How to Make AMD Excellence the Norm in Your Practice
By Jeffry Gerson, OD
As is the case with the introduction of any new technology, the early adopters of the AdaptDx® had unique implementation strategies, opportunities,and challenges. In many practices, this involved testing only the highest-risk patients who have night vision complaints. Indeed, this strategy resulted in countless diagnoses that otherwise might have been missed. But as we began to take inventory of all the patients with abnormal results, many of us began to wonder if we were casting a wide enough net. How many more patients were we missing? Our own clinical experience, coupled with what our colleagues were also echoing left little doubt that we should make dark adaptation testing part of the standard patient workup based on the leading risk-factor for the disease, age. This might sound like a radical shift in how you practice optometry and, in theory, it is because it means AMD won’t live in the shadows of your practice anymore. But just because it wasn’t front-and-center before doesn’t mean it wasn’t always there.
With the original tabletop dark adaptometer, testing all patients aged 50 or older in a busy practice just wasn’t practical. Then, the head-mounted AdaptDx Pro® guided by Theia™ came along and completely changed the game. The idea of a portable darkroom that can be brought to the patient combined with a built-in technician that significantly reduces the amount of technician oversight needed created new – and realistic—workflow opportunities. Now we had the tool needed to address AMD head-on, making it a whole lot easier to diagnose, monitor, and manage this potentially devastating, prevalent stealer of sight. As the saying goes, the more regularly you do something, the easier it becomes. Many of us have found this to be particularly true of dark adaptation testing. Here’s a snapshot of how our colleagues have implemented new AMD protocols and have worked with MacuLogix to incorporate these best practices into their AMD Excellence Program to make it easier to implement from day one.
The AdaptDx Pro completely changed the game
"The idea of a portable darkroom that can be brought to the patient combined with a built-in technician that significantly reduces the amount of technician oversight needed created new — and realistic — workflow opportunities." - Dr. Gerson
Consistency is Key
By Tammy Tully, OD
AMD can be scary, but it doesn’t have to be when you have a plan. If we didn’t have dark adaptation testing and we didn’t know that many of our patients have early AMD, we could stick our heads in the sand and ignore what we couldn’t see. That’s one option, but it’s not one I’m particularly comfortable with and it’s inconsistent with our practice philosophy. So now we’re faced with a new source of uncertainty: namely, how do we manage all these AMD patients? Rather than question every decision we make day in and day out, we developed an easy-to-follow protocol that guides next steps.
We screen every patient over age 50 with an AdaptDx Pro Rapid Test and if their dark adaptation is impaired, we bring them back for an Extended Test and an OCT. Next, based on the results of the Extended Test, we monitor them based on the level of dark adaptation impairment (higher RI score).
- Slightly impaired dark adaptation speed and no major structural concerns. See this patient annually.
- RI is getting slower and OCT is showing signs of drusen. See this patient every six months.
- Slow RI with visible drusen on OCT. See this patient quarterly or even more frequently
With the additional metric of the RI, we are able to continue to evaluate structural and functional findings and move the patient up or down based on the complementary information these tests provide. This RI score helps me decide how soon I need to see the patient back, using structure and function together the same way I do for a glaucoma patient. I follow the same protocol for every patient over age 50 so I never worry or second guess myself. I have a complete picture with all of the relevant data to make my clinical decision for each case. Interpretation of the RI score couldn’t be more straightforward. And I am confident it’s working because even though we’ve had patients convert to CNV, our elevated standard of care with more frequent monitoring gave us the opportunity to ensure that they were promptly referred for injections while their vision was still 20/20. That goes to show you how much of an impact optometry can make if only we would all embrace this common-sense paradigm.
The Hurdles Are Easily Overcome
By Claudio Lagunas, OD
We’ve been using dark adaptation testing for years, beginning with the tabletop unit and then, later, with the AdaptDx Pro. Honestly, I thought we were doing great. Patients were happy and we were catching a lot of AMD that we didn’t know we had in our practice. But testing based on night vision complaints alone was just the beginning. When the AMD Excellence Program was first introduced and our MacuLogix Practice Management Consultant showed us how to efficiently test every patient over age 50, it seemed like a logical next step for our practice and for the overall public health challenge posed by AMD. However, I quickly learned that even though I thought we were doing pretty well, testing more patients made it abundantly clear that we still needed to improve our protocols. That was our first hurdle.
In the first six weeks, we tested 152 patients (the test was included in their pre-test at no cost)—when we had been averaging about 17 tests per month previously – and 42% of them had impaired dark adaptation speeds. For those patients, we schedule a follow-up medical visit within two weeks. These follow-up visits include a reimbursable AdaptDx Pro Extended Test (CPT 92284 at ~$60) and an OCT.
