{"text_format":"1","workbook":"xlsx","n_sheets":4,"sheets":["Cover sheet","Introduction","Data sheet","Table 1"],"not_rendered":{"charts":0,"images":1,"macros":1,"external_links":0,"defined_names":198,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Cover sheet","index":0,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":false,"merged":[]}

{"sheet":"Introduction","index":1,"n_rows":23,"n_cols":2,"rows_kept":23,"cut":false,"hidden":false,"merged":[]}
[null,"Baseline assessment tool for age-related macular degeneration (NICE clinical guideline NG82)"]
[]
[null,"This baseline assessment tool can be used to evaluate whether practice is in line with the recommendations in Age-related macular degeneration.  It can also help to plan activity to meet the recommendations."]
[]
[null,"The tool can be used by individual services or organisations. Alternatively, an assessment completed with the involvement of all relevant services or organisations would help to develop a picture of activity in the local area."]
[]
[null,"It should be used in conjunction with Age-related macular degeneration (NICE clinical guideline NG82)."]
[]
[null,"In the first instance, consider whether the guideline is relevant and record the conclusion in the box below."]
[]
[null,"Is the guideline relevant?"]
[]
[]
[null,"The data sheet contains the recommendations from the guideline. Information can be entered about current activity relevant to the recommendation, actions needed to meet the recommendation, deadlines and the names of the responsible leads.  Useful documents can be added as hyperlinks."]
[]
[null,"The table can be adapted to include any other local information that is thought to be useful."]
[]
[null,"If it would be helpful to group the recommendations, for example those that are key priorities for implementation or by deadline, use the filter function in the data menu. "]
[]
[null,"Tools and resources to help put the guidance into practice are available on the NICE website. "]
[]
[]
[null,"National Institute for Health and Care Excellence\nLevel 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT; www.nice.org.uk\n\nCopyright\n© NICE 2018. All rights reserved. Subject to Notice of rights.\n"]

{"sheet":"Data sheet","index":2,"n_rows":81,"n_cols":11,"rows_kept":81,"cut":false,"hidden":false,"merged":[[0,1,0,10]]}
[null,"Baseline assessment tool for age-related macular degeneration (NICE clinical guideline NG82)"]
[]
[null,null,null,null,"Number of relevant recommendations",{"$f":"COUNTIF(D8:D995,\"Yes\")","v":0}]
[null,null,null,null,"Number of recommendations met",{"$f":"COUNTIF(F8:F995,\"Yes\")","v":0}]
[null,null,null,null,"Percentage of recommendations met",{"$f":"IF(ISERROR(F4/F3),\"\",F4/F3)","v":""}]
[]
[null,"NICE recommendation","Guideline reference","Is the recommendation relevant?","Current activity/evidence","Recommendation met?","Actions needed to implement recommendation","Is there a risk associated with not implementing this recommendation?","Is there a cost or saving?","Deadline","Lead"]
[null,"1.1  Classifying age-related macular degeneration "]
[null,"Classify age-related macular degeneration (AMD) using table 1.","1.1.1"]
[null,"Do not refer to late AMD (wet inactive) as 'dry AMD'.","1.1.2"]
[null,"1.2 Information and support"]
[null,"Provide people with AMD, and their family members or carers (as appropriate), with information that is:\n• available on an ongoing basis \n• relevant to the stage of the person’s condition \n• tailored to the person’s needs \n• delivered in a caring and sensitive fashion.\n\nBe 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.","1.2.1"]
[null,"Provide opportunities to discuss AMD with the person. Topics to cover should include:\n• what AMD is and how common it is\n• types of AMD\n• causes of AMD \n• stopping smoking and other lifestyle advice\n• how AMD may progress and possible complications\n• the possibility of developing visual hallucinations associated with retinal dysfunction (Charles Bonnet syndrome)\n• vision standards for driving\n• tests and investigations\n• treatment options, including possible benefits and risks \n• who to contact for practical and emotional support\n• where the person’s appointments will take place\n• which healthcare professionals will be responsible for the person’s care\n• expected wait times for consultations, investigations and treatments\n• the benefits and entitlements available through certification and registration when sight impaired or severely sight impaired\n• when, where and how to seek help with vision changes (see section 1.7)\n• signposting to other sources of information and support.","1.2.2"]
