macular degeneration (AMD) accounts for almost 50% of those registered
as blind or partially sighted. 1-4 The development of management
strategies is limited by the diverse nature of the age related changes
and a lack of a clear understanding of the process of visual loss in the
elderly. Effective treatment is limited to the management of sub-retinal
neovascularisation (SRNV) in selected cases). Despite early expectations
that laser treatment might provide significant benefit in preventing blindness
5-7 recurrent disease and progressive visual failure limit the final outcome.
8-9. Early recognition and prevention of potential disease is not as yet
applicable to disease other than that related to SRNV.
aim of management is to minimise visual loss and disability in order to
maintain independence. The provision of visual aids, advice about lighting
and support in the home and community, with registration as necessary,
remain the mainstay of management.
purpose of these guidelines is, therefore, to define our current understanding
of the condition and to outline a management strategy (Appendix 1) that
may be adopted or modified, depending on local needs and facilities, by
ophthalmic services in the UK.
attempts to derive a classification and grading system for the disease
there is no fully accepted definition of age related macular degeneration.
The International Epidemiological Study Group 10 defines Age
Related Maculopathy (ARM) as a disorder of the macular area, most often
clinically apparent after 50 years of age, characterised by:
age related changes with progressive accumulation of debris under the retina
predispose to late stage ARM identified as Age Related Macular Degeneration
(AMD) 11,12 which may be 'wet or dry' and feature:
whitish-yellow spots identified as drusen.
pigment or hyperpigmentation associated with drusen.
demarcated areas of depigmentation or hypopigmentation of the retinal pigment
epithelium and associated drusen.
changes lead to progressive visual loss and worsening function in the elderly.
atrophy of the retinal pigment epithelium with visible underlying choroidal
pigment epithelial detachment with or without neurosensory detachment.
or sub-pigment epithelial neovascularisation.
scar tissue, haemorrhages and exudates.
13,000 and 14,000 people are registered each year as blind or partially
sighted in England and Wales4 but it is difficult to determine
the total number of visually disabled people in the United Kingdom. There
are approximately 150,000 people aged 16 years and over living in private
households who are registered as visually disabled. This probably significantly
underestimates the true number that may be up to 1,000,00013
and closer to the 2.2% of the population over 65 years identified in the
Framingham Study3 as blind in one or both eyes from AMD.
incidence and prevalence of severe visual loss increases with age. 1,14
In 1997-8 3.7 million ophthalmic consultations were undertaken in England
15 60% of which will have involved people aged 60 or over. 16
In one study 14.1% of all visits to ophthalmologists by those over 65 were
for retinal problems. 17 Macular degeneration accounted for
the biggest single group. With the population over the age of 60 set to
increase by 45% in the next 20-25 years the increased load on both the
Health and Social Services and personal costs to the quality of life of
individuals affected by macular degeneration is daunting.
usually held that AMD is most prevalent in Indo-European societies, 18
but it may be increasing in other communities. 19-22 Genetic
and environmental factors appear to modify the risk of visual loss although
the relative importance of these remains unclear. 23-30. Cigarette
smoking has recently emerged as a reasonably consistent risk factor. 31,32
Vascular disease and hypertension are sometimes associated with macular
degeneration but other associations such as light exposure 33
are not established risk factors. Dietary carotinoids, vitamin levels and
antioxidant use has not to date been shown to modify risk.34, 37
and Natural History
relating to the natural history of any condition will be dependent on the
population studied. Hospital-based studies include a substantial proportion
of patients for whom symptoms have prompted presentation, and who consequently
may be at greater risk of visual loss. Community derived studies should
provide a better reflection of the true risk and prevalence involved.
with bilateral soft drusen (ARM) seen in hospital the risk of progressing
to AMD with loss of vision in one eye appears to be in the order of 8%
per year over a three year period. 38,39 This risk is highest
in those with confluent drusen, focal hyperpigmentation or slow choroidal
perfusion on angiography. 40
visual loss affecting one eye the risk of losing vision in the fellow eye
increases to between 7 and 10% annually. 41-43 The five year
risk is lowest in the absence of large drusen or pigment hyperplasia but
increases with one of these risk factors to 30% or with both to over 50%.
