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Age-related macular degeneration

Classifying age-related macular degeneration

  • Classify age-related macular degeneration (AMD) using table 1

Table 1 Age-related macular degeneration classification 

AMD classificationDefinition

Normal eyes

  • No signs of age-related macular degeneration (AMD)
  • Small (‘hard’) drusen (less than 63 micrometres) only 

Early AMD

  • Low risk of progression:
    • medium drusen (63 micrometres or more and less than 125 micrometres) or
    • pigmentary abnormalities
  • Medium risk of progression:
    • large drusen (125 micrometres or more) or
    • reticular drusen or
    • medium drusen with pigmentary abnormalities
  • High risk of progression:
    • large drusen (125 micrometres or more) with pigmentary abnormalities or
    • reticular drusen with pigmentary abnormalities or
    • vitelliform lesion without significant visual loss (best-corrected acuity better than 6/18) or
    • atrophy smaller than 175 micrometres and not involving the fovea 

Late AMD (indeterminate)

  • Retinal pigment epithelial (RPE) degeneration and dysfunction (presence of degenerative AMD changes with subretinal or intraretinal fluid in the absence of neovascularisation)
  • Serous pigment epithelial detachment (PED) without neovascularisation

Late AMD (wet active)

  • Classic choroidal neovascularisation (CNV)
  • Occult (fibrovascular PED and serous PED with neovascularisation)
  • Mixed (predominantly or minimally classic CNV with occult CNV)
  • Retinal angiomatous proliferation (RAP)
  • Polypoidal choroidal vasculopathy (PCV) 

Late AMD (dry)

  • Geographic atrophy (in the absence of neovascular AMD)
  • Significant visual loss (6/18 or worse) associated with:
    • dense or confluent drusen or
    • advanced pigmentary changes and/or atrophy or
    • vitelliform lesion 

Late AMD (wet inactive)

  • Fibrous scar
  • Sub-foveal atrophy or brosis secondary to an RPE tear
  • Atrophy (absence or thinning of RPE and/or retina)
  • Cystic degeneration (persistent intraretinal fluid or tubulations unresponsive to treatment)

NB Eyes may still develop or have a recurrence of late AMD (wet active) 

  • Do not refer to late AMD (wet inactive) as ‘dry AMD’

Information and support

  • Provide people with AMD, and their family members or carers (as appropriate), with information that is:
    • available on an ongoing basis
    • relevant to the stage of the person’s condition
    • tailored to the person’s needs
    • delivered in a caring and sensitive fashion
  • Be aware of the obligation to provide accessible information as detailed in the NHS Accessible Information Standard. For more guidance on providing information to people and discussing their preferences with them, see the NICE guideline on patient experience in adult NHS services
  • Provide opportunities to discuss AMD with the person. Topics to cover should include:
    • what AMD is and how common it is
    • types of AMD
    • causes of AMD
    • stopping smoking and other lifestyle advice
    • how AMD may progress and possible complications
    • the possibility of developing visual hallucinations associated with retinal dysfunction (Charles Bonnet syndrome)
    • vision standards for driving
    • tests and investigations
    • treatment options, including possible benefits and risks
    • who to contact for practical and emotional support
    • where the person’s appointments will take place
    • which healthcare professionals will be responsible for the person’s care
    • expected wait times for consultations, investigations, and treatments
    • the benefits and entitlements available through certification and registration when sight impaired or severely sight impaired
    • when, where, and how to seek help with vision changes (see Monitoring AMD)
    • signposting to other sources of information and support
  • Provide information in accessible formats for people with AMD to take away at their first appointment, and then whenever they ask for it (see above). The information should cover the following:
    • information about AMD and treatment pathways, including likely timescales
    • key contact details—for example, who to contact if appointments need to be altered
    • advice about what to do and where to go if vision deteriorates
    • available support (including transport and parking permits)
    • links to local and national support groups
  • Allow enough time to discuss the person’s concerns and questions about their diagnosis, treatment, and prospects for their vision. Assess the person’s priorities when making management decisions
  • Promote peer support for people with AMD, particularly for people who are beginning intravitreal injections, who may be reassured by discussion with someone who has previously had the same treatment