The next hurdle we had to overcome was an ethical one. Now that we knew how much more AMD there was in our practice, we felt strongly that we had to give this our full attention, with no excuses for delaying the Rapid Test as part of a routine exam for each and every patient aged 50 and older. And in the early days, we learned a valuable lesson the hard way. We had a situation where a couple came in at the same time and they each saw a different optometrist. The wife failed the Rapid Test and when we brought her back, she failed the Extended Test and needed an OCT as well. During the second visit she asked why her husband hadn’t been tested and, of course, we had no good answer other than that we didn’t have enough units available to test them both that day. We all want to give every patient the same quality of care, and sometimes that’s hard. This realization led us to acquire an additional headset, which turned out to be a very easy decision since we already had a clear understanding of the ROI.
There were two other hurdles that I expected to be monumental but which turned out to be surprisingly insignificant. The first was the staff and the second was the scheduling.
- How would the technicians react to the directive to test every patient over age 50? In this regard, you have to be clear about why dark adaptation testing is so important. We wanted our staff to be a part of this initiative and to understand why, as primary eye care providers, we need to champion finding all of the AMD in our practice. When we communicated that clearly, they understood and wanted to be part of it as well.
- With respect to scheduling, you have to be considerate of your staff. It’s the responsibility of the practice owners and managers to adjust to the new patient flow. When we did this, we encountered no resistance. In fact, the only pressure we got from the staff was the push to add another “Theia” to the team. Having Theia onboard as an extension of our technician team to administer the test, enables our technicians to be more productive while the patient is being tested by Theia.
Pilot Testing in a Satellite Office
By Amanda Legge, OD
We have three office locations, each of which is at a different stage in terms of how evolved the dark adaptation protocol is at this point. In our largest office, we have 11 exam rooms, up to four doctors working at a time, and only one AdaptDx tabletop which is constantly in use—primarily for the purpose of clarifying suspected AMD based on visual complaints and structural findings and for monitoring these patients over time. For example, if a patient presents with pinpoint drusen, we perform dark adaptation testing to help determine whether this is normal age-related drusen versus macular degeneration. This protocol worked well for years, but we always suspected that we could be doing more. The AdaptDx Pro set that aspiration in motion.
When the AdaptDx Pro was introduced, we used it as an opportunity to see how much more we could improve our AMD care. To do this, we piloted the AMD Excellence Program in a smaller satellite office before rolling it out in the larger practice, which we now look forward to accomplishing based on how well the program is working. When we fully implemented the AMD Excellence Program to test all patients over age 50 at the first satellite office, we found that we had about a 30% fail rate among new and established patients who had never before undergone dark adaptation testing. The established patients had no note of drusen prior to testing. For the new patients, the dark adaptation screening was performed first, so some of these patients already had early or intermediate AMD with noted drusen during clinical examination.
In either case, this is significantly higher than the data in our medical records would have suggested. Clearly, we were missing AMD. When we consider those numbers and how many patients’ lives will be impacted when we roll this out on a larger scale it’s staggering. Thanks to the portability of the AdaptDx Pro and the onboard technician, shifting protocols on a larger scale doesn’t sound as impractical as it once did. Given the results of our pilot, we have much more confidence that this will be successful in all of our practices and, more importantly, it will impact the lives of many more patients. When we are able to provide a superior level of care to our patients, they are more appreciative and loyal to our practice.
Q: Is AMD more prevalent than we thought?
Many practices that commit to testing all patients over age 50 find more patients with impaired dark adaptation than they anticipated. What does this mean? Here are five perspectives from your peers:
Dr. Marshall: When a patient has impaired dark adaptation, it prompts me to do further testing to determine the cause and appropriate treatment plan. While impaired dark adaptation is most likely due to AMD, it can be associated with a variety of conditions, such as retinitis pigmentosa, Stargardt disease, vitamin A deficiency, plaquenil toxicity or macular edema. It’s our job to use all of our tools, technology and knowledge to make the appropriate diagnosis.
Dr. Lagunas: It’s important to consider the definition of what AMD is in cited average numbers. Hopefully, we already know when most of our patients have intermediate or advanced disease, and that’s what is generally reported in the data. With dark adaptation, we’re looking at a whole new segment of subclinical AMD and possibly catching some early AMD we may have otherwise missed.
Dr. Rodman: Consider that the Beckman scale classifies a patient as having “no AMD” based exclusively on the presence or absence of clinical findings. If a patient does not have clinical findings and the OCT looks great yet the patient has a dark adaptation delay, I’d say that patient has subclinical AMD, which would not be counted as such in the inclusion criteria of most prevalence investigations.
Dr. Tully: I agree with Dr. Rodman. We can’t point to these historical studies and expect them to reflect something we didn’t even know we could measure in a practical way a decade ago. There will be new longitudinal studies, but for obvious reasons, these take time. Until then, we have to use common sense.
Dr. Gerson: We’ve known since 2014 that false positives are not a huge concern with this technology.1 To calculate the diagnostic sensitivity and specificity for the Rapid Test, dark adaptation was measured by using the AdaptDx dark adaptometer in two groups: subjects with normal retinal health and subjects with clinical AMD. Subjects were assigned to their group by clinical examination and grading of fundus photographs. Sensitivity was defined as the percentage of AMD subjects who exhibited a Rod Intercept® > 6.5 minutes. Specificity was defined as the percentage of normal subjects who exhibited a Rod Intercept ≤ 6.5 minutes. Diagnostic test sensitivity was calculated to be 90.6% (P < 0.001). The 95% CI for diagnostic sensitivity had a lower bound of 85.1% and an upper bound of 100%. Diagnostic test specificity was calculated to be 90.5% (P=0.0271). The 95% CI for diagnostic specificity had a lower bound of 72.9% and an upper bound of 100%.