[null,"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:\n• information about AMD and treatment pathways, including likely timescales \n• key contact details – for example, who to contact if appointments need to be altered\n• advice about what to do and where to go if vision deteriorates\n• available support (including transport and parking permits)\n• links to local and national support groups.\n","1.2.3"]
[null,"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.","1.2.4"]
[null,"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.","1.2.5"]
[null,"1.3 Risk factors"]
[null,"If you suspect AMD, recognise that the following risk factors make it more likely that the person has AMD:\n• older age \n• presence of AMD in the other eye\n• family history of AMD\n• smoking\n• hypertension\n• BMI of 30 kg/m2 or higher \n• diet low in omega 3 and 6, vitamins, carotenoid and minerals\n• diet high in fat\n• lack of exercise.","1.3.1"]
[null,"1.4 Diagnosis and referral"]
[null,"Offer fundus examination as part of the ocular examination to people presenting with changes in vision (including micropsia and metamorphopsia) or visual disturbances.","1.4.1"]
[null,"Early AMD"]
[null,"Confirm a diagnosis of early AMD using slit-lamp biomicroscopic fundus examination alone.","1.4.2"]
[null,"Do not refer people with asymptomatic early AMD to hospital eye services for further diagnostic tests.","1.4.3"]
[null,"Late AMD (dry)"]
[null,"Confirm a diagnosis of late AMD (dry) using slit-lamp biomicroscopic fundus examination.","1.4.4"]
[null,"Refer people with late AMD (dry) to hospital eye services only:\n• for certification of sight impairment or\n• if this is how people access low-vision services in the local pathway (see recommendation 1.6.5) or\n• if they develop new visual symptoms that may suggest late AMD (wet active) or\n• if it would help them to participate in research into new treatments for late AMD (dry).","1.4.5"]
[null,"Late AMD (wet active)"]
[null,"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.","1.4.6"]
[null,"Offer optical coherence tomography (OCT) to people with suspected late AMD (wet active).","1.4.7"]
[null,"Do not offer fundus fluorescein angiography (FFA) to people with suspected late AMD (wet active) if clinical examination and OCT exclude neovascularisation.","1.4.8"]
[null,"Offer FFA to people with suspected late AMD (wet active) to confirm the diagnosis if OCT does not exclude neovascular disease.","1.4.9"]
[null,"For eyes with confirmed late AMD (wet active) for which antiangiogenic treatment is recommended (see section 1.5), offer treatment as soon as possible (within 14 days of referral to the macula service).","1.4.10"]
[null,"Referral pathway"]
[null,"Commissioners and providers should agree a clear local pathway for people with AMD, which should cover:\n• referral from primary to secondary care, with direct referral preferred\n• discharge from secondary to primary care, covering ongoing management and re-referral when necessary.","1.4.11"]
[null,"1.5 Pharmacological management of AMD"]
[null,"Antiangiogenic therapies"]
[null,"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.","1.5.1"]
[null,"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.","1.5.2"]
[null,"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). ","1.5.3"]
[null,"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.","1.5.4"]
[null,"Ensure intraocular injections are given by suitably trained healthcare professionals, for example:\n• medical specialists, such as ophthalmologists\n• nurse practitioners, optometrists and technicians with experience in giving intraocular injections.\n\nIf the injection is delivered by someone who is not medically qualified, ensure that cover is in place to manage any ophthalmological or medical complications.","1.5.5"]
