Latest macular degeneration guidelines : NICE

The latest NICE guideline on macular degeneration covers diagnosing and managing age-related macular degeneration (AMD) in adults. and it aims to improve the speed at which people are diagnosed and treated to prevent loss of sight.

Key Recommendations :

Risk Factors

• 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
  
  
  
  

Diagnosis and referral

• 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

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


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

Late AMD (dry)

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


• 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 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)

• 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 the emergency referral

Pharmacological management of AMD

Antiangiogenic therapies

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


• 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.


• 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).


• 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.


• 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


• 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 Muorescein angiography, or recent visual acuity changes)
    
    
    
    
  
  
  
  

and

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


• Pegaptanib is not recommended for the treatment of wet age-related macular degeneration


• 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


• Aflibercept solution for injection is recommended as an option for treating wet age-related macular degeneration only if:
  
  
  
  • it is used in accordance with the recommendations for ranibizumab in NICE technology appraisal guidance 155 [re-issued in May 2012 and the manufacturer provides aflibercept solution for injection with the discount agreed in the patient access scheme
  
  
  
  


• People currently receiving aflibercept solution for injection whose disease does not meet the criteria above should be able to continue treatment until they and their clinician consider it appropriate to stop


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

Switching and stopping antiangiogenic treatment for late AMD (wet)

• 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


• Consider observation without giving anti-VEGF treatment if the disease appears stable .


• Consider stopping anti-VEGF treatment if the eye develops severe, progressive loss of visual acuity despite treatment as recommended in Pharmacological management of AMD


• Ensure that patients are actively involved in all decisions about the stopping or switching of treatment

Non-pharmacological management of AMD

Supporting people with AMD and visual impairment

• Be aware that people with AMD are at an increased risk of depression so Identify and manage the depression.


• Be aware that many people with AMD have other significant comorbidities. For guidance on optimising care for adults with multiple long-term conditions.


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


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


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


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

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 (see Self-monitoring)
  
  
  • 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

Self-monitoring

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


• 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
  
  
  
  


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


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

For full Guideline refer to :

https://www.nice.org.uk/guidance/ng82