The highest risk is for those with a pigment epithelial tear in one eye
for whom the annual risk of second eye involvement is closer to 40%. 45
epithelial detachment in patients under the age of 55 years is not usually
associated with significant visual loss 46,47 but occurring
in those over 55 is likely to result in visual loss within 4 years in the
majority of patients. 48 Such loss may reflect the presence
of neovascularisation under the detachment.
neovascularisation can occur throughout the fundus but rarely gives rise
to complications save in the macular area where it is associated with visual
loss. Angiographically well defined neovascular systems lying away from
fixation may on occasions be modified by treatment. If untreated, visual
loss may be rapid with neovascular extension under fixation in 75% of cases
within a year 6,7 such that 60% develop severe visual loss within
3 years. 9 Less well defined neovascularisation is considered
untreatable and grows more slowly, but still 40% develop severe visual
loss within 2 years. 49, 50 Juxta papillary lesions tend to
extend towards the macula but do not invariably cause visual loss as they
grow more slowly and may involute spontaneously.
location and angiographic characteristics of neovascular systems are used
in determining the approach to management. Away from the macula they are
described as peripheral or juxtapapillary. In the macula,
but lying more than 200 microns from fixation, they are defined as extrafoveal.
They are juxtafoveal or subfoveal when immediately adjacent
to, or under, the foveola. Neovascular systems with well defined leakage
seen on fluorescein angiography are described as classical and those
with ill defined leakage are considered occult. Some complexes are
with both classical and occult components.
of vascular change that may be confused with AMD has recently been described
in which haemorrhagic pigment epithelial detachments are associated with
angiographic varicose complexes at a choroidal level. These are best seen
on indocyanine angiography. The lesions of polypoidal choroidopathy 51-54
were first described in black middle aged women but can occur in any racial
group. Lesions may subside spontaneously or be associated with recurrent
haemorrhages leading ultimately to severe visual loss.
a growing interest in AMD the options for treatment remain limited. Treatment
is mainly targeted at the neovascular form of the disease using laser photocoagulation.
As the course of AMD, as opposed to ARM, can be highly variable, and the
final outcome dependent on the treatment and support offered it is appropriate
for an ophthalmologist with a special interest and experience in the care
of AMD to be involved from an early stage.
the majority of patients the main management option remains the provision
of low vision aids by the hospital or optometric services and community
support with partial sighted or blind registration as appropriate. The
provision of low vision care has been addressed in a separate College report
published in 1998. 55
value of routine screening, given the lack of effective treatment, is unproven.
There may be a case for self assessment, using an Amsler Grid, in those
patients with high risk of neovascular disease which includes those with
large soft drusen and pigment hyperplasia and those with established exudative
AMD in one eye.
low risk disease (ARM) requires no special management and, coming on slowly,
can be managed in the community. Optometrists would seem to be well placed
to carry out routine examinations and offer advice about the value of magnification
and lighting. Optometrists can reassure patients with minimal symptoms
or signs of ARM and should not refer further. Referral from the primary
sector usually occurs when visual impairment begins to interfere with normal
lifestyle. Referral is indicated when:
practitioners and optometrists need to be aware of the urgent nature of
referrals for patients with recent onset of distortion and visual loss
(less than a month) and who still have reasonably good vision (6/12 or
better). 56 Such patients may still have treatable disease and
should be referred urgently to either the ophthalmic casualty department
or to the outpatient clinic following discussion with the local ophthalmologist.
This is particularly true for the second eye when the other eye is already
involved. In the elderly population with AMD concurrent ophthalmic disease,
such as cataract and glaucoma, may also frequently occur and needs to be
identified and treated appropriately.
is rapidly developing visual failure but still reasonable vision suggestive
of exudative disease that might benefit from urgent assessment and laser
is significant visual loss needing accurate diagnosis.
is significant visual loss needing partially sighted or blind registration.
management pathway will involve the following stages and it is important
that the resources and personnel to achieve these are properly funded:
of suitable optical aids in the primary or secondary sector and training
in their use.
and assessment of macular disease including angiography and exclusion of
other treatable causes of visual failure.
by laser photocoagulation or otherwise as appropriate.
Completion when appropriate of the form BD8 (BP1 in Scotland, A 655 in
Northern Ireland) and referral to Social Services (Appendix 2).
