Article Date: 7/1/2010

Upfront: From the Editor-in-Chief

Upfront: From the Editor-in-Chief

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JASON S. SLAKTER, MD

A patient came to see me a few weeks ago for routine follow-up for ongoing treatment with anti-VEGF therapy for neovascularization secondary to AMD. Before my examination, he had his vision tested and eyes dilated and had an OCT performed. It's my routine to examine the chart, speak to the patient, and perform my clinical exam before reviewing the imaging studies. I'll typically tease the patient about "not wanting to cheat and look at the OCT first," until I've had a chance to look at the back of the eye. On that particular visit, my evaluation revealed not only the manifestations of his AMD, but a somewhat subtle appearance of what appeared to be refractile plaque in a branch retinal artery. There were no other manifestations of vascular occlusive disease, and his OCT showed minimal fluid, indicating a successful result from his ongoing therapy.

On careful questioning, however, he did explain that he had one episode of a "curtain-like effect in vision," which he had attributed to his AMD and had not mentioned previously. A thorough medical work-up revealed elevated cholesterol and significant carotid disease for which he is now undergoing treatment.

This encounter reminded me of the importance of having a routine in evaluating patients and not taking quick shortcuts in pushing them through the examination process. With the increasing volume of patients requiring care and the growing load on our practices with the delivery of intraocular drugs, it's too easy to fall into the trap of taking a quick look at a scan, doing a cursory evaluation, and pushing patients out the door to keep up with our busy schedules.

Whenever I attend a retina meeting, particularly one that focuses on interesting case presentations, I am most fascinated by those that involve patients who present with routine conditions and who are subsequently found on thorough evaluation to have unusual diseases or conditions. I ask myself whether I would have noticed that subtle finding or performed that extra test that would have revealed the true diagnosis. I certainly hope that the answer is yes, but I fear that, in many cases, the pressure and demands on our time might result in a different answer, particularly as our practice patterns continue to evolve.

In this issue of Retinal Physician, there are several articles that pertain to this line of thinking, including a discussion of the "high-volume injection practice" by Dr. Pravin Dugel. Although this article is more business-oriented, it highlights a problem that we all face, with what seems to be medical practices now functioning as "injection clinics." More clinically focused are articles by Dr. Usha Chakravarthy, reviewing the importance of a proper baseline evaluation in patients with AMD, and Dr. Irene Barbazetto, on conditions that masquerade as diabetic retinopathy. Both of these articles remind us of the importance of a thorough clinical evaluation and, more importantly, the thoughtful assessment of a patient's findings prior to the initiation of treatment.

Without question, we're all dealing with the stresses of changing economic times, as well as changes in our practice patterns. However, we should not lose sight of our primary goals: performing thorough and appropriate evaluations of our patients' symptoms, and findings and delivering the highest level of care for their conditions, without falling into the trap of taking shortcuts to get through our day.



Retinal Physician, Issue: July 2010