Glaucoma plus diabetes plus AMD? AMD plus dry eye plus cataract? The ophthalmic patient with comorbidities is not uncommon, but your treatment plan might be.

“Cataract, glaucoma, AMD and ocular surface disease. That describes many 85-year-old Caucasian women,” said glaucoma and anterior segment specialist Steven R. Sarkisian Jr., MD. “That’s not an infrequent list of diagnoses to be seen in many octogenarians.”

Andrea V. Gray, MD, a comprehensive ophthalmologist, agreed. “Having one disease does not preclude a person from getting another. A common combination that I see is cataract and another disease. There are a lot of dreadful things a patient can have. People who are doubly unlucky can have multiple problems.”

Nobody is sure just how many doubly or triply unlucky patients there are out there, but they aren’t unusual. “The average person who walks into your practice probably has more than one condition. Multiple diagnoses are just a way of life,” said retina specialist Jennifer I. Lim, MD. “The question is: How much does each diagnosis contribute to the total visual impairment?”

Treating these challenging patients raises other questions, too. Which condition do you treat first? Or do you treat them concomitantly with a combined procedure, such as phacotrabeculectomy or endocyclophotocoagulation? When should you refer to another physician? Will the treatment of one condition lead to the progression of the other? And where, oh where, will you find the time to spend with these more vulnerable, time-consuming patients?

LENS, DISC OR RETINA?

“The concern in a multiply diagnosed patient is, first of all, sorting out how much of vision loss is from this, that or the other thing,” Dr. Gray said. Consider the patient with both drusen and a cataract, whose vision is 20/80. “Sometimes it is tough to sort out how much vision loss is AMD and how much is cataract, until I take out the cataract,” she said.

Dr. Gray acknowledged that certain tests are helpful in the sorting-out process. The potential acuity meter, for example, bypasses the media opacity, allowing the examiner to test the visual acuity without interference from the cloudy lens. This makes it easier to determine how much visual deficit is due to the cataract and how much to the retina. But her office doesn’t have this device. “In my practice, I look at the eye and kind of estimate.” As she looks at the cataract, she assesses whether it’s severe enough to cause vision loss. “There’s definitely a judgment that a doctor has to make because you don’t want to operate and not make them better.”

Clouding, cupping or leaking? Edward Sung, MD, agrees that active evaluation is key. In a patient with both AMD and glaucoma, he said the best way to determine the cause of vision loss is careful examination of the optic nerve. Dr. Sung, a glaucoma and cataract specialist, called that “the most important part of differentiating the cause of vision loss. If the optic nerve shows no signs of loss, then it’s probably the retina.”

Ultraspecialization is a different kind of impediment to the sorting-out process. “When you’re a hammer, everything’s a nail,” said Mariannette J. Miller-Meeks, MD, explaining that, to a retina specialist, if the cataract doesn’t look bad, the problem is obviously in the retina. “But it could be that in looking at the macula, you miss the nerve right next to it,” she said. Or you can be looking only through a dilated pupil with the bright indirect and underestimate the opacity from a small central cataract, said Dr. Miller-Meeks, a comprehensive ophthalmologist.

She recalls the time when a patient with multiple sclerosis, who’d had several bouts of optic neuritis, was under observation at the University of Iowa’s neuro-ophthalmology clinic. The woman’s vision had suddenly declined to hand motions. The neuro-ophthalmologists detected nothing new in an MRI, or in various tests for optic nerve deficits. Retina specialists saw nothing abnormal in the macula. Finally, Dr. Miller-Meeks, who was a faculty member at the time, was called in. The woman had a posterior subcapsular cataract causing precipitous vision impairment. The cataract was removed and the vision improved to 20/40. “The furthest thing from everyone’s mind was that it was a cataract,” she said, adding the cataract would have been more obvious to a comprehensive ophthalmologist, who knows that certain types of cataracts can lead to sudden vision loss.

On the other hand, though the comprehensive ophthalmologist tends to look at the big picture, the problem may be outside his or her area of expertise, Dr. Miller-Meeks said. “It’s kind of an interesting dance.”

