What Is Co-Management?
Co-management is a care model in which a specialist and a primary care provider — your family physician, nurse practitioner, or optometrist — share responsibility for monitoring and managing a patient's eye condition over time. Rather than patients bouncing between isolated specialists without a coordinating framework, co-management creates a structured team approach where each provider's role is clearly defined and communication is systematic.
In ophthalmology, co-management is particularly well-suited to chronic conditions that require regular monitoring but where stable patients do not need a full specialist visit at every interval. For example, a patient with early dry macular degeneration may be monitored by their optometrist between annual specialist reviews. A post-cataract-surgery patient may be followed up with their optometrist for glasses and routine care, with the surgeon available for surgical concerns.
Dr. Sundaram is committed to accessible, efficient specialist care. Clear consultation letters after every visit, defined shared-care protocols, and an open line of communication with referring providers are central to how this practice operates. The goal is always the best outcome for the patient — and that means their entire care team working from the same information and plan.
Conditions We Co-Manage
Age-Related Macular Degeneration (AMD)
AMD is the leading cause of vision loss in Canadians over age 65, affecting the macula — the central area of the retina responsible for sharp, detailed vision. It presents in two forms:
Dry (non-exudative) AMD is the most common form, characterized by deposits called drusen under the retinal pigment epithelium and gradual thinning of the macular tissue. Early and intermediate dry AMD are monitored with regular OCT imaging and Amsler grid testing. Patients with intermediate AMD are advised to use AREDS2-formula nutritional supplements, which reduce progression to advanced AMD by approximately 25%.
Wet (neovascular) AMD occurs when abnormal blood vessels grow beneath the retina, leaking fluid and blood that rapidly damages central vision. This is treated with intravitreal anti-VEGF injections (ranibizumab, aflibercept, brolucizumab) and requires regular monitoring visits. Early detection of conversion from dry to wet AMD is critical — patients are taught to monitor their Amsler grid at home and report any new distortion promptly. Dr. Sundaram provides ongoing monitoring and co-ordinates anti-VEGF therapy, while referring providers manage systemic health and support medication adherence.
Uveitis
Uveitis is inflammation of the uveal tract of the eye — comprising the iris, ciliary body, and choroid. It can be isolated to the eye or may be a manifestation of systemic inflammatory or autoimmune disease, including ankylosing spondylitis, HLA-B27-associated conditions, sarcoidosis, rheumatoid arthritis, inflammatory bowel disease, and infections such as tuberculosis or toxoplasmosis.
Management of uveitis requires close collaboration between the ophthalmologist and the patient's rheumatologist or internist when a systemic cause is identified. Dr. Sundaram manages the ocular component — topical and systemic anti-inflammatory therapy, monitoring for complications such as cataracts, elevated IOP, and macular edema — while staying in close communication with the treating systemic specialists. Recurrent uveitis patients benefit from a coordinated long-term management plan.
Ocular Hypertension
Ocular hypertension (OHT) is the presence of elevated intraocular pressure above the statistical norm (typically >21 mmHg) without detectable glaucomatous optic nerve damage or visual field loss. Patients with OHT have an increased risk of developing glaucoma over time, with the risk modified by factors such as corneal thickness, disc appearance, age, and family history.
Many patients with OHT are appropriately managed with an observation protocol — regular IOP checks, OCT of the optic nerve and RNFL, and visual field testing at defined intervals — rather than immediate treatment. This monitoring can be shared between Dr. Sundaram and the optometrist, with clearly agreed parameters for when IOP elevation, structural change, or functional loss would prompt escalation to treatment or more frequent specialist review.
Post-Surgical Monitoring
After cataract surgery or blepharoplasty, most long-term follow-up can be comfortably managed by the patient's optometrist. Dr. Sundaram provides early post-operative visits (day 1, week 1, month 1) and communicates the specific findings and any ongoing concerns to the optometrist who will update the patient's glasses prescription and monitor for late complications. Clear post-operative instructions and a shared care plan are provided at discharge.
