Age-Related Macular Degeneration (AMD)
NICE guideline [NG82] Age-related macular degeneration. Published: Jan 2018.
NICE CKS Macular degeneration – age-related. Last revised: Aug 2022.
Background Information
Classification
There 2 main types of AMD:
| Dry AMD (Atrophic) | Wet AMD (Neovascular / Exudative) | |
|---|---|---|
| Prevalence | ~90% of AMD cases | ~10% of AMD cases |
| Pathophysiology | Gradual atrophy of retinal pigment epithelium (RPE) and photoreceptors | Choroidal neovascularisation → leakage, haemorrhage, fibrosis |
NICE Classification
This is the classification system used by NICE, but it is of excessive detail and unlikely to be examined.
| AMD classification | Definition |
|---|---|
| Normal eyes |
|
| Early AMD | Low risk of progression:
Medium risk of progression:
High risk of progression:
|
| Late AMD (indeterminate) |
|
| Late AMD (wet active) |
|
| Late AMD (dry) | Geographic atrophy (in the absence of neovascular AMD)
Significant visual loss (6/18 or worse) associated with:
|
| Late AMD (wet inactive) |
Note that eyes may still develop or have a recurrence of late AMD (wet active) |
Guidelines
Disclaimer
This article presents a high-yield summary of the NICE guideline and common clinical practice on AMD, created for educational purposes. It focuses on core diagnostic and treatment principles and may omit some details, eligibility thresholds, or procedural steps found in the full guideline.
Investigation and Diagnosis
Primary Care
| Test | Findings suggestive of AMD |
|---|---|
| Amsler grid |
|
| Fundoscopy |
|
Secondary Care
Slit lamp biomicroscopic fundus examination is the mainstay for the diagnosis of both early and late AMD
- If dry AMD is suspected, slit lamp alone is enough, no need for the below investigations
Further imaging for wet AMD:
- 1st line: optical coherence tomography – detects subretinal / intraretinal fluid
- 2nd line: fundus fluorescein angiography (FFA) – used to confirm (if present on fundus examination) choroidal neovascularisation (dye leaks out of vessels)
Management
If AMD is suspected, refer urgently to ophthalmology
Dry AMD
There are currently no pharmacological treatments for dry AMD.
Mainstay of management is active observation and supportive:
- Stop smoking – proven to reduce risk of progression
- Consider antioxidant vitamin and mineral supplementation (AREDS2 formula: vitamin C, vitamin E, zinc oxide, copper, lutein, and zeaxanthin)
- Healthy balanced diet (low glycaemic index, rich in fruits, green leafy vegetables and fish high in omega-3 fatty acids)
Wet AMD
Mainstay of management: intravitreal anti-VEGF therapy (ranibizumab, aflibercept, bevacizumab)
NICE recommends not to offer photodynamic therapy and intravitreal corticosteroids as an adjunct to anti-VEGF therapy.
NB – laser photocoagulation is not routinely used in the treatment of wet age-related macular degeneration. It is generally reserved for rare cases of extrafoveal choroidal neovascularization where anti-VEGF therapy is not feasible or effective.
References
Original Guideline