Expanding the Visual Field

Retina Associates of Kentucky enters the Louisville market and continues to be a leader in restoring vision in seniors

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A 2012 report by Prevent Blindness America estimates almost 30,000 Kentuckians over age 50 suffer from age-related macular degeneration (AMD) and nearly 103,000 Kentuckians over 40 are affected by diabetic retinopathy, one of the highest rates in the nation. Problems are compounded in more rural areas of the state such as eastern Kentucky, where obesity is endemic and health care access is a challenge.

Retina Associates of Kentucky (RAK), founded in 1975 in Lexington by William J. Wood, MD, has spent the last 37 years treating retina diseases in central and eastern Kentucky and has recently expanded its physician line-up and its geographic reach. “From the very beginning, the guiding principle in the development of this practice was to provide nothing but the finest of care and the way to accomplish this is to be associated with the highest caliber and best trained physicians possible,” says Wood.

RAK is the largest retina-only practice in Kentucky with five physicians and offices in Lexington, Louisville, Ashland, Prestonsburg, Somerset, Richmond, Campbellsville, Danville, and London, Kentucky, and Huntington, West Virginia. “Referring physicians and patients appreciate the availability and support that having offices in so many locations can have for them,” says Maryanne Inman, MBA, practice administrator.

Rick D. Isernhagen, MD, was the first physician to join Wood in practice. “When I started 26 years ago, Dr. Wood and I were the only two retinal surgeons in Lexington, central Kentucky, and eastern Kentucky … I think our biggest asset is that as the need grew, so did our practice in terms of the training and skills our partners brought to the practice when they joined us,” says Isernhagen. Those partners include Thomas W. Stone, MD, John W. Kitchens, MD, and Andrew A. Moshfeghi, MD, who joined the practice this summer.

The New Recruit

Regarded as a world-renowned retina surgeon, Moshfeghi interned at MetroWest Medical Center at Harvard Medical School and completed his residency at North Shore University Hospital at New York University School of Medicine. He completed medical retina and vitreoretinal surgery fellowships at Bascom Palmer Eye Institute in Miami, Florida. Moshfeghi spent seven years at Bascom Palmer before coming to RAK. His professional interests include AMD, surgical interventions for detached retina and macular holes, diabetic retinopathy, and imaging of the eye.

At a point in his career where he was evaluating his next steps, Moshfeghi tried to keep an open mind about geography. “I really wanted to look for the right type of practice. Part of looking for the right type was identifying people I could collaborate with,” he says. As it happens, Moshfeghi trained with Kitchens at Bascom Palmer and the two are close friends. Additionally, Moshfeghi had known Stone for about a decade through Moshfeghi’s brother, Darius Moshfeghi, MD, who is also a retina surgeon at Stanford University in Palo Alto, California.

Moshfeghi and his wife, Arlanna Moshfeghi, MD, a pediatric ophthalmologist who will begin practicing in the area in January, began to fall in love with Lexington on their visits there. “I was drawn to the people in the practice, drawn to the way they practiced, and drawn to the capabilities they had, as well as to Lexington,” says Moshfeghi.

New Frontiers

The practice recently expanded geographically, both to the east and the west, with the opening of a Huntington, West Virginia office in August 2013 and a Louisville office in October 2013. “We’ve been asked each year, as years have gone by, to bring our services to patients where they live,” says Wood.

“While many physician practices are consolidating and either affiliating with, or becoming employees of hospitals and hospital groups, Retina Associates of Kentucky remains a private practice of dedicated physicians who provide specialized services for our patients,” says Inman. “Because this specialized care is not available in many areas of the state and surrounding states, RAK has multiple satellite offices where we care for patients in addition to our two main offices in Lexington and Louisville.” As a second “main office,” Louisville is equipped with the same technology and services as the Lexington office, capable of treating emergency, medical, and surgical needs of the retina, vitreous, and macula. Surgical services also are available in Lexington and Ashland.

