop treat and extend clinic (VTX) in which intravitreal injections are performed by a team of nurse practitioners with macular surveillance by an ophthalmologist in a virtual review clinic. We compare this model to a traditional ophthalmologist-only “as needed” (PRN) evaluation and treatment protocol with the hypothesis that VTX can maintain or improve visual acuity more efficiently.
We compared 2 cohorts of 40 treatment-naïve patients with one eye with wet-AMD who were treated with intravitreal ranibizumab for 12 months in either a VTX or PRN clinic. Both groups received: an initial exam and consent by an ophthalmologist, a baseline fluorescein angiogram, and an ocular coherence tomography scan (OCT) of the maculae. In VTX, the first intravitreal injection of ranibizumab was given by the ophthalmologist. During all follow up visits, eyes were injected by a nurse practitioner and visual acuity and macular OCT was performed prior to each treatment. Within a week of treatment, the OCT was reviewed by the ophthalmologist during a “virtual clinic” who then decided the interval for the next injection. VTX treatments were set at 4 weekly intervals until the macula was dry in appearance and extended every 2 weeks if it remained dry or brought forward by 2 weeks if wet. In the PRN group, all patients were reviewed and treated, as needed, on a monthly basis. Data was collected on: visual acuity, central retinal thickness, and total number of patient appointments and treatments.
On average, the visual acuity and CRT at 12 months improved in both groups (Mean LogMar VA at 1 year in VTX: 0.58 and PRN: 0.60) compared to baseline but was greater in VTX. PRN patients had more clinic visits (Mean visits in PRN: 9.5 and VTX: 8.5) but VTX patients had more injections (VTX mean: 8.5 and PRN mean: 5.8). The interval between the final 2 treatments was also larger in VTX than PRN.
VTX is a promising clinical pathway that increases the amount of wet AMD treatments, reduces the amount of patient appointment burden, and improves visual acuity utilizing a team approach where nurse practitioner and ophthalmologist work together to maximize efficiency.
This is an abstract that was submitted for the 2017 ARVO Annual Meeting, held in Baltimore, MD, May 7-11, 2017.
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