Don’t wait to treat everything. Even if he can’t determine whether the visual impairment is due to glaucoma or AMD, Dr. Sung will aggressively treat the glaucoma. Then he’ll refer the patient to a retina colleague for thorough evaluation. “When the exact cause of vision loss is unclear, you treat glaucoma aggressively, in case that’s the cause of vision loss.”

Finally, don’t forget the possibility of what Dr. Lim calls “separated-in-time multiple diagnoses.” Five years ago, the patient may have been treated for a vein occlusion. Now you’re seeing him for a cataract. Is the vision impairment due to the old condition or the new? “Of course, you need to perform a thorough retinal exam,” Dr. Lim said. “However, it is important to also know the prior level of visual impairment for the vein occlusion. For that, you need to check the old medical records.”

TO REFER OR NOT TO REFER

“The majority of multiple diagnoses are fairly straightforward,” Dr. Sung said. “For example, most comprehensive ophthalmologists are comfortable treating both cataract and ocular surface disease. But when complications arise, it’s time to refer.”

But referral requires “taking your ego out of the picture and putting the best interests of the patient first,” Dr. Miller-Meeks said. While a certain amount of ego strength is an asset in medical practice, “your ego can get in the way of referring a patient.” Dr. Miller-Meeks is likely to refer when a patient she has been following experiences a change in vision with no obvious cause. Consider, for example, the 68-year-old patient with both cataract and AMD, whose vision is getting worse, but whose retina and cataract appear stable. Or perhaps the cataract doesn’t look as bad as those causing that level of vision loss in previous patients, or the macula doesn’t look as bad as in other patients who have lost vision from AMD or macular pucker. Cataract surgery is an option, but it may not lead to improved vision. Instead, she refers to a retina specialist. On the other hand, if the patient is new and they’re presenting with AMD, cataract and decreased vision, most often she’ll wait and do a recheck in six months.

When to step up concern. Dr. Gray pays close attention to the patient’s level of functional impairment. “If I had someone with very severe AMD and a very aggressive case of glaucoma, I would get a subspecialist earlier because the patient doesn’t have nerve tissue to spare. That’s a patient I would not be likely to sit on and watch what happens because they have two things that are working to take their vision.”

Division of labor is another reason to refer. If Dr. Sarkisian can’t address all of a patient’s concerns in a single visit, he’s likely to refer. “At those two separate visits, the respective ophthalmologists may focus on the smaller set of problems and give the patient the time they need to tackle those sets of problems,” he said. One of Dr. Sarkisian’s biggest challenges are patients with both glaucoma and ocular surface disease, the latter often brought on by preservatives in the glaucoma drops. This calls for comanagement, he said. “I might have wonderfully controlled their eye pressure, but they’re miserable because of their dry eye.” He’ll refer to a cornea specialist to manage the dry eye. Similarly, he’ll refer patients with AMD to a retina specialist. “I’ll focus on the glaucoma and cataract issues.”

Anxiety = second opinion. In some cases, the patient needs the referral to allay fears and anxieties, said Dr. Miller-Meeks, adding that if they don’t ask for the second opinion, it may be good to offer. Dr. Gray agrees. “Let the patient know that if they want a second opinion you’ll support them,” she said. “Whenever I have a patient who is losing vision from even one process, but especially from two, I recognize that patient has anxiety.” She suggested ways to relieve anxiety, including: extra time educating the patient and taking extra care with treatment. If the anxiety continues, despite the best efforts, she recommends helping the patient get a second opinion.

Confidence = one provider. On the other hand, many patients prefer being treated by one doctor, Dr. Miller-Meeks said. “We can’t underestimate the convenience and reassurance patients have when one doctor can take care of multiple conditions.” Dr. Sung agrees, noting that one dilated exam can cover everything, whereas visits to multiple specialists may require multiple dilations. “As long as all the diseases are stable, and there’s no need for surgery or complex medical treatments, one physician following someone with fairly stable cataract, dry AMD, some glaucoma and ocular surface disorders would be more convenient to the patient.”

