Roya Attar, OD, MBA, DHA, associate professor and director of optometric services at the University of Mississippi Medical Center Department of Ophthalmology, outlined the OD’s role in retinal care in her “Medical Retina in the Anti-VEGF Era: What Optometrists Need to Monitor and Manage” presentation at the American Academy of Optometry meeting in Anaheim, California. She described how optometrists have evolved from referral gatekeepers to active longitudinal care partners.

Stabilization is a central goal of anti-VEGF therapy, Dr. Attar said. Approximately 90% of patients with neovascular age-related macular degeneration (nAMD) maintain vision with treatment, while 30% to 40% experience vision improvement. For diabetic macular edema (DME), vision can improve in 40% to 60% of patients, and 30% to 40% experience complete resolution. Vision improves in 50% to 70% of patients with retinal vein occlusion (RVO), while edema resolves in 60% to 80%.

Response to anti-VEGFs can vary with genetic factors, lesion subtype, and disease chronicity, Dr. Attar said, and a single post-injection visit does not establish a patient's trajectory. Assessment should therefore be longitudinal.

Treatment schedules may also place a substantial burden on patients. Traditional protocols can involve monthly loading injections for 3 to 6 months followed by treatment every 4 to 8 weeks. Treat-and-extend protocols may lengthen intervals in 2-week increments to a maximum of 12 to 16 weeks, while PRN (as-needed) protocols use monthly monitoring with treatment decisions based on visual acuity, optical coherence tomography (OCT), and clinical examination.

What ODs Should Monitor

OCT, best-corrected visual acuity (BCVA), and functional measures such as Amsler grid testing and contrast sensitivity are all components of an optometrist's monitoring toolkit. At each visit, OCT documentation should include central subfield thickness (CST), the presence and location of intraretinal fluid (IRF) and subretinal fluid (SRF), and ellipsoid zone integrity. BCVA should be measured consistently because subtle changes may precede patient-reported symptoms. Amsler grid and contrast sensitivity testing can provide additional information about functional changes that may not be reflected in Snellen acuity.

Anatomic and functional responses should be assessed independently. OCT may show improvement in retinal fluid and structure without corresponding visual improvement, while functional vision can change despite stable OCT findings. Dr. Attar recommended tracking both at every visit. For nAMD specifically, IRF is the most concerning finding and a reason for prompt escalation discussion. Some SRF may be tolerated under treat-and-extend protocols, but pigment epithelial detachment alone is not identified as a retreatment trigger.

Recognizing Stability and Recurrence

For patients with DME, stability is characterized as CST within approximately 10% of baseline, no new IRF, and stable VA. Findings that indicate instability include an increase in CST greater than 50 µm, new IRF, or VA loss of at least 5 ETDRS letters. Any of these findings should prompt contact with the retina specialist rather than waiting for the patient's next scheduled visit.

More generally, Dr. Attar said, stability includes CST within 10% of the patient's dry baseline, no new fluid, a stable ellipsoid zone, VA within 1 line of baseline, and no new distortion, scotoma, hemorrhage, or neovascularization, along with stable intraocular pressure (IOP). Not every fluctuation represents recurrence, however. CST variation of approximately 20 to 30 µm can occur normally, and a 1-line change in VA may result from media or testing variability. When findings are questionable, Dr. Attar recommends repeating the measurement before escalating care.

RVO requires particular attention to neovascular complications. Ischemic central retinal vein occlusion (CRVO) can lead to rubeosis iridis and subsequent neovascular glaucoma. This finding means that IOP and gonioscopy should be checked at every visit. The appearance of new vessels warrants same-day or next-day retina referral.

Identifying Partial or Diminishing Response

A dry macula on OCT, stable or improved acuity, and an absence of new symptoms at follow-up indicate stability. Minor fluid fluctuations may not be clinically significant, Dr. Attar said. Trends are more important than an isolated finding, but sudden increases in fluid, new hemorrhage, or unexplained decline in vision warrant prompt communication with the retina specialist. Persistent IRF is particularly important because it correlates more strongly with photoreceptor damage and poorer visual outcomes than SRF. Persistent fluid following 3 or more injections may indicate an inadequate dosing interval, poor drug response, or a change in disease mechanism and warrants prompt communication with the retina specialist.

A gradual return of fluid at previously stable treatment intervals can signal diminishing response. Because subtle anatomic changes may precede functional decline, Dr. Attar recommends comparing OCT scans rather than relying on VA alone. Nonresponse is indicated by no meaningful fluid reduction or VA improvement after 3 loading doses; missed appointments and declining adherence can mimic clinical nonresponse.

Maintaining Continuity After Referral

Referral to a retina specialist should not end the optometrist's involvement. Rather, follow-up can include monitoring adherence, addressing patient concerns, treating other ocular conditions, updating refractive correction, and providing low vision services, Dr. Attar suggested.

Communication with the retina specialist should include current and previous BCVA, patient-reported changes such as new distortion or scotoma, comparative OCT scans when available, and new clinical findings such as hemorrhage.

The optometrist's longitudinal record can provide the cumulative history of injection burden, previous fluid patterns, and adherence that informs subsequent treatment decisions.

“It’s your greatest clinical asset in comanagement,” Dr. Attar concluded. “Build it deliberately at every encounter.”