Risk factors

  • If you suspect AMD, recognise that the following risk factors make it more likely that the person has AMD:
    • older age
    • presence of AMD in the other eye
    • family history of AMD
    • smoking
    • hypertension
    • BMI of 30 kg/m2 or higher
    • diet low in omega 3 and 6, vitamins, carotenoid, and minerals
    • diet high in fat
    • lack of exercise

Diagnosis and referral

  • Offer fundus examination as part of the ocular examination to people presenting with changes in vision (including micropsia and metamorphopsia) or visual disturbances

Early AMD

  • Confirm a diagnosis of early AMD using slit-lamp biomicroscopic fundus examination alone
  • Do not refer people with asymptomatic early AMD to hospital eye services for further diagnostic tests

Late AMD (dry)

  • Confirm a diagnosis of late AMD (dry) using slit-lamp biomicroscopic fundus examination
  • Refer people with late AMD (dry) to hospital eye services only:
    • for certification of sight impairment or
    • if this is how people access low-vision services in the local pathway (see Supporting people with AMD and visual impairment) or
    • if they develop new visual symptoms that may suggest late AMD (wet active) or
    • if it would help them to participate in research into new treatments for late AMD (dry)

Late AMD (wet active)

  • Make an urgent referral for people with suspected late AMD (wet active) to a macula service, whether or not they report any visual impairment. The referral should normally be made within 1 working day but does not need emergency referral

Referral pathway

  • Commissioners and providers should agree a clear local pathway for people with AMD, which should cover:
    • referral from primary to secondary care, with direct referral preferred
    • discharge from secondary to primary care, covering ongoing management and re-referral when necessary

Pharmacological management of AMD

Antiangiogenic therapies

  • Offer intravitreal anti-vascular endothelial growth factor (VEGF) treatment* for late AMD (wet active) for eyes with visual acuity within the range specified below
  • Be aware that no clinically significant differences in effectiveness and safety between the different anti-VEGF treatments have been seen in the trials considered by the guideline committee.
  • In eyes with visual acuity of 6/96 or worse, consider anti-VEGF treatment for late AMD (wet active) only if a benefit in the person’s overall visual function is expected (for example, if the affected eye is the person’s better-seeing eye).
  • Be aware that anti-VEGF treatment for eyes with late AMD (wet active) and visual acuity better than 6/12 is clinically effective and may be cost effective depending on the regimen used*,†
  • Ensure intraocular injections are given by suitably trained healthcare professionals, for example: medical specialists, such as ophthalmologists nurse practitioners, optometrists and technicians with experience in giving intraocular injections
  • If the injection is delivered by someone who is not medically qualified, ensure that cover is in place to manage any ophthalmological or medical complications
  • Ranibizumab, within its marketing authorisation, is recommended as an option for the treatment of wet age-related macular degeneration if: 
    • all of the following circumstances apply in the eye to be treated:
      • the best-corrected visual acuity is between 6/12 and 6/96
      • there is no permanent structural damage to the central fovea
      • the lesion size is less than or equal to 12 disc areas in greatest linear dimension
      • there is evidence of recent presumed disease progression (blood vessel growth, as indicated by Muorescein angiography, or recent visual acuity changes) and
      • the manufacturer provides ranibizumab with the discount agreed in the patient access scheme (as revised in 2012)
  • Pegaptanib is not recommended for the treatment of wet age-related macular degeneration
  • People who are currently receiving pegaptanib for any lesion type should have the option to continue therapy until they and their clinicians consider it appropriate to stop
  • Aflibercept solution for injection is recommended as an option for treating wet age-related macular degeneration only if: 
    • it is used in accordance with the recommendations for ranibizumab in NICE technology appraisal guidance 155 [re-issued in May 2012 (see above)] and the manufacturer provides aflibercept solution for injection with the discount agreed in the patient access scheme
  • People currently receiving aflibercept solution for injection whose disease does not meet the criteria above should be able to continue treatment until they and their clinician consider it appropriate to stop
  • Do not offer photodynamic therapy alone for late AMD (wet active)

