Manual. Manual Welsh Eye Care Initiative. A Welsh Eye Care Initiative. Protocol. The Assessment and Management of Age-related Macular Degeneration

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Kerry Simpson
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1 A Protocol 1.0 Definitions The following terms are important in this text: Wet Macular Degeneration Condition caused by the growth of abnormal blood vessels under the retina. Symptoms appear suddenly and progress over days or weeks. Person complains of distorted central vision. The most important signs are subretinal fluid and haemorrhage. Disciform macular scar The end-stage of wet macular degeneration occurs in 90% of cases without treatment. Person has a blank patch in the centre of their vision. The most important sign is an elevated patch of scar tissue centered on the macula. Dry Macular Degeneration Condition caused by the accumulation of waste products under the retinal pigment epithelium. Symptoms develop gradually and progress over months or years. Most people are asymptomatic but may eventually complain of difficulty reading and poor vision in dim light. The most important signs are drusen, pigment epithelial atrophy and pigment clumping (so-called pigmentary changes). The Assessment and Management of Age-related Macular Degeneration Geographic atrophy The end-stage of dry macular degeneration occurs in about 10% of cases. Person has a blank patch in the centre of their vision. The most important sign is a roughly circular, flat or slightly depressed pale area centered on the macula. Recent Within the last three months.

2 2.0 Optometric assessment and management The frequency and composition of optometric assessment and the management protocols for different groups of patients with macular changes and/ or degeneration is summarised in this section. 2.1 Category A Macular changes without visual problem If a patient is aged over 55 years and has macular changes without visual problem they should be followed up regularly and given appropriate advice. 1) Recording findings - Macular signs should be recorded diagrammatically and/or using a photograph if a fundus camera is available 2) Recall - Recall in one year for Private or GOS Eye Examination (using code 2.0 if required) depending on eligibility. 3) Information - Inform the person about the retinal signs and give advice about how to monitor for reduced or distorted vision and return promptly if a change is noticed. 4) Advice - Advise the person about the benefits of a healthy diet and if they smoke explain the increased risk associated with the development of macular degeneration. 2.2 Category B VA 6/60 with recent onset symptoms or retinal signs A PEARS examination should be carried out to differentiate between treatable and non- treatable macular degeneration Any patient with visual acuity of 6/60 or better in the affected eye and: or suspected onset of macular degeneration due to retinal signs and recent visual loss or distortion previously recorded macular changes or degeneration presenting with recent visual loss or distortion should be examined at the earliest opportunity to differentiate treatable and non treatable macular degeneration. The PEARS examination should include: Symptoms and History Symptoms Duration of visual changes Description of visual changes Which eye? Ocular History Previous optometric investigation Previous ophthalmological investigation/ treatment Previous low vision intervention General Health Smoking history (current, ex-smoker or non-smoker) High blood pressure or treatment for high blood pressure Family Ocular History Family History of macular degeneration

3 Clinical Examination (of both eyes) Best corrected distance and near monocular visual acuity Potentially treatable Wet Macular Degeneration Refer urgently by telephone the same day (see referral pathways below) Refraction Management Pupil responses to light Anterior chamber angle assessment Contact Tonometry Dilation using Tropicamide 1% and Phenylephrine 2.5% Stereoscopic fundus examination using a slit lamp biomicroscope and a 60D lens noting the presence or absence of the following signs: - Macular drusen - Pigmentary changes - Retinal thickening (oedema and exudates) - Sub-RPE or sub-retinal fluid - Sub-RPE, sub-retinal, intra-retinal and pre-retinal haemorrhages - Fibrosis - Features of other conditions e.g. angioid streaks A fundus photograph if a camera is available In order to manage the person appropriately practitioners must use the signs and symptoms to decide if the patient is presenting with: Potentially treatable Wet Macular Degeneration Dry Macular Degeneration or Other pathology Dry Macular Degeneration 1) Information- Inform the patient about dry macular degeneration and provide them with an information booklet or tape 2) Refer Low Vision- If both eyes are affected and the person has best corrected Binocular Distance VA < 6/9 or Near < N6 they should be offered referral to the all Wales Low Vision Service (WLVS) 3) Registration- If eligible, the person should be advised of the process and benefits of registration and offered referral for this. 4) Monitor- Advise the person how to monitor for reduced or distorted vision and return promptly if a change is noticed. 5) Diet and Nutrition- Advise the person about the benefits of a healthy diet for all and the finding that nutritional supplements halt progression in some cases. 6) Smoking- If the person smokes advise them to stop smoking and provide them with details of local support networks to do this. 7) Driving- If the person's vision is outside the legal requirements for driving they should be advised to stop driving. 8) Social Services- If you are concerned that the person is at risk to themselves or others (e.g. burning, falling, medication) then they should be referred urgently to social services. Otherwise referral will be initiated by the low vision service. 9) Recall- Recall in one year for a Welsh Eye Health Examination. Other pathology Other pathology should be managed according to agreed local and national protocols and/ or guidelines