Counselling and rehabilitation within the hospital and statutory or voluntary
services in the community.
to macular degeneration include recent change in visual function particularly
affecting reading, face recognition and difficulties with change of lighting.
A dark patch that rapidly fades may also be recognised on waking. Distortion
is a feature of macular disease in contrast to the ghosting, doubling or
multiplication of images associated with cataract. If the change is recent
and rapid, sub retinal fluid associated with neovascularisation is often
the basis for the disturbance. This is in contrast to the gradual decline
that reflects developing atrophy.
distance acuity and near vision should be recorded. The corrected Snellen
acuity does not normally improve with the use of a pin hole in macular
disease. Amsler grid examination reflects change lying within the upper
and lower temporal arcade vessels, identifies the areas of involvement
and establishes a base line for future comparison. Slit lamp fundus examination
of both eyes, usually with an indirect or contact lens, confirms the diagnosis
and provides clues as to the location of any neovascularisation. Such clues
will include small areas of sub-retinal fluid, exudate, haemorrhage or
pigment epithelial elevation. The presence of co-existing conditions such
as cataract, glaucoma and corneal disease should be sought.
and colour photography.
angiography, which is available in 96.4% (189 out of 196) of UK eye departments
recently surveyed, 57 will confirm the findings and provide
the basis for subsequent management. it is usually performed by a trained
ophthalmic photographer. Whilst colour photography alone may suffice as
a clinical record intravenous fluorescein angiography is indicated when:
may also be justified to provide permanent records and for teaching or
research but should only be undertaken with fully informed consent and
due consideration of the risks.
is a need to confirm the diagnosis of exudative macular degeneration as
suggested by the symptoms and clinical findings.
is a need to define the exact location of any neovascular tissue and, if
well defined (classical), to determine the precise area to be treated by
is a need to detect persistent or recurrent neovascular tissue following
previous laser treatment. Sometimes this may be needed to reassure an anxious
patient fearing further neovascular growth.
is unexplained visual loss requiring further evaluation.
risks of fluorescein angiography 58 should be borne in mind,
particularly when assessing individuals with a history of atopy or a previous
reaction to the dye. Apart from the yellowing of the skin and urine, about
one in ten suffer some nausea and retching. The more serious complications
of anaphylaxis and collapse are much rarer occurring in less than 1 in
2,000. Death, whilst extremely rare, is reported in one in 1-200,000. Staff
should be trained in basic life support and emergency drugs should be readily
available in the photography department.
is appropriate that information is available to patients undergoing angiography
preferably in accessible leaflet form (currently available in 123 departments
or 68%). An example is seen in Appendix 3. Whilst the provision of information
is probably more important, the issue of signed consent (obtained in 1998
in 118 UK departments or 62.4%/)57 must be considered and agreed
with the Trust concerned.
fluorescein injection can be done by anyone designated to do so, subject
to certification of competence, provided the ophthalmologist is responsible
for ordering the test and for ensuring that all reasonable safety precautions
are observed. The use of nurses may provide opportunities to streamline
an angiographic service making it more accessible and effective. Nurse
led fluorescein administration was performed in 57 departments in 1998
should be available with a minimum of delay particularly given the rapid
growth potential of any neovascular lesion. As the angiographic features
may progress rapidly, laser treatment should be undertaken within 48 hours
of the latest angiogram if at all possible. Time savings in obtaining an
early angiogram for study will be achieved by the use of digital rather
than conventional angiography (available in 35 UK departments in 1998).
Whilst the capital outlay may be higher, the saving on photographic time
and consumables will be considerable and there is the added advantage that
angiograms are immediately available. Such a digital system will also attract
other uses for research and teaching, and may be adapted for indocyanine
angiography has a role in the assessment of vascular systems under the
pigment epithelium which may be ill defined on fluorescein angiograph,
and in the assessment of the particular condition of polypoidal choroidopathy.59
How far it results in benefit in terms of management remains controversial.60
If an iodine based dye is used allergy to iodine and shellfish should be
excluded before its use.
is normal to photograph the central 30 degrees centred on the macula, and
all angiography should include views of the second eye. This will allow
for comparison in respect of the disease involved and help to exclude other
unidentified problems. Stereo photography offers a definite advantage in
the clinical information gained and can be achieved by the use of a stereo
separator or by displacing the camera from side to side during the study.