Hydroxychloroquine (Plaquenil) Monitoring
Hydroxychloroquine is widely prescribed by rheumatologists for lupus, rheumatoid arthritis, and other autoimmune conditions. Long-term use can rarely cause a toxic maculopathy — a pattern of retinal damage that can progress even after the medication is stopped. Current guidelines recommend baseline retinal imaging before or soon after starting hydroxychloroquine, and annual monitoring after 5 years of use (or earlier in high-risk patients). Dr. Sundaram provides these surveillance examinations and reports results directly to the prescribing rheumatologist.
Complex Systemic Conditions with Eye Manifestations
Many systemic diseases affect the eye. Thyroid eye disease (Graves' ophthalmopathy), sarcoidosis with ocular involvement, vasculitis causing retinal complications, and neuro-ophthalmic manifestations of neurological conditions all require close collaboration between the ophthalmologist and the systemic disease team. Dr. Sundaram is experienced in coordinating care across specialties and communicating clearly with referring physicians to ensure integrated, patient-centred management.
How We Work With Your Care Team
Effective co-management depends on clear, reliable communication. Dr. Sundaram's practice is committed to the following standards for every co-managed patient:
- Detailed consultation letters sent to referring providers after every visit, including findings, diagnosis, treatment plan, and follow-up instructions
- Defined shared-care parameters — the letter specifies what monitoring the GP or optometrist can provide between specialist visits and what findings should trigger a re-referral
- Timely communication — urgent findings are communicated by phone or same-day fax, not left for the next scheduled letter
- Accessible point-of-contact — referring providers can reach the office directly for provider-to-provider questions on specific patients
- Patient-centred education — patients are given clear written instructions about their condition, their monitoring schedule, and warning symptoms that require prompt attention
What to Expect at Your Appointment
Patients referred for co-managed conditions can expect a thorough and unhurried specialist assessment. Your first consultation with Dr. Sundaram typically includes:
Full Clinical History
Review of your visual symptoms, eye history, systemic medical history, current medications, and family history of eye disease.
Comprehensive Eye Examination
Including visual acuity, slit-lamp assessment, intraocular pressure, and a dilated fundus examination to assess the retina and optic nerve.
Advanced Imaging
OCT, visual fields, fundus photography, and other imaging as indicated — providing baseline documentation and objective monitoring data over time.
Discussion & Plan
Dr. Sundaram explains findings in plain language, outlines a management plan, and discusses what you and your primary care team need to watch for between appointments.
Frequently Asked Questions — Eye Disease Co-Management
Co-management means Dr. Sundaram and your family physician or optometrist work as a coordinated team to manage a chronic eye condition. Dr. Sundaram provides specialist assessment, diagnosis, and treatment planning; your GP or optometrist provides ongoing primary care and monitoring between specialist visits. Clear communication — with shared reports and a defined follow-up structure — is central to effective co-management.
Common co-managed conditions include age-related macular degeneration (monitoring for conversion from dry to wet AMD), ocular hypertension (elevated IOP without glaucoma), uveitis (recurrent inflammation requiring both specialist and GP involvement), post-surgical care after cataract surgery, hydroxychloroquine (Plaquenil) toxicity surveillance, and complex systemic conditions with eye involvement such as thyroid eye disease, sarcoidosis, or vasculitis.
After every consultation and follow-up, Dr. Sundaram's office sends a detailed letter to the referring physician or optometrist summarizing findings, diagnosis, treatment plan, and recommended follow-up. For co-managed conditions, the letter specifies what monitoring the GP or optometrist can provide and what findings should prompt re-referral. Dr. Sundaram is reachable by phone or email for provider-to-provider discussions on complex cases.
Dry (non-exudative) AMD involves deposits called drusen under the retina and gradual macular thinning. There is no direct treatment to reverse dry AMD, but patients with intermediate AMD benefit from AREDS2 nutritional supplements, which reduce risk of progression to advanced AMD by approximately 25%. Regular OCT monitoring and Amsler grid home testing detect conversion to wet AMD — which requires prompt treatment — at the earliest possible stage.
Family physicians and optometrists can refer directly to Dr. Sundaram's office by fax or email. Please include a brief clinical summary, the specific concern or diagnosis, and any available investigation results (OCT, visual fields, fundus photos). Indicate whether you are seeking a one-time consultation or an ongoing co-management arrangement. Dr. Sundaram will clarify the follow-up structure in the consultation letter.