4 2.3 Category C VA 6/60 in either eye without recent onset or change Patients in this group have untreatable Macular Degeneration but they may develop treatable wet Macular Degeneration in future. Therefore, they should be monitored closely. A WEHE examination should be carried out to rule of any signs of treatable disease and the management is essentially the same as that outlined in 2.2 for those diagnosed as having dry Macular Degeneration. 1) Recording findings - Macular signs should be recorded diagrammatically and/ or using a photograph if a fundus camera is available 2) Information- Inform the patient about macular degeneration and provide them with an information booklet or tape. 3) Low Vision- If both eyes are affected and the person has best corrected Binocular Distance VA < 6/9 or Near < N6 they should be offered referral to the all Wales Low Vision Service (WLVS) 4) Registration- If eligible, the person should be advised of the process and benefits of registration and offered referral for this. 5) Monitor- Advise the person how to monitor for reduced or distorted vision and return promptly if a change is noticed. 6) Diet and Nutrition- Advise the person about the benefits of a healthy diet for all and the finding that nutritional supplements slow progression in some cases. 7) Smoking- If the person smokes advise them to stop smoking and provide them with details of local support networks to do this. 8) Driving- If the person's vision is outside the legal requirements for driving they should be advised to stop driving. 9) Social Services- If you are concerned that the person is at risk to themselves or others (e.g. burning, falling, medication) then they should be referred urgently to social services. Otherwise referral will be initiated by the low vision service. 2.4 Category D Binocular VA < 6/60 Patients in this group have untreatable Macular Degeneration and due to current NHS protocols will not be offered treatment. Therefore, they should be monitored using the GOS system to ensure that any other ocular pathology is detected at the earliest opportunity and that they are receiving appropriate rehabilitation for their needs. 1) Information- Inform the patient about macular degeneration and provide them with an information booklet or tape. 2) Low Vision- Ensure patients have been offered referral to the all Wales Low Vision Service (WLVS) and check this at each opportunity. 3) Registration- Registration status should be checked at each visit and the person offered referral for initiation of registration or to change their status from sight impaired to severely sight impaired if appropriate. 4) Monitor- Advise the person of the importance of regular eye tests to detect other abnormal ocular conditions. 5) Diet and Nutrition- Advise the person about the benefits of a healthy diet for all and the finding that nutritional supplements slow progression in some cases. 6) Smoking- If the person smokes advise them to stop smoking and provide them with details of local support networks to do this. 7) Driving- The person should be advised that they are outside legal visual requirements for driving. 8) Social Services- If you are concerned that the person is at risk to themselves or others (e.g. burning, falling, medication) then they should be referred urgently to social services. Otherwise referral will be initiated by the low vision service. 9) Recall- Recall using GOS recommended intervals. 10) Recall- Recall in one year for a Welsh Eye Health Examination.

5 3.0 Referral Pathways The referral pathways for different services and urgency of referral for patients with macular degeneration living in Wales is summarised in this section. 3.1 Urgent Referral of Potentially Treatable Wet Macular Degeneration Patients with potentially treatable Macular Degeneration should be referred the same day by telephone or fax (depending on the centre). 3.5 Referral to Social Services Anyone who is at risk to themselves or others (e.g. due to risk of burning, falling, or taking medication incorrectly) then they should be referred urgently to social services. Contact details for social services teams are updated regularly on the website When referring people urgently it is essential to make it clear that you want to refer the person urgently giving reasons for this. Routine rehabilitative support will be initiated by the low vision service. Practitioners may wish to use one of the Rapid Access Referral Forms (See Appendix 1) prior to phoning so that they have all the relevant information to hand. This referral may also be faxed or posted to the relevant hospital. Contact details for Wales are listed in Appendix 2 and on the website Routine Referral of Non Treatable Macular Degeneration Patients who have Macular Degeneration that is not treatable who request an ophthalmological opinion should be referred to a local Hospital Eye Service routinely using normal the normal referral pathway. 3.3 Referral for Registration Patients who are eligible and would like to be registered or have their registration status changed should be referred to a Consultant Ophthalmologist in the local Hospital Eye Service. Give details of factors making the person especially vulnerable, for example profoundly deaf, living alone etc. 3.4 Referral for a Low Vision Assessment Patients who would like to have a low vision assessment should be referred to a community based WLVS in the first instance. Waiting times should be less than two weeks for most people. Contact details for services are updated regularly on the website or can be obtained by phoning the Administration team in Carmarthen LHB

A service and clinical guide for the Eye Health Examination Wales (EHEW) part of the Wales Eye Care Service (WECS)

A service and clinical guide for the Eye Health Examination Wales (EHEW) part of the Wales Eye Care Service (WECS) For optometrists and ophthalmic medical practitioners (OMPs) Issued by the Welsh Government