treatment

Last edited 03/2021 and last reviewed 06/2022

The aim of treatment is to minimise visual loss and associated physical and emotional disability and to optimize vision-related quality of life (1).

The Royal College of Ophthalmologists' guidelines have stated that all self referrals should be considered as exudative wet AMD and therefore as urgent (2).

Patients with distorted or reduced vision of recent onset should be referred urgently to an ophthalmologist - early treatment may delay or prevent deterioration (1), and so that arrangements may be made for visual support (e.g. magnifiers, brighter reading lights) and rehabilitation

Non-exudative - treatment usually consists of counselling and rehabilitation (2) but no treatment is of proven benefit, but progress may be slow and may stabilise. However, it may enter the exudative stage at any time. Patients should be advised on:

  • cessation of smoking
  • eating healthy diet rich in anti oxidants such as carotenoids, vitamine C & E, zinc (2)

NICE state that (3):

  • Pharmacological management of AMD

    Antiangiogenic therapies

    • intravitreal anti-vascular endothelial growth factor (VEGF) treatment should be offered for late AMD (wet active) for eyes with visual acuity within the range specified stated below

    • 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)

    • note 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

    • 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
      • and the manufacturer provides ranibizumab with the discount agreed in the patient access scheme (as revised in 2012)

    • Brolucizumab is recommended as an option for treating wet age-related macular degeneration in adults, only if, in the eye to be treated (5):
      • 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 and
      • there is recent presumed disease progression (for example, blood vessel growth, as shown by fluorescein angiography, or recent visual acuity changes)

    • aflibercept solution for injection is recommended as an option for treating wet age-related macular degeneration only in specified circumstances (1)

    • photodynamic therapy alone for late AMD (wet active) should not be offered

    Adjunctive therapies

    • do not offer photodynamic therapy as an adjunct to anti-VEGF as first-line treatment for late AMD (wet active).
    • 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.
    • do not offer intravitreal corticosteroids as an adjunct to anti-VEGF for late AMD (wet active)

    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 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.
  • nutritional supplementation in age-related macular degeneration (4):
    • study evidence from the Age-Related Eye Disease Study (ADREDS) suggests that in patients with advanced age-related macular degeneration in one eye only, a specific combination of high doses of zinc and antioxidant vitamins (AREDS formula) helps prevent advanced disease and deterioration of visual acuity in the other eye
      • the AREDS formula is unsuitable for current and former smokers
      • seems reasonable to advise patients with macular degeneration to stop smoking and to eat a healthy diet rich in green vegetables (4)

Note:

The Royal College of Ophthalmologists' guideline recommends that treatment should be initiated by an ophthalmologist with experience in the management of patients with age related macular degeneration (2).

Reference:

Related pages:

NICE guidance - photodynamic therapy for age-related macular degeneration

brolucizumab - risk of intraocular inflammation and retinal vascular occlusion increased with short dosing intervals

faricimab for treating wet age-related macular degeneration