Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Classifying age-related macular degeneration

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

Table 1 Age-related macular degeneration classification

AMD classification

Definition

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 fibrosis secondary to an RPE tear

  • Atrophy (absence or thinning of RPE and/or retina)

  • Cystic degeneration (persistent intraretinal fluid or tubulations unresponsive to treatment)

Note that eyes may still develop or have a recurrence of late AMD (wet active)

1.1.2 Do not refer to late AMD (wet inactive) as 'dry AMD'.

1.2 Information and support

1.2.1 Provide people with AMD, and their family members or carers (as appropriate), with information that is:

1.2.2 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 the section on monitoring AMD)

  • signposting to other sources of information and support.

1.2.3 Provide information in accessible formats for people with AMD to take away at their first appointment, and then whenever they ask for it (see recommendation 1.2.1). 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.

1.2.4 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.

1.2.5 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.

1.3 Risk factors

1.3.1 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.

1.4 Diagnosis and referral

1.4.1 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

1.4.2 Confirm a diagnosis of early AMD using slit-lamp biomicroscopic fundus examination alone.

1.4.3 Do not refer people with asymptomatic early AMD to hospital eye services for further diagnostic tests.

Late AMD (dry)

1.4.4 Confirm a diagnosis of late AMD (dry) using slit-lamp biomicroscopic fundus examination.

1.4.5 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 recommendation 1.6.5) 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)

1.4.6 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.

1.4.7 Offer optical coherence tomography (OCT) to people with suspected late AMD (wet active).

1.4.8 Do not offer fundus fluorescein angiography (FFA) to people with suspected late AMD (wet active) if clinical examination and OCT exclude neovascularisation.

1.4.9 Offer FFA to people with suspected late AMD (wet active) to confirm the diagnosis if OCT does not exclude neovascular disease.

1.4.10 For eyes with confirmed late AMD (wet active) for which antiangiogenic treatment is recommended (see the section on pharmacological management of AMD), offer treatment as soon as possible (within 14 days of referral to the macular service).

Referral pathway

1.4.11 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.

1.5 Pharmacological management of AMD

Antiangiogenic therapies

1.5.1 Offer intravitreal anti-vascular endothelial growth factor (VEGF) treatment for late AMD (wet active) for eyes with visual acuity within the range specified in recommendation 1.5.6. 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.

1.5.2 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. 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.

1.5.3 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).

1.5.4 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. 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.

1.5.5 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.

1.5.6 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 fluorescein angiography, or recent visual acuity changes)

      and

  • the manufacturer provides ranibizumab with the discount agreed in the patient access scheme (as revised in 2012). [This recommendation is from NICE's technology appraisal guidance on ranibizumab and pegaptanib for the treatment of age-related macular degeneration.]

1.5.7 Pegaptanib is not recommended for the treatment of wet age-related macular degeneration. [This recommendation is from NICE's technology appraisal guidance on ranibizumab and pegaptanib for the treatment of age-related macular degeneration.]

1.5.8 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. [This recommendation is from NICE's technology appraisal guidance on ranibizumab and pegaptanib for the treatment of age-related macular degeneration.]

1.5.9 Aflibercept solution for injection is recommended as an option for treating wet age-related macular degeneration only if:

1.5.10 People currently receiving aflibercept solution for injection whose disease does not meet the criteria in recommendation 1.5.9 should be able to continue treatment until they and their clinician consider it appropriate to stop. [This recommendation is from NICE's technology appraisal guidance on aflibercept solution for injection for treating wet age-related macular degeneration.]

1.5.11 Do not offer photodynamic therapy alone for late AMD (wet active).

Adjunctive therapies

1.5.12 Do not offer photodynamic therapy as an adjunct to anti-VEGF as first-line treatment for late AMD (wet active).

1.5.13 Only offer photodynamic therapy as an adjunct to anti-VEGF as second-line treatment for late AMD (wet active) in the context of a randomised controlled trial.

1.5.14 Do not offer intravitreal corticosteroids as an adjunct to anti-VEGF for late AMD (wet active).

Switching and stopping antiangiogenic treatment for late AMD (wet)

1.5.15 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.

1.5.16 Consider observation without giving anti-VEGF treatment if the disease appears stable (in this event, see the sections on monitoring and self-monitoring).

1.5.17 Consider stopping anti-VEGF treatment if the eye develops severe, progressive loss of visual acuity despite treatment as recommended in the section on antiangiogenic therapies.

1.5.18 Stop anti-VEGF treatment if the eye develops late AMD (wet inactive) with no prospect of functional improvement.

1.5.19 Ensure that patients are actively involved in all decisions about the stopping or switching of treatment (see the section on information and support).

1.6 Non-pharmacological management of AMD

Strategies to slow the progression of AMD

1.6.1 Do not offer thermal laser therapy (for example, argon, diode) for treating drusen in people with early AMD.

Supporting people with AMD and visual impairment

1.6.2 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.

1.6.3 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.

1.6.4 Offer certification of visual impairment to all people with AMD as soon as they become eligible, even if they are still receiving active treatment.

1.6.5 Consider referring people with AMD causing visual impairment to low-vision services.

1.6.6 Consider a group-based rehabilitation programme in addition to a low-vision service to promote independent living for people with AMD.

1.6.7 Consider eccentric viewing training for people with central vision loss in both eyes.

1.7 Monitoring AMD

1.7.1 Do not routinely monitor people with early AMD or late AMD (dry) through hospital eye services.

1.7.2 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 recommendation 1.7.5)

  • continue to attend routine sight-tests with their community optometrist.

1.7.3 For people being monitored for late AMD (wet inactive), review both eyes at their monitoring appointments.

Self-monitoring

1.7.4 Discuss self-monitoring with people with AMD, and explain the strategies available.

1.7.5 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.

1.7.6 Encourage and support people with AMD who may lack confidence to self-monitor their symptoms.

1.7.7 If people are not able to self-manage their AMD, discuss AMD monitoring techniques with their family members or carers (as appropriate).

Monitoring for late AMD (wet active)

1.7.8 Offer people with late AMD (wet active) ongoing monitoring with OCT for both eyes.

1.7.9 Offer fundus examination or colour photography if OCT appearances are stable, but:

  • there is a decline in visual acuity or

  • the person reports a decline in visual function.

1.7.10 Consider FFA to identify unrecognised neovascularisation if OCT appearances are stable, but:

  • there is a decline in visual acuity or

  • the person reports a decline in visual function.

1.7.11 If OCT results suggest macular abnormalities but the abnormalities are not responding to treatment, think about:

  • using alternative imaging

  • alternative diagnoses.

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.

  • National Institute for Health and Care Excellence (NICE)