The decision to expand into Louisville was a simple one. Not only was it a new “western frontier” for RAK, but Stone lives in Louisville and is there full-time to meet the needs of patients. “With the number of physicians we have and the number of treatments and research studies we offer, we felt it would be an attractive alternative to open the office in Louisville,” says Wood.

A Vision for Excellence

Wood’s philosophy to be the best and recruit the best has been a not-so-secret element of the practice’s success.

All five of the physicians were trained at top 10 ophthalmology programs, as ranked by US News & World Report, and all five have been chosen as Best Doctors in America, a designation voted on by their peers. Wood completed his residency at the prestigious Wilmer Ophthalmological Institute at Johns Hopkins University and was awarded the Heed Fellowship at the Massachusetts Eye and Ear Infirmary at Harvard University. Isernhagen was a fellow at the Wilmer Institute at Johns Hopkins and chief resident during his residency at Dean McGee Eye Institute in Oklahoma. Stone did his residency at Duke University Eye Center, including a year as chief resident, and pursued his fellowship in Retinal Diseases at Emory University in Atlanta. A native of Indiana, Kitchens performed his residency at the University of Iowa and completed a fellowship and chief residency at the Bascom Palmer Eye Institute.

RAK physicians are also invested in educating the next generation of retina specialists and surgeons. In conjunction with the University of Kentucky, RAK sponsors a two-year medical/surgical fellowship and a one-year retina medical fellowship. The practice typically has three fellows at any given time who spend half their time with RAK and half with UK.

Time Takes its Toll

Age-related diseases are the number one cause of visual impairment and blindness in the US. Because of that, a large majority of RAK’s patient population is over the age of 60 and suffers from common conditions such as: age-related macular degeneration (AMD), diabetic retinopathy/diabetic macular edema, and retinal vein occlusion (RVO).

AMD is the leading cause of blindness and vision loss for people over 65 and makes up the largest portion of RAK’s patient base. To address this large population of patients, Wood founded the Macular Degeneration Institute. “It’s the only facility of its kind in this region of the US serving all the needs of patients with macular degeneration in one location,” says Wood. Rehabilitation services are offered through RAK’s Low Vision Services, another arm of the practice, which provides magnification tools, electronic devices, services, and education to those who cannot be helped by surgery or glasses.

Diabetic retinopathy is a particular problem for the state of Kentucky because of the prevalence of obesity and diabetes. “As we see the baby boomer generation moving into their sixth and seventh decades, we’re seeing more and more patients with diabetic retinopathy who are older,” says Kitchens. However, treatments are advancing. “While we’re seeing many more diabetic patients, their outcomes are improving because I can treat it more effectively now,” says Stone.

Reversing the Clock

As little as 10 years ago, the only treatments for AMD and diabetic retinopathy, among others, were laser therapy and surgery. While those treatments were effective at slowing disease progression, they did nothing to improve patients’ vision.

Then, eight years ago, the advent of injectable anti-vascular endothelial growth factor agents (anti-VEGFs) opened a realm of possibilities for medical treatment of these diseases. Not only do these injected medications stabilize patient’s conditions, they also restore lost vision in some patients. Stone contends intravitreal injections can “reverse the clock.” He says, “We have many patients who were legally blind, couldn’t drive, couldn’t read, couldn’t work, couldn’t read their medicine so they couldn’t live alone. In many cases we can improve their condition so they now live independent, productive, healthy lives.”

In addition to avoiding surgical intervention, the injections also help preserve normal tissue. “When you apply thermal laser to the retina or macula, it actual destroys tissue in the area immediately around where you apply the laser … The injections don’t destroy any tissues,” says Moshfeghi, who uses the analogy of applying weed killer to your lawn, which kills the weeds but not the lawn.

The drawback of injections is that the results are not permanent, and they must be given every one to two months to maintain the effects. This has dramatically changed not only the way retina specialists administer treatment but also how often they see patients in the clinic.