[null,"Ranibizumab, within its marketing authorisation, is recommended as an option for the treatment of wet age-related macular degeneration if:\n• all of the following circumstances apply in the eye to be treated:\n- the best-corrected visual acuity is between 6/12 and 6/96\n- there is no permanent structural damage to the central fovea\n- the lesion size is less than or equal to 12 disc areas in greatest  linear dimension\n- there is evidence of recent presumed disease progression (blood vessel growth, as indicated by fluorescein angiography, or recent visual acuity changes)\nand\n• the manufacturer provides ranibizumab with the discount agreed in the patient access scheme (as revised in 2012). [This recommendation is from Ranibizumab and pegaptanib for the treatment of age-related macular degeneration (NICE technology appraisal guidance 155).]\n","1.5.6"]
[null,"Pegaptanib is not recommended for the treatment of wet age-related macular degeneration. [This recommendation is from Ranibizumab and pegaptanib for the treatment of age-related macular degeneration (NICE technology appraisal guidance 155).]","1.5.7"]
[null,"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 Ranibizumab and pegaptanib for the treatment of age-related macular degeneration (NICE technology appraisal guidance 155).]","1.5.8"]
[null,"Aflibercept solution for injection is recommended as an option for treating wet age-related macular degeneration only if:\n• it is used in accordance with the recommendations for ranibizumab in NICE technology appraisal guidance 155 (re-issued in May 2012 [see recommendation 1.5.6]) and \n• the manufacturer provides aflibercept solution for injection with the discount agreed in the patient access scheme. [This recommendation is adapted from Aflibercept solution for injection for treating wet age-related macular degeneration (NICE technology appraisal guidance 294).]","1.5.9"]
[null,"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 Aflibercept solution for injection for treating wet age-related macular degeneration (NICE technology appraisal guidance 294).]","1.5.10"]
[null,"Do not offer photodynamic therapy alone for late AMD (wet active).","1.5.11"]
[null,"Adjunctive therapies"]
[null,"Do not offer photodynamic therapy as an adjunct to anti-VEGF as first-line treatment for late AMD (wet active).","1.5.12"]
[null,"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.","1.5.13"]
[null,"Do not offer intravitreal corticosteroids as an adjunct to anti-VEGF for late AMD (wet active).","1.5.14"]
[null,"Switching and stopping antiangiogenic treatment for late AMD (wet)"]
[null,"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.","1.5.15"]
[null,"Consider observation without giving anti-VEGF treatment if the disease appears stable (in this event, see section 1.7 for recommendations on monitoring and self-monitoring).","1.5.16"]
[null,"Consider stopping anti-VEGF treatment if the eye develops severe, progressive loss of visual acuity despite treatment as recommended in 1.5.1–1.5.11.","1.5.17"]
[null,"Stop anti-VEGF treatment if the eye develops late AMD (wet inactive) with no prospect of functional improvement.","1.5.18"]
[null,"Ensure that patients are actively involved in all decisions about the stopping or switching of treatment (see section 1.2 on information and support).","1.5.19"]
[null,"1.6 Non-pharmacological management of AMD"]
[null,"Strategies to slow the progression of AMD"]
[null,"Do not offer thermal laser therapy (for example, argon, diode) for treating drusen in people with early AMD.","1.6.1"]
[null,"Supporting people with AMD and visual impairment"]
[null,"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.","1.6.2"]
[null,"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.","1.6.3"]
[null,"Offer certification of visual impairment to all people with AMD as soon as they become eligible, even if they are still receiving active treatment.","1.6.4"]
[null,"Consider referring people with AMD causing visual impairment to low-vision services.","1.6.5"]
[null,"Consider a group-based rehabilitation programme in addition to a low-vision service to promote independent living for people with AMD.","1.6.6"]
[null,"Consider eccentric viewing training for people with central vision loss in both eyes.","1.6.7"]
[null,"1.7 Monitoring AMD"]
[null," Do not routinely monitor people with early AMD or late AMD (dry) through hospital eye services.","1.7.1"]
[null,"Advise people with late AMD (dry), or people with AMD who have been discharged from hospital eye services to:\n• self-monitor their AMD\n• consult their eye-care professional as soon as possible if their vision changes (see recommendation 1.7.5)\n• continue to attend routine sight-tests with their community optometrist.","1.7.2"]