Transitioning from Research to Routine
By Julie Rodman, OD
Increasingly, dark adaptation is being used as an endpoint in clinical trials, making it important for universities like ours to remain current. To that end, we’ve had a tabletop AdaptDx for several years at Nova Southeastern University and, until recently, we used it primarily for research purposes. In the past several years, however, there’s been a significant shift in how dark adaptation is perceived and utilized in the United States. As more and more practices make dark adaptation a standard test for detecting and monitoring AMD, the more I begin to look at best practices for integration in our university setting. Having AdaptDx technology makes all the difference in this regard. Now that we are actively using the AdaptDx clinically, we are looking at how to streamline in order to run a Rapid Test on every patient over age 50.
It’s interesting because, in many ways, universities lead the way insofar as we’re entrenched in cutting-edge research. But sometimes, we aren’t the first to fully adopt new standards due to legalities that we contend with. Billing is the first example that comes to mind since these decisions aren’t made by a single practice owner but rather by several departments and committees university-wide. That said, having seen the success of colleagues who are changing the public health paradigm in AMD, we are committed to joining the ranks of those who perform dark adaptation testing based on the number one AMD risk factor: age. Based on everything I’ve heard and read, this is the model that makes practice integration easier as well as maximizes the clinical benefits, and so it’s what I am working to adopt as soon as possible.
It’s my hope that the implementation of the AMD Excellence Program® at our clinic will provide a novel perspective and add to our understanding of early AMD in non-Caucasian patients. Our patient base is largely African-American and they are often under-represented in AMD research. The opportunity to evaluate our population in a more comprehensive way can contribute immensely to what we know about the role of demographics at different stages in disease development. As they say, “once a researcher, always a researcher.”
WHAT TO EXPECT FROM MACULOGIX’S AMD EXCELLENCE PROGRAM
1. DEVICE TRAINING
As the core training session for all AdaptDx Pro customers, this virtual, hands-on education focuses on getting your team comfortable using the device. You will gain confidence with the technology and learn how to work with Theia to guide patients through the test.
The skills covered include:
- Charging and cleaning the device
- Navigating the user interface
- Instructing patients to appropriately don the
- Starting the test for the patient
- Understanding and recording test results
At the end of the session, a practice management consultant (PMC) will observe team members setting up the device for testing and provide coaching tips.
2. PRACTICE IMPLEMENTATION & PROGRAM LAUNCH
This step of the process will align your entire team thorough the following:
- Practice Implementation — This includes a working session with key team members. The PMC spends time getting to know your practice and will help you set goals for your AMD program. Together, you’ll outline processes, workflows, and smart scheduling to set your practice up for future success in identifying and managing AMD.
- Program Launch — Your entire team will be included in the last part of this session to ensure sure that everyone knows and understands their role in making your AMD program a success—from the identification of patients to scheduling, patient
education, and follow-up.
3. WEEKLY CHECK-INS
Your MacuLogix PMC will schedule weekly calls with your practice’s AMD leader to catch up on progress, understand roadblocks, modify processes, and answer questions. The PMC will also check in to see how your team is performing against your goals.
4. ONGOING SUPPORT
To help you maximize your success and maintain your efforts to capture and monitor AMD, you’ll have access to the following:
- PMC Support — Reach out to the PMC team for ongoing guidance and education as needed.
- AMD Academy® — 24/7 access to online training videos, clinical resources, patient education materials and professional marketing support.
- AMD Enrichment Sessions — Register for any or all of the MacuLogix AMD Enrichment Sessions on the AMD Academy to further your team’s knowledge in support of your goals with personalized, live training sessions.
- Peer-to-peer Learning Opportunities — These learning forums provide an opportunity to talk to other optometrists—both experienced AMD clinicians and those new to AMD. There will be time to ask questions and learn how others are achieving success.
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Practical Implementation of Dark Adaptation in Optometric Practice
This resource goes beyond explaining why dark adaptation is so important in optometric practice. Having already established the reasons why functional testing is essential, this year’s report outlines the practical strategies for how to make routine testing a reality in your own eye care practice.
About the Author
Dr. Jeffry Gerson graduated from Indiana University school of optometry in 1997. He then went on to complete a residency at the VA medical center in Kansas City concentrating on ocular disease and low vision. He quickly became faculty at the University of Kansas school of medicine in the department of ophthalmology. Dr. Gerson has authored several articles in journals such as “Review of Optometry” and lectures on retinal disease and systemic disease in the US and abroad. He is a member of the American Optometric Association as well as the Kansas optometric association which named him their 2008 Young OD of the Year. He is a fellow of the Academy of Optometry and Optometric Retina Society.