photography is routinely undertaken with angiography. It helps to determine
the nature of changes seen of the angiogram particularly in defining exudative
change and the cause of blocked fluorescence due to haemorrhage, pigment
or other cause. Drusen are sometimes much more visible on angiography than
colour photography and vice versa.
neovascularisation is a major cause of visual loss in AMD and one that,
when well defined, may be amenable to treatment. Effective treatment protocols
for laser photocoagulation have been published 5-7 but treatment can be
difficult and better undertaken by an ophthalmologist who has a special
interest and experience in managing such lesions. Pending the confirmed
results of the current prospective treatment trials of radiation and photodynamic
therapy (PDT), and their approval for use if appropriate, the mainstay
of interventional treatment is that of laser photocoagulation. When first
seen, unfortunately, most eyes with choroidal neovascularisation have poorly
defined complexes and are untreatable.49,61 Argon, or equivalent lasers,
are almost universally available in UK eye departments (98.9%). The green
argon wavelength (514mu) or yellow (577nm) is used to avoid unnecessary
lutein uptake and retinal damage. Yellow light has the advantage of being
transmitted more predictably through a nuclear sclerotic lens.
three studies showed treatment benefit from argon laser photocoagulation
when a well defined neovascular complex lay outside 200 microns from fixation.
This is most likely to be the case when the visual acuity is still good
(6/12 or better) and the duration of symptoms short (less than a month).56
Such situations are, however, rare and occur in only 5-10% of those seen.
61 Despite the initial hopes of treatment it is now recognised
that continued growth of the membrane and recurrent disease are major limiting
factors for success and occur in about 50% within 5 years after initial
successful treatment. 8,9,56
patients with juxta and sub foveal membranes may benefit from treatment
Sub foveal treatment produces a marginal benefit at 12 months and a maximal
one at 24 months. As treatment destroys the fovea there is an immediate
fall in visual acuity that often makes this treatment unacceptable. Any
benefit from treating juxtafoveal lesions is limited by their tendency
to continue growing. Polypoidal choroidopathy may benefit from treatment
and the recurrence of haemorrhage leading to visual loss may be prevented.
Any of these treatments should, therefore, only be carried out after careful
consideration, detailed explanation and counselling.
epithelial detachments do not usually benefit from laser treatment 65
Treatment is frequently complicated by rapid visual loss associated with
a pigment epithelial tear or rapid progression of an unrecognised neovascular
response. A few neovascular lesions outside the detachment itself or within
the 'notch' have been shown to respond favourably to focal laser treatment.66
Pigment epithelial detachments occurring in patients under the age of 55
do not require treatment as the prognosis is good.46, 47
can progress with great rapidity resulting in significant visual loss even
within a few days.67 If, on the basis of new symptoms or clinical
examination, choroidal neovascularisation is suspected fluorescein angiography
should be performed urgently and interpreted with a minimum of delay to
avoid the risk of irreversible damage and a lost opportunity for laser
treatment. 67,68 Well defined extrafoveal neovascularisation
should be photocoagulated following careful explanation of the implications
and expectations of treatment that, it is hoped, will reduce, but not eliminate,
the risk of severe visual loss. The treatment scotoma produced and possibility
of further visual loss should be discussed.
is evidence from controlled trials that lesions with the characteristics
below can benefit from treatment:
complexes and lesions of polypoidal choroidopathy may also benefit from
treatment. juxtafoveal and sub foveal lesions are treated only after careful
extraffiveal neovascularisation located 200 microns from fixation.
complexes of less than 1 disc area and with vision of less than 6/24. As
any treatment benefit is only fully achieved at 24 months, most ophthalmologists
feel that treatment is not justified given the immediate loss of vision
recommended treatment protocol usually involves:
may require long burns and at a high power level to ablate the membrane
adequately. Retrobulbar anaesthesia to reduce extraneous movement is not
usually needed and may require the presence of an anaesthetist. Injection
complications which, whilst rare, can be serious.69 Monitoring
by pulse oximetry and intravenous access are necessary in view of the low
but significant risk of cardio-respiratory collapse70.
confluent laser photocoagulation (514nm or 577nm) covering the whole of
the angiographic lesion and a margin of 100 microns around it.
power setting and duration to achieve an intense white coagulum.
