Dr. Freeman: Hello, and welcome to PracticeUpdate. I'm Paul Freeman, co-editor of the Eye Care site on the PracticeUpdate channel. It is my pleasure to interview a good friend and colleague, Dr. Michael Lewen.
Dr. Lewen specialized in the medical and surgical management of conditions affecting the retina and the vitreous, including macular degeneration, diabetic eye disease, retinal vascular disease, macular holes, epiretinal membranes, retinal detachment, and complex intraocular lens surgeries. Dr. Lewen earned his medical degree from Drexel University College of Medicine at Philadelphia, where he was inducted into the Alpha Omega Alpha Honor Society. Dr. Lewen completed his ophthalmology residency at the New England Eye Center at Tufts Medical Center in Boston, Massachusetts, and completed his fellowship training in vitreoretinal surgery at Lahey Medical Center and Beth Israel Deaconess Medical Center in Boston as well. Dr. Lewen is a board-certified ophthalmologist and a member of the American Academy of Ophthalmology and the American Society of Retinal Specialists. He's affiliated with the ophthalmology department at Allegheny General Hospital in Pittsburgh, where coincidentally, so am I.
Welcome, Dr. Lewen.
Dr. Lewen: Thank you very much for having me.
Dr. Freeman: Well, thanks for being here. Let's talk about one of the more common maladies in today's society, given that we have a growing senior population, and I want to look at this from two different perspectives. You're a recent graduate, recent into the field. I don't think that you expected to be dealing with patients that were COVID-19– positive. Let me know, as a person coming into the field, and we'll do this pre- and post-COVID, how you handle dry macular degeneration and wet macular degeneration.
Dr. Lewen: Sure. I'll start with the pre-coronavirus era, where for me, as you say, coming recently out of training and into practice, my approach has been one of erring on the side of closer follow-up with many of my patients. With the patients with dry macular degeneration, I like to initially have an in depth conversation with them about the status of their current disease, how extensive it is, what interventions we might be able to go ahead with, but also then what their expectations might be. For those patients also, I like to typically see them back in a few months to make sure that their condition is overall relatively stable, and if it remains such, then I'll confidently extend their visit intervals out.
I, of course, have a close conversation with them and their family members about any modifiable risk factors such as tobacco use. I want to make sure that anyone with intermediate dry disease or beyond, that they're using AREDS vitamins, and that they know how to monitor when they're at home. I also, for patients with geographic atrophy, like to make sure they have a good understanding of Charles Bonnet syndrome because, in an elderly population, this is something that can be quite startling for the patients themselves or their family members. I find that oftentimes patients know that they're seeing certain things that aren't actually there, but they're worried to talk about it because their family members might think that they have dementia. That's one thing, for me, that I really try to have an in depth conversation about with patients. With wet macular degeneration, we have, of course, made tremendous strides over the years that preceded my career. I'm fortunate enough to be coming into my practice well within the anti-VEGF era.
Dr. Freeman: Dr. Lewen, when patients don't do as well as you might expect, and their visual quality of life suffers, then what do you do with those patients?
Dr. Lewen: The thing that I do initially is I really try to make sure they have a good understanding of exactly what to expect with the progression of macular degeneration. One thing that I find when I explain this, there's a palpable sense of relief, both from the patient and family members, is that we talk about, what is blindness? Blindness can mean a lot of different things to different people. I stress that blindness, in the setting of macular degeneration, is not that everything goes completely dark. That while their central vision may very well be significantly impaired, that their peripheral vision should otherwise be intact, and that their capabilities can actually remain. They're still able to maintain some degree of independence, even with severely affected central visual acuity. Then, I work very closely with my optometry colleagues to make sure that we're providing everything we can to optimize the patient's quality of life, with optimizing their vision.
Dr. Freeman: We're going to start seeing more quality of life articles where patients don't do well, so the quality of life means they have to move on to the continuum of care, which is low-vision rehabilitation, psychological rehabilitation, and all sorts of things, but from my end of it, it's low-vision rehabilitation. I think that's an important consideration. It really is a continuum if you think about it. The difference between what I do and what anybody else does is I add that part that makes them see using devices that are not conventional. I'm really the backup player in this one because I don't assume the primary responsibility. Somebody like Dr. Lewen would assume the primary responsibility, and my job is to keep the patient seeing so that they can maintain independence, quality of life, and things of that nature. That's where that give and take comes in. I think that's the ticket.