The three gold standards of anti-VEGF treatment RAK uses are Lucentis®, Avastin®, and Eylea®, the newest treatment for wet AMD. In fact, Moshfeghi was part of the team who first described the benefits of Avastin in AMD patients while at Bascom Palmer in 2005.

RAK was one of 43 clinical sites selected to participate in the prestigious Comparison of Age-Related Macular Degeneration Treatment Trial (CATT), which Isernhagen deems “one of most important studies” they have been involved in. Sponsored by the National Institutes of Health (NIH) and National Eye Institute (NEI), the study compared the efficacy of Lucentis vs. Avastin (which is much more cost-effective) in patients with wet AMD. The study found the two drugs were comparable in their effectiveness. “It’s particularly important in the age of the Affordable Care Act (ACA), knowing that the use of medication like Avastin could reduce overall healthcare burden by upwards of several billion dollars,” says Kitchens.

Still Cutting-Edge

Although medical treatments have replaced some surgical procedures, some common age-related retina conditions often still require surgery, including: retinal detachment, macular holes, and macular pucker. For emergency situations, such as retinal detachment, “We have someone on call at all times and available to operate whenever needed,” says Wood.

Currently, three of the partners – Stone, Kitchens, and Moshfeghi – perform in-hospital surgery and offer medical treatments, while Wood and Isernhagen perform in-office surgery and medical treatments.

“The biggest innovation in retina surgery has been the advent of sutureless vitrectomy with microscopic instrumentation,” says Moshfeghi. The instruments are now so small that no stitches are necessary in most cases, so patients recover much faster, have less irritation and pain, and have improved visual outcomes.

According to Stone, surgery for diabetic retinopathy has become progressively safer. “Anti-VEGF medication has made the disease less fulminant when it comes to surgery, and the machinery has improved. What used to take me three hours in the operating room, I can now do in less than 60 minutes,” says Stone. These advancements also cause less pain, less discomfort, and better outcomes for patients.

RAK physicians do not just embrace innovation, they also create it. Kitchens has a particular interest in designing methods to solve surgical problems and is widely known for developing a technique to repair choroidal detachments. “Choroidal detachments are quite rare, but can occur after glaucoma surgery if pressure goes too low. I developed a technique to drain the choroidal detachment less invasively and in a more controlled manner using a guarded needle attached to aspirations,” says Kitchens.

In the Line of Sight

“Our physicians are really national leaders in the development of wide-field imaging and were the first in Kentucky to use the OPTOS wide-angle imaging angiography system,” says Wood. Previous imaging technology only allowed physicians to see 30 to 50 degrees of the retina at one time. Wide-field visualization nearly accommodates 180 degrees of viewing, allowing physicians to see most of the whole retina.

“Another big advance, a monumental transformational technology that revolutionized the way we practice retina repair is the advent and popularization of optical coherence tomography (OCT),” says Moshfeghi. Although OCT has been around since the early 90s, it was not readily available in retina offices until 2003. Kind of like a CAT scan for the retina, it provides a quick and non-invasive qualitative and quantitative assessment of retinal problems.

Fine-Tuning

RAK is currently researching longer lasting treatments for wet AMD, as well as different formulations of injectables and combination therapy.

In diabetic retinopathy, studies are now looking to fine tune the use of newer treatments. RAK is part of a NIH-sponsored consortium of retina researchers called the Diabetic Retinopathy Clinical Research Network (DRCR). Stone is the PI for these studies at RAK. “While we know these medicines work in diabetics, which individual medicine might be better under certain circumstances? What role do they play in using laser vs. doing medicine? When do you recommend surgery?” asks Stone.

What will the next 10 years bring in the field of retina? Isernhagen predicts, “I think we will see more drugs not only for macular degeneration and histoplasmosis and diabetes, but we will also see some of these drugs that have come out replacing surgery where surgical diseases become medical diseases, and I think we’ll be using less invasive surgical techniques.”

Whatever the changes, RAK is poised to continue the fight against vision loss in Kentucky.