sequence of burns around and onto the lesion avoiding other structures.
of the initial burns to minimise the risk of movement causing an exclamation
mark burn up to fixation .
disease remains the main obstacle to successful management with figures
of 10% at 1-2 months, 21% at 3 months increasing to 42% at a year and 53%
at 3 years being reported.8,9 The optimal review interval following
laser treatment is uncertain but the first visit usually occurs at two
to three weeks. Clinical examination and angiography are performed at this
visit with further treatment if necessary although the best results occur
when the first treatment is successful. Thereafter the review intervals
increase provided the situation is stable (e.g. 6 and 12 weeks and 3 monthly
thereafter). Repeat angiograms are needed if membrane persistence or recurrence
should be made aware of the risk of recurrent disease particularly in the
first year. A patient's observation of subjective change or on the Amsler
Grid should not be overlooked as it may indicate recurrence.71
Patients should have easy return access to the ophthalmologist both for
their treated eye but also for the other eye which is at significant risk41,43
of similar disease. Patients are also more likely to present earlier should
disease in the second eye occur at which stage a developing lesion may
be more amenable to treatment. Patients and all staff should be aware of
this and direct access may be needed to avoid missed treatment opportunities.
a number of alternative managements have been proposed and have or are
being subjected to clinical trial. These include:
interferon which was not shown to be beneficial in a controlled study.
therapy using a photosensitising dye has been subject to a multicentre
prospective study.77-82 The findings imply some improvement
in visual outcome at one year if more than 50% of the neovascular complex
is classical. The high costs of this treatment may not prove generally
acceptable and will be subject to considerable further discussion.
radiation by external beam application is the subject of several studies.
removal may have some value in idiopathic disease and that associated with
the presumed histoplasmosis syndrome but much less so for membranes associated
with AMD.87-90 Although some authors have reported benefit from
surgery good reading facility is rarely achieved.
translocation of the central retina with simultaneous membrane ablation
is subject to ongoing study.
and dietary supplements including the use of zinc and selenium that have
not proved helpful. 36,37,91,92
laser treatment causes the disappearance of drusen but has also been shown
to provoke neovascular complications.93-100 It is undergoing
further evaluation in multicentre clinical trials.
of co-existing disease.
degeneration may co-exist with other conditions. Studies have shown that
both AMD and cataract are common in the elderly each being present in almost
half of those over the age of 75.101 It is not surprising that
for about a quarter of the population both coexist. Given the changes in
threshold for cataract surgery 102 such surgery is not always
contraindicated in the presence of macular degeneration. The improved clarity
and illumination can be significant even if central acuity remains affected.
There is, however, a small risk of the neovascular process being accelerated
by surgery that should be kept in mind.103
aggressive glaucoma treatment may be justified to forestall peripheral
field loss adding to the central failure. The constraints of clinical governance
should not prevent surgery being offered with each clinical situation being
judged and managed on its own merits.
losing vision due to AMD will suffer significant loss of independence
be it through the inability to drive, to read or to manage their own affairs.
The early provision of advice and support will encourage independence and
minimise the socio economic isolation that AMD causes. Care in the community
involving the family, statutory social services, patient or disease centred
voluntary services is, therefore, vital. Often but, not invariably, this
is triggered by visual handicap registration. The pattern of help available
around the country is very variable and the attention given to sight loss
in community care plans diverse.104 There is a need for greater
public awareness of AMD and a more uniform standard of care in which ophthalmologists
must have a central role working with the statutory and voluntary sectors
to achieve this.
of low vision aids.
for the provision of low vision aids and initiation of rehabilitation should
be integral to the advice and care provided by an ophthalmologist. The
recent College document55 on the provision of low vision care
has defined a person with low vision as someone 'who with a normal correction
is not able to perform those visual tasks needed for vocational, avocational
and social needs'. Almost all patients suffering visual loss due to AMD
may be helped by visual aids. Optical aids involve high powered reading
additions, magnifiers, illuminated magnifiers and telescopes. Electronic
aids include closed circuit television or specialised adaptations of existing
systems e.g. computer software. Non-optical aids include lights and typoscopes.
models of low vision aid provision exist around the country involving ophthalmologists,
optometrists and low vision therapists?55 In 1998 178 eye units
in the United Kingdom (90.8%) had some form of low vision aid service.
