AOA 2024: Catching toxicity in the retina before it is too late

In a collaborative effort with other medical professionals, optometrists can aid in catching toxicities in the retina stemming from medication side effects before they do major damage to the eye. Raman Bhakhri, OD, FAAO, touched on those medications and utilizing technology to help spot those toxicities in his presentation at this year's AOA and AOSA Optometry's Meeting in Nashville, Tennessee.

Video transcript

Editor's note: This transcript has been lightly edited for clarity.

Jordana Joy:

Hi everyone. I'm here today with Raman Bhakhri, associate professor at the Illinois College of Optometry. He's here to chat about his presentation, "Toxic Retina!", which he gave at this year's Optometry's Meeting in Nashville. So welcome. It's a pleasure to have you here.

Raman Bhakhri, OD, FAAO:

Thanks so much for having me.

Joy:

Awesome, great. So first, could you give an overview of the presentation that you gave?

Bhakhri:

Sure, so it was a 2 hour lecture on toxic retina, more specifically, was looking at common and even uncommon medications that we encounter as optometrists that can potentially lead to damage in the retina. Now that damage might be really insignificant, but something we should still pick up, or it can be pretty visually devastating, in which case, it might be too late. So the idea with a lecture was to introduce the drugs, what they're used for, what their indications are basically, potential side effects, how those side effects manifest in the retinas — so what that specific appearance is — what type of technologies we can use to detect that stuff early on before it leads to that visually-damaging type side effect. And then communication with a PCP, because for the most part, we're not prescribing these medications at all. It's going to be a primary care doctor, an oncologist, which is what I talked about. So that communication, that back and forth, the interprofessional relationship, basically.

Joy:

Sure, absolutely. So what do you hope becomes commonplace knowledge about some of these toxicities that may not be commonplace now?

Bhakhri:

I think the big picture I was trying to get across was taking a careful look at the medications. I think we get drawn up in the details of the actual examination. When we take a step back, look at the history. "What medications do you take?" is something I feel like we don't look at it enough. We don't update sometimes; sometimes it's on us, sometimes it's on our techs. Someone should be looking at the medications, updating them as we go. And from there, again, it's just recognizing like, oh, you take tamoxifen, which is a pretty common drug that we use for breast cancer, we should be screening for that right away, right? Whether the patient has symptoms or doesn't have symptoms, that's something we should be looking for. Because a lot of these conditions, like I mentioned, you don't pick up till it's too late. The idea is to pick it up early on.

Joy:

Absolutely. So what are some of your main tips for picking up those side effects early? Are there any telltale signs or does it depend on the medication?

Bhakhri:

It does depend on the medication. That's a great point. So it does depend on the medication, just because the medications can manifest in so many different ways in the retina. It could be a cystic change within the inner retina, it could be an outer retinal chain such as [retinal pigment epithelium, or] RPE damage, or photoreceptor damage, which usually leads to a pretty devastating vision loss once that part's involved. But the big things I would mention are again, using that technology. If you're just using your own two eyes and 90 diopter lens, what you're going to pick up is going to be again, [inaudible] stuff because that's what our own 2 eyes are going to show us. Our job again, get in a little bit deeper, use that multimodal imaging. So during the presentation, I showed a lot of images, but we went deeper and we went and looked at fundus autofluorescence images, we looked at OCTs. Those are probably the 2 big pieces of technology I would insist on us as clinicians, using our fundus autofluorescence and OCT.

Joy:

Sure, so knowing all of this information, how does having this knowledge and expertise in identifying these side effects and symptoms advance eye care in terms of patient care.

Bhakhri:

It just makes us a player in the field, right? Once that PCP or oncologist recognizes, okay, if these optometrists are more than willing and more than trained to prepare and to look at these kinds of conditions, we can get more involved in the patient's care. Again, I'll use a patient who takes tamoxifen for breast cancer. Once the patient is put on that drug, they should be sent to us for a screening exam, right? We do that baseline OCT, or that baseline fundus autofluorescence. Again, the baseline exam, we're probably not going to find the thing, which is fantastic. But again, it's that continued care, that continued communication with the PCP, the oncologist, the endocrinologist, whatever it may be. It just makes us a player in the field and, you know, puts us in the game.

Joy:

Absolutely. So I feel like you've probably already touched on this. But if there was 1 key takeaway, or maybe a handful of key takeaways that you hope attendees have taken away from your presentation, what would that be?

Bhakhri:

Sure. We mentioned the first part, just reviewing the history. So basically, looking at the medications, how long you've been taking it, what is the dosage, basic things like that. From there, again, using our own two eyes to look for damage. And if you don't see anything, again, that doesn't mean they don't have anything, the next step would be to, again, use that multimodal imaging. So again, we would use OCT at the macula and or the optic nerve, depending on what the drug is and what we think might be going on, fundus autofluorescence, just because it does a great job of looking at the RPE and any type of potential damage or accumulation of a toxic medication right there. And once the damage is detected, there's 2 things we're going to do. One is communicate with that referring doctor or that doctor would prescribe those medications and then the second step would be, again, how are you going to tailor that type of exam to a follow up exam? If it's a minor change, does that necessitate the patient coming off the drug? Again that goes in hand and hand with communicating with the doctor, or is it so minor that you can just keep watching them, that yeah, you tell the doctor what's up but it's not that big of a deal. It's not affecting their vision, it probably won't. Let's just keep following up. It's that follow-up period as well. So that continued care.

Joy:

Absolutely. Was there anything else that we haven't touched on yet that you wanted to touch on?

Bhakhri:

No, I think the questions you asked were fantastic. Again, the big takeaways: review the medications, don't rely on your own 2 eyes. So even fundus photos which basically is are own two eyes, very superficial. Look, you got to go deeper. That's where the multimodal imaging comes in.

Joy:

Absolutely. Well thank you very much for taking the time, Dr. Bhakhri, we definitely appreciate it.

Bhakhri:

Thanks so much. Have a great day.

Joy:

You too.