Many ophthalmologists are missing AMD indicators

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Approximately 25% of eyes deemed to be normal based on dilated eye examination by a primary eye care ophthalmologist or optometrist had macular characteristics that indicated age-related macular degeneration (AMD).

Approximately 14m Americans have AMD and, as the baby boomer population ages, this public health problem is expected to worsen. Age-related macular degeneration is the leading cause of irreversible vision impairment in older adults in the US, yet little is known about whether AMD is appropriately diagnosed in primary eye care.

Dr David C Neely, of the University of Alabama at Birmingham, and colleagues conducted a study that included 644 people 60 years or older with normal macular health per medical record based on their most recent dilated comprehensive eye examination by a primary eye care ophthalmologist or optometrist. Presence of AMD was based on imaging (colour fundus photography).

The sample consisted of 1,288 eyes from 644 participants (average age, 69 years) seen by 31 primary eye care ophthalmologists or optometrists. A total of 968 eyes (75%) had no AMD, in agreement with their medical record; 320 (25%) had AMD despite no diagnosis of AMD in the medical record. Among eyes with undiagnosed AMD, 78% had small deposits under the retina (called drusen), 78% had intermediate drusen and 30% had large drusen. Undiagnosed AMD was associated with older patient age, male sex and less than a high school education. Prevalence of undiagnosed AMD was not different for ophthalmologists and optometrists.

The authors note that the eyes with undiagnosed AMD that had AMD with large drusen would have been treatable with nutritional supplements had it been diagnosed.

The study noted some limitations.

“The reasons underlying AMD underdiagnosis in primary eye care remain unclear. As treatments for the earliest stages of AMD are developed in the coming years, correct identification of AMD in primary eye care will be critical for routing patients to treatment as soon as possible so that the disease can be treated in its earliest phases and central vision loss avoided.”

Abstract
Importance: Age-related macular degeneration (AMD) is the leading cause of irreversible vision impairment in older adults in the United States, yet little is known about whether AMD is appropriately diagnosed in primary eye care.
Objectives: To examine the prevalence of eyes with AMD in patients seen in primary eye care clinics who purportedly have normal macular health per their medical record and the association of AMD with patient and physician characteristics.
Design, Setting, and Participants: In this cross-sectional study of primary eye care practices in Birmingham, Alabama, 644 persons 60 years or older with normal macular health per medical record based on their most recent dilated comprehensive eye examination by a primary eye care ophthalmologist or optometrist were enrolled from May 1, 2009, through December 31, 2011. Data analysis was performed from May 1, 2016, through December 20, 2016.
Main Outcomes and Measures: Presence of AMD as defined by the Clinical Age-Related Maculopathy Staging system based on color fundus photography and a masked grader. Types of AMD-associated lesions were noted. Patient health and physician characteristics were collected.
Results: The sample consisted of 1288 eyes from 644 participants (231 [35.9%] male and 413 [64.1%] female; mean [SD] age, 69.4 [6.1] years; 611 white [94.9%]) seen by 31 primary eye care ophthalmologists or optometrists. A total of 968 eyes (75.2%) had no AMD, in agreement with their medical record; 320 (24.8%) had AMD despite no diagnosis of AMD in the medical record. Among eyes with undiagnosed AMD, 32 (10.0%) had hyperpigmentation, 43 (13.4%) had hypopigmentation, 249 (77.8%) had small drusen, 250 (78.1%) had intermediate drusen, and 96 (30.0%) had large drusen. Undiagnosed AMD was associated with older patient age (odds ratio [OR], 1.06; 95% CI, 1.04-1.09; P < .001), male sex (age-adjusted OR, 1.39; 95% CI, 1.02-1.91; P = .04), and less than a high school education (age-adjusted OR, 2.40; 95% CI, 1.03-5.62; P = .04). Prevalence of undiagnosed AMD was not different for ophthalmologists and optometrists (age adjusted OR, 0.99; 95% CI, 0.71-1.36; P = .94).
Conclusions and Relevance: Approximately 25.0% of eyes deemed to be normal based on dilated eye examination by primary eye care physicians had macular characteristics that indicated AMD revealed by fundus photography and trained raters. A total of 30.0% of eyes with undiagnosed AMD had AMD with large drusen that would have been treatable with nutritional supplements had it been diagnosed. Improved AMD detection strategies may be needed in primary eye care as more effective treatment strategies for early AMD become available in the coming years.

Authors
David C Neely; Kevin J Bray; Carrie E Huisingh; Mark E Clark; Gerald McGwin Jr; Cynthia Owsley

JAMA material
JAMA Ophthalmology abstract


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