The remainder had access to local providers. Nationally the availability
of LVA services in general was very uneven when surveyed in 1999.105,106
Patient acceptance and improved ability in the use of aids has been demonstrated
when full support and training are given. A range of aids may be needed
to meet specific tasks. It is not adequate to issue a patient with a magnifying
aid and not provide sufficient after care.
trained in eccentric fixation and the use of better lighting can greatly
improve their reading ability. 107
low vision centres, within or outside hospitals, will be staffed by a multidisciplinary
team to assess the low vision and the daily living skills needed. A simpler
hospital service involves a visiting low vision therapist who will provide
and explain the use of low vision aids and advise on eccentric viewing
and lighting. The problems of daily living skills and rehabilitation can
also be addressed in a limited fashion. Optometrists in high street practice
and some social service and voluntary organisations offer similar provision
and advice about aids which will depend on local organisation, interest
a framework document from the Low Vision Services Working Group108
proposed the establishment of Low Vision Services Committees at a local
level to address the fragmentation of current services and stimulate multi-disciplinary
working to improve communication and differences in care.
of blind people in Britain has been counted since 1851 starting with a
simple declaration of blindness on census returns. Ophthalmologists now
have a vital role in identifying those with visual handicap (Appendix 2)
and initiating the process of visual handicap registration by social services
leading to access to the statutory services and allowances available. The
form BD8 in England and Wales, BP1 in Scotland and A655 in Northern Ireland
also provide the basis for analysis of the causes, incidence and prevalence
of visual handicap across the country.
social and economic benefit to society must be substantial if independence
is maintained. When treatment has not proved possible or effective, there
are two aspects to rehabilitation. These consist of firstly maximising
the residual vision, often employing low vision aids, and secondly providing
education and training to enable the patient to lead as normal a life as
possible within the limits of the disease. No firm data, however, exist
as to the costs and benefits of good management.
and coping strategies.
to terms with chronic visual disability either as a result of untreatable
disease or following unsuccessful treatment is a depressing and arduous
process. Patients with severe visual loss due to AMD often have unrealistic
expectations and some patients never adjust to their disability.
the management of AMD requires patience and sympathy. Patients with AMD
greatly benefit from continuing support and information about their condition
and all patients losing vision need hope and encouragement. When no specific
treatment is available it should be emphasised from the beginning that
peripheral vision will be maintained and that there is no harm in using
the eyes. Advice with regard to the future prognosis should be an integral
part of the management. Often great anxiety with its attendant risk of
depression can be relieved by understanding that complete blindness does
not occur as a result of AMD.
of existing vision can be greatly enhanced by ensuring that objects are
bigger, brighter and bolder and that contrast is increased. This may be
achieved by such devices as angle poise lamps, larger print and the use
of felt tipped, rather than ball point, pens. Liquid level indicators,
markers for cooker dials, free directory enquiries, enlarged telephone
dial numbers are available as are large print books, bank statements, talking
books, newspapers and clocks.
is aided with the use of either symbol or guide canes and can improve confidence
outside the patient's home. Guide dogs are rarely of benefit for patients
with AMD although they are entitled to apply for one. A home visit from
a low vision therapist will often provide the basis for useful advice.
and voluntary support services in the community.
associated with care in the community and boundary changes have altered
the role of the statutory social services. They and the new primary care
groups or their equivalent now have a greater role as the purchasers of
care. Training and rehabilitation courses for those recently registered
as visually handicapped and others with vision difficulties are provided
by social services and blind associations . Such courses will include the
elements of a low vision rehabilitation service.
support and advice are available in information documents, tapes and large
print material from the national organisations such as the Royal National
Institute for the Blind or from local charitable blind associations. Disease
focused societies such as the Macular Disease Society provide a useful
source of information for those affected by AMD. A list of a number of
these bodies is in the appendix 4. With the predicted increase in the older
population over the next 20 years the effect of macular degeneration remains
daunting. The greater co-operation developing between all those involved
provides the hope of a more focused and effective service in the future.
and objectives for the management of macular degeneration
development of clinical guidelines and good practice statements provide
a basis for clinical governance and for measurement of practice and its
following should be the national aim of an effective service.
should be objectives for the management of an individual patient and could
provide the basis for audit.
data with regard to risk factors and disease characteristics.