Switching and stopping antiangiogenic treatment for late AMD (wet)

  • Consider switching anti-VEGF treatment for people with late AMD (wet active) if there are practical reasons for doing so (for example, if a different medicine can be given in a regimen the person prefers), but be aware that clinical benefits are likely to be limited
  • Consider observation without giving anti-VEGF treatment if the disease appears stable (in this event, see Monitoring AMD)
  • Consider stopping anti-VEGF treatment if the eye develops severe, progressive loss of visual acuity despite treatment as recommended in Pharmacological management of AMD
  • Ensure that patients are actively involved in all decisions about the stopping or switching of treatment (see Information and support)

Non-pharmacological management of AMD

Supporting people with AMD and visual impairment

  • Be aware that people with AMD are at an increased risk of depression. Identify and manage the depression according to the NICE guideline on depression in adults with a chronic physical health problem
  • Be aware that many people with AMD have other significant comorbidities. For guidance on optimising care for adults with multiple long-term conditions, see the NICE guideline on multimorbidity
  • Offer certification of visual impairment to all people with AMD as soon as they become eligible, even if they are still receiving active treatment
  • Consider referring people with AMD causing visual impairment to low-vision services
  • Consider a group-based rehabilitation programme in addition to a low-vision service to promote independent living for people with AMD
  • Consider eccentric viewing training for people with central vision loss in both eyes

Monitoring AMD

  • Do not routinely monitor people with early AMD or late AMD (dry) through hospital eye services
  • Advise people with late AMD (dry), or people with AMD who have been discharged from hospital eye services to:
    • self-monitor their AMD
    • consult their eye-care professional as soon as possible if their vision changes (see Self-monitoring)
    • continue to attend routine sight-tests with their community optometrist
  • For people being monitored for late AMD (wet inactive), review both eyes at their monitoring appointments

Self-monitoring

  • Discuss self-monitoring with people with AMD, and explain the strategies available
  • Advise people with AMD to report any new symptoms or changes in the following to their eye-care professional as soon as possible:
    • blurred or grey patch in their vision
    • straight lines appearing distorted
    • objects appearing smaller than normal
  • Encourage and support people with AMD who may lack confidence to self-monitor their symptoms
  • If people are not able to self-manage their AMD, discuss AMD monitoring techniques with their family members or carers (as appropriate)

Terms used in this guideline

Low vision

People with low vision have visual impairments that cause restriction in their everyday lives and that cannot be corrected by surgery, medicine, or glasses or contact lenses. This definition includes, but is not limited to, those who are registered as sight impaired or severely sight impaired. It can include blurred vision, blind spots, or tunnel vision. A low-vision service provides a range of services for people with low vision to enable them to make use of their eyesight to achieve maximum potential

Hospital eye services

Services set in secondary care providing diagnosis or treatment of the eye or vision-related conditions

* At the time of publication (January 2018), bevacizumab did not have a UK marketing authorisation for, and is considered by the Medicines and Healthcare products Regulatory Agency (MHRA) to be an unlicensed medication in, this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the prescribing decision. Informed consent would need to be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines, and the MHRA’s guidance on the Supply of unlicensed medicinal products (specials), for further information. The guideline may inform any decision on the use of bevacizumab outside its UK marketing authorisation but does not amount to an approval of or a recommendation for such use

† Given the guideline committee’s view that there is equivalent clinical effectiveness and safety of different anti-VEGF agents (aflibercept, bevacizumab and ranibizumab), comparable regimens will be more cost effective if the agent has lower net acquisition, administration and monitoring costs

© NICE 2018. Age-related macular degeneration.  Available from: www.nice.org.uk/guidance/NG82. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

First included: February 2018.