[null,"For people being monitored for late AMD (wet inactive), review both eyes at their monitoring appointments.","1.7.3"]
[null,"Self-monitoring"]
[null,"Discuss self-monitoring with people with AMD, and explain the strategies available.","1.7.4"]
[null,"Advise people with AMD to report any new symptoms or changes in the following to their eye-care professional as soon as possible:\n• blurred or grey patch in their vision\n• straight lines appearing distorted\n• objects appearing smaller than normal.","1.7.5"]
[null,"Encourage and support people with AMD who may lack confidence to self-monitor their symptoms.","1.7.6"]
[null,"If people are not able to self-manage their AMD, discuss AMD monitoring techniques with their family members or carers (as appropriate).","1.7.7"]
[null,"Monitoring for late AMD (wet active)"]
[null,"Offer people with late AMD (wet active) ongoing monitoring with OCT for both eyes.","1.7.8"]
[null,"Offer fundus examination or colour photography if OCT appearances are stable, but:\n• there is a decline in visual acuity or\n• the person reports a decline in visual function.","1.7.9"]
[null,"Consider FFA to identify unrecognised neovascularisation if OCT appearances are stable, but:\n• there is a decline in visual acuity or\n• the person reports a decline in visual function.","1.7.10"]
[null,"If OCT results suggest macular abnormalities but the abnormalities are not responding to treatment, think about:\n• using alternative imaging\n• alternative diagnoses.","1.7.11"]

{"sheet":"Table 1","index":3,"n_rows":35,"n_cols":3,"rows_kept":35,"cut":false,"hidden":false,"merged":[[30,2,30,9],[31,2,31,9],[32,2,32,9],[33,2,33,9],[34,2,34,9],[1,1,1,9],[24,2,24,9],[25,2,25,9],[26,2,26,9],[27,2,27,9],[28,2,28,9],[29,2,29,9],[18,2,18,9],[19,2,19,9],[20,2,20,9],[21,2,21,9],[22,2,22,9],[23,2,23,9],[12,2,12,9],[13,2,13,9],[14,2,14,9],[15,2,15,9],[16,2,16,9],[17,2,17,9],[6,2,6,9],[7,2,7,9],[8,2,8,9],[9,2,9,9],[10,2,10,9],[11,2,11,9],[0,2,0,9],[2,2,2,9],[3,2,3,9],[4,2,4,9],[5,2,5,9],[4,1,5,1],[6,1,17,1],[18,1,19,1],[20,1,24,1],[25,1,29,1],[30,1,34,1]]}
[]
[null,"Table 1 Age-related macular degeneration classification"]
[]
[null,"AMD classification","Definition"]
[null,"Normal eyes","·     No signs of age-related macular degeneration (AMD)"]
[null,null,"·     Small (‘hard’) drusen (less than 63 micrometres) only"]
[null,"Early AMD","·     Low risk of progression:"]
[null,null,"-     medium drusen (63 micrometres or more and less than 125 micrometres) or"]
[null,null,"-     pigmentary abnormalities"]
[null,null,"·     Medium risk of progression:"]
[null,null,"-     large drusen (125 micrometres or more) or"]
[null,null,"-     reticular drusen or"]
[null,null,"-     medium drusen with pigmentary abnormalities"]
[null,null,"·     High risk of progression:"]
[null,null,"-     large drusen (125 micrometres or more) with pigmentary abnormalities or"]
[null,null,"-     reticular drusen with pigmentary abnormalities or"]
[null,null,"-     vitelliform lesion without significant visual loss (best-corrected acuity better than 6/18) or"]
[null,null,"-     atrophy smaller than 175 micrometres and not involving the fovea"]
[null,"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)"]
[null,null,"·     Serous pigment epithelial detachment (PED) without neovascularisation"]
[null,"Late AMD (wet active)","·     Classic choroidal neovascularisation (CNV)"]
[null,null,"·     Occult (fibrovascular PED and serous PED with neovascularisation)"]
[null,null,"·     Mixed (predominantly or minimally classic CNV with occult CNV)"]
[null,null,"·     Retinal angiomatous proliferation (RAP)"]
[null,null,"·     Polypoidal choroidal vasculopathy (PCV)"]
[null,"Late AMD (dry)","·     Geographic atrophy (in the absence of neovascular AMD)"]
[null,null,"·     Significant visual loss (6/18 or worse) associated with:"]
[null,null,"-     dense or confluent drusen or"]
[null,null,"-     advanced pigmentary changes and/or atrophy or"]
[null,null,"-     vitelliform lesion"]
[null,"Late AMD (wet inactive)","·     Fibrous scar"]
[null,null,"·     Sub-foveal atrophy or fibrosis secondary to an RPE tear"]
[null,null,"·     Atrophy (absence or thinning of RPE and/or retina)"]
[null,null,"·     Cystic degeneration (persistent intraretinal fluid or tubulations unresponsive to treatment)"]
[null,null,"NB Eyes may still develop or have a recurrence of late AMD (wet active)"]