by the purchasers of service (Primary Care Groups or their equivalent)
of the significance of sight loss and its amelioration by treatment and
patient and public awareness of macular degeneration and the pointers to
to care across the country~ Such care should enable the early recognition
of impending disease within the primary sector and its early referral to
achieve optimal treatment benefit.
response within the ophthalmic community to minimise the visual morbidity
resultant from macular degeneration. This may, in turn, demand concentration
of resources both in terms of equipment and ophthalmic and other personnel.
of developing AMD:
of a treatable neovascular complex:
referral if there is recent onset of distortion and dropping vision. A
telephone call may be needed to determine urgency in individual cases.
A patient at risk should be seen as soon as possible and preferably within
a week if a neovascular membrane that might be treatable is suspected.
resulting in ophthalmic assessment within 3 months for non urgent cases
with the identification of any other disease or specific risk factors.
of untreatable AMD in one eye or following unsuccessful treatment:
by an ophthalmologist with knowledge and experience in the care of patients
angiography to be reviewed and used as the basis for treatment.
explanation and counselling.
treatment within 48 hours of the angiogram, if at all possible. Delay after
this time may necessitate further angiography to exclude progression.
2 - 3 weeks following laser treatment with repeat anglogram and if needed
re-treatment. Review thereafter is as appropriate.
of bilateral untreatable AMD:
explanation by the ophthalmologist at the time of diagnosis as to the nature
of the problem.
and counselling about risks for the other eye and how to identify developing
as to how to obtain further information and how to seek urgent help should
the second eye become involved.
essential that a full assessment of need is undertaken and the appropriate
support provided. It is likely that the patient will need to be seen and
visited at home to achieve this.
explanation by the ophthalmologist at the time of diagnosis as to the nature
of the problem.
and counselling about future visual function and an indication as to how
to obtain further information.
visual handicap registration and referral for low vision aid assessment
within 13 weeks or earlier as appropriate.
of advice and support in the community at an early stage in keeping with
local arrangements. This should follow an initial contact or visit being
made by Social Services, or voluntary agency for the blind, within a month.
for recommendation for partially sighted or blind registration 109
is no legal definition of partial sight. The guidelines are that a person
can be certified as partially sighted if they are:
and permanently handicapped by defective vision caused by congenital defect
or illness or injury.
a general guide this will apply when the following apply:
6/60 Snellen with a full field.
6/24 Snellen with moderate contraction of the field, opacities in media
or better if there is a gross field defect, for example hemianopia, or
if there is marked contraction of the visual field, for example in retinitis
pigmentosa or glaucoma.
National Assistance Act 1948 says that a person can be certified as blind
if they are: So blind that they cannot do any work for which eyesight
will generally apply when:
points to consider relate to how recently the person's eyesight has failed
and the person's age at which the eyesight failed.
acuity is below 3/60.
acuity is between 3/60 and below 6/60 when there is a very contracted visual
is 6/60 or better when there is a very contracted visual field especially
if the contraction is in the lower part of the field.
is a suggested outline describing fluorescein angiography, Headings should
be boxed. The text should be in a font size of 16 and in bold to facilitate
is fluorescein angiography?
is a simple test to give your doctor more information about the condition
of the back of your eye. It helps decide the best form of treatment or
does the test involve?
you arrive at the out-patient department your eyes will be tested. You
will be asked a few questions about your general health. Drops will be
put into both eyes to dilate your pupils. The drops may blur your vision
for a short time. It is, therefore, advisable that you do not drive yourself
for the appointment. It is important that you let us know if you have any
allergies, or if you have had an unwanted reaction to fluorescein before,
your pupils are dilated you will be taken into the Angiography room. Photos
will be taken of the back of your eye using a special camera. Then a small
amount of dye will be injected into a vein in your arm. Within seconds
the dye travels in your blood to the blood vessels in your eye. Your eye
is then is photographed to give more information about the condition of
the back of your eye. No X-rays or radioactive substances are used. The
eye is not touched during the test. The actual test takes about 10 to 15
minutes. Following the test we ask you to stay in the department for about
1/2hour to check that you do not have any side effects and are all right
to go home. If you are elderly or have a long way to come it is advisable
to bring someone with you.
it be all right to have the test if 1 am on tablets?