Bottom line = know your limits. But there are limits to what one doctor can, or should, do. In Dr. Sung’s practice, the majority of patients with glaucoma will have either developing cataracts or pseudophakia. Many will also have drusen or frank macular degeneration. And many may also have glaucoma and ocular surface disorders, such as dry eye. “My approach to the patient with multiple diagnoses is to stay within the realm of my experience and training, to manage those conditions that I’m comfortably able to treat: cataract, glaucoma and ocular surface diseases, such as dry eye. For patients with frank AMD and vision loss, I refer to a retina colleague for evaluation and further follow-up.”

TRIAGE, TRIAGE, TRIAGE

At some point, whether you refer the patient or treat on your own, the physician has to decide which condition to treat first or whether to treat concomitantly. One consideration is the effect the treatment of one disease process may have on the other. In some cases, treating one condition may aggravate the other. For example, intravitreal steroids or other injections for AMD have the potential to make the cataract worse, according to Dr. Gray.

Fine-tuning the course of action. In other cases, treatment won’t aggravate the other condition. Patients with completely dense cataracts are often referred to Dr. Lim for help in determining the cause of vision loss. In these patients with no view of the retina by clinical examination, ultrasound has an important role, she explained. Echography can determine whether there is a tumor in the posterior segment, or whether there is thickening in the macula from an AMD lesion or scar. In such cases, one would treat the tumor, or, in cases of macular scarring, compare the current vision with that expected from a macular lesion. Removing cataract in the first scenario is not indicated; in the AMD scenarios removal has limited effect on the vision, she said. “You want the surgery to make a big difference in the person’s vision and life.”

Killing two Dx with one Sx. Sometimes the conditions should be treated together. “On any given week, almost half of all the surgeries I do are a combination of phaco and some glaucoma procedure,” said Dr. Sarkisian. Phacotrabeculectomy and phaco with endocyclophotocoagulation are the two most frequent combined procedures he performs. He noted that phaco combined with pars plana vitrectomy is used for a variety of retinal problems, with the phaco being done to aid the visualization of the retina.

Glaucoma and corneal disease may be treated with a combined core vitrectomy with a glaucoma tube shunt placed in pars plana prior to penetrating keratoplasty, Descemet’s stripping endothelial keratoplasty or even keratoprosthesis, Dr. Sarkisian said, adding that sometimes, all three procedures can be performed at the same sitting, if needed. Such combined procedures are not uncommon in a large academic practice setting, where a large staff can support each other with challenging cases, he said.

Prime directive: preserve vision. Naturally, physicians will address the most vision-threatening condition first, even though that particular problem may not be the patient’s biggest concern. “If they told you that they had some irritation and you did a laser treatment or took out the cataract and they still had the irritation, they’ll think you don’t know what you’re doing,” Dr. Miller-Meeks said. Or they may think you’re not helping them because they have a complaint you’re not addressing, she added. To avoid such misunderstandings, Dr. Miller-Meeks advises asking the patient: “‘What are you worried about the most? What bothers you the most?’ At least acknowledge that you heard them and it’s something that can be addressed, even if another thing to you has more urgency.”

Dr. Gray agrees, saying, “It’s important to spend extra time with these patients to educate them and give them a prognosis and treat them so they feel they have control.”

Patients are people, too. Finding that extra time may be one of the biggest challenges in working with the patient with multiple diagnoses. “Usually the patient comes with a set of complaints that they want to have addressed. The challenging aspect is that you might not have the ability even in a long office visit of half an hour to appropriately address all the issues,” said Dr. Sarkisian. “I focus on problems depending on the needs of the patient at a given office visit. If I feel the AMD is relatively stable, I might focus on other things instead. You can’t have a rigid treatment algorithm for every patient. You have to listen to the patient and address their needs and concerns, even if you disagree with what the patient feels is most important. There’s a person behind those eyeballs.” None of the physicians interviewed for this story report related financial interests.
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None of the physicians interviewed for this story report related financial interests.