it is all right to take any tablets or medicines as usual on the day of
it all right to eat and drink before the test?
you can cat or drink what you like before the test.
there any side effects?
dye will give your skin a yellow tinge and your urine will be bright yellow
for one or two days. There may be some blurring of vision caused by the
drops and some dazzle from the camera flash. One in ten patients feels
slightly sick or short of breath but the feeling rarely lasts more than
a few seconds. If, in rare cases, patients have severe breathing or circulatory
difficulties the emergency team will be called. Although extremely rare,
a few deaths have been reported in the past.
will 1 know the results?
may not be given the results of the test straight away. The results will
be given to you at your next appointment. Please check that you know when
your next appointment is. Staff in the department will be happy to assist
should be obtainable locally or through the RNIB
National Institute for the Blind,
Great Portland Street,
Guide Dogs for the Blind Association.
Reading, Berks, RG7 3YG
Macular Disease Society,
Hampshire, SP10 1BE
Partially Sighted Society,
South Yorkshire, DN1 2NX
Association for the Education, Training and Support of Blind and Partially
Sighted People (OPSIS).
Birmingham, B17 9TG
Newspaper Association of the UK,
East Sussex, TN21 8D13
Talking Book Service
Middx HAO I RR
of the independent services available for the blind and visually impaired
is available from the Royal College of Ophthalmologists.
Related Maculopathy (ARM):
disorder of the macular area, most often clinically apparent after 50 years
of age, and characterised by:
Macular Degeneration AMD (ARMD):
whitish-yellow spots identified as drusen.
pigmentation or hyperpigmentation associated with drusen.
demarcated areas of depigmentation or hypopigmentation of the retinal pigment
epithelium and associated drusen.
is no universally accepted definition of this term. The late stages of
ARM are identified as Age Related Macular Degeneration (AMD) which may
be 'wet or dry' and feature:
changes lead to progressive central visual loss and worsening function
in the elderly.
atrophy with visible underlying choroidal vessels.
epithelial detachment with or without neurosensory detachment.
or sub pigment epithelial neovascularisation.
scar tissue, haemorrhages and exudates.
fibrovascular tissue, often part of the healing response following choroidal
excrescences external to the retinal pigment epithelium that are well defined
small deposits (hard drusen) or ill defined deposits (soft drusen) lying
between the basement membrane of the retinal pigment epithelium and Bruch's
membrane. Drusen are the ophthalmoscopic and histological hallmark of age-related
change at the level of Bruch's membrane. They may be discrete, sub-confluent
or confluent in configuration.
neovascularisation that is no closer than 200 microns from the centre of
the foveal avascular zone as judged by fluorescein angiography.
of choroidal neovascularisation and/or pigment epithelial detachment in
a patient with AMD and may be referred to as being 'wet'.
or several areas of well demarcated zones of apparent atrophy of retinal
pigment epithelium. Drusen are usually present as well and are often crystalline.
neovascularisation that is closer than 200 microns from the centre of the
foveal avascular zone but that does not reach the centre of the foveal
Photocoagulation Study (MPS):
series of ongoing multicentre clinical trials funded by the National Eye
Institute that are investigating the value of laser photocoagulation for
patients with exudative AMD.
changes characterised by drusen, pigment changes and atrophy but not serous
elevation of the neuroretina associated with choroidal neovascularisation
or pigment epithelial detachment.
of fluid ('serous pigment epithelial detachment') or blood ('haemorrhagic
pigment epithelial detachment') beneath the retinal pigment epithelium.
Associated choroidal neovascularisation is usually present in older patients.
Pigment Epithelial Changes:
are either i) atrophic changes of the pigment epithelial-Bruch's membrane
complex that lead to an appearance of hypopigmentation, or ii) hyperplastic
changes of the retinal pigment epithelial-Bruch's membrane complex that
lead to an appearance of hyperpigmentation.
drusen are larger than hard drusen and usually have ill-defined, non-discrete
margins. Histologically, these represent diffuse deposits lying between
the basement membrane of the retinal pigment epithelium and Bruch's membrane.
They are often sub-confluent or confluent in their distibution.
neovascularisation that involves the centre of the foveal vascular zone.
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A.C. Bird Institute of Ophthalmology, London.
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S. Roxburgh Ninewells Hospital, Dundee.