Guideline:
Care of the patient with age-related macular degeneration
Bibliographic Source(s)
- American Optometric Association. Care of the patient with age-related macular degeneration. 2nd ed. St. Louis (MO): American Optometric Association; 1997. 47 p. (Optometric clinical practice guideline; no. 6). [73 references]
Guideline Status
This is the current release of the guideline.
According to the guideline developer this guideline has been reviewed on a biannual basis and is considered to be current. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.
Guideline Category
Diagnosis
Evaluation
Management
Intended Users
Health Plans
Optometrists
Guideline Objective(s)
- To identify ocular personal and environmental risk characteristics for age-related macular degeneration (AMD)
- To accurately diagnose AMD
- To develop a decision making strategy for management of patients at risk for severe vision loss from AMD
- To provide information and resources for appropriate patient education in the area of vision rehabilitation
- To propose a philosophy and rationale for management and prevention of AMD
Target Population
Adults with age-related macular degeneration
Interventions and Practices Considered
Diagnosis of age-related macular degeneration
- Patient history
- Ocular examination
- Best corrected visual acuity including near monocular visual acuity
- Amsler grid testing
- Sensorimotor examination
- Refraction
- Biomicroscopy
- Tonometry
- Stereoscopic fundus examination with pupillary dilation
- Supplemental testing
- Macular function assessment (e.g. contrast sensitivity photostress test)
- Color vision
- Central 10-degree computerized automated perimetry
- Fundus photography (including the use of a red-free filter)
- Scanning laser ophthalmoscope
Management of age-related macular degeneration
- Laser photocoagulation treatment
- Amsler gird self-assessment
- Patient education
- UVR protection
- Antioxidant supplementation
- Low vision consultation and evaluation
- Consultation and referral
Major Outcomes Considered
Not stated
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The guideline developer performed literature searches using the National Library of Medicine's Medline database and the VisionNet database.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence
Not stated
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not applicable
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
The Reference Guide for Clinicians was reviewed by the American Optometric Association (AOA) Clinical Guidelines Coordinating Committee and approved by the AOA Board of Trustees.
Major Recommendations
Summarized by the National Guideline Clearinghouse (NGC):
Diagnosis of Age-Related Macular Degeneration
The evaluation of patients with retinal changes suggestive of age-related macular degeneration (AMD) or patients with diagnosed AMD may include but is not limited to the following areas:
- Patient history
- Ocular examination
- Best corrected visual acuity including near monocular visual acuity
- Amsler grid testing
- Sensorimotor examination
- Refraction
- Biomicroscopy
- Tonometry
- Stereoscopic fundus examination with pupillary dilation
- Supplemental testing
- Macular function assessment (e.g. contrast sensitivity photostress test)
- Color vision
- Central 10-degree computerized automated perimetry
- Fundus photography (including the use of a red-free filter)
- Scanning laser ophthalmoscope
These components of patient care are described in greater detail in the guideline document.
Management of Age-Related Macular Degeneration
The extent to which an optometrist can provide medical treatment for age-related macular degeneration may vary depending on the state's scope of practice laws and regulations and the individual optometrist's certification. Treatment of the patient with AMD may require consultation with or referral to the patient's primary care physician an ophthalmologist or other health care practitioner for those services outside the optometrist's scope of practice.
Management of the patient with nonexudative AMD varies considerably from that of the patient diagnosed with exudative AMD for whom immediate treatment is critical. Treatment options for patients with nonexudative AMD and exudative AMD are described in greater detail in the guideline document.
The frequency and composition of evaluation and management visits for age-related macular degeneration is summarized in the following table:
Frequency and Composition of Evaluation and Management Visits for Age-Related Macular Degeneration
| Type of Patient | Frequency of Examination | Amsler Grid | Stereo Fundus Biomicroscopy | Central 10 degree Automated Visual Field (AVF) | Fundus Photography | Management Plan |
| Patient with two or more risk factors for AMD over age 55 | Annual examination | Yes | Yes | Yes; baseline repeat every 2 years | Yes; baseline repeat every 2 years or as necessary | Patient education; Recommend UVR protection antioxidant supplementation home Amsler weekly |
| Patient with hard drusen and/or pigmentary degeneration | 6 to 12 months depending on extent of atrophy | Yes | Yes | Yes; repeat every 2 years | Yes; repeat every 2 years | Patient education; Recommend UVR protection antioxidant supplementation home Amsler twice each week |
| Patient with geographic atrophy VA 20/20-20/70 | 6 to 12 months depending on extent of atrophy | Every interim visit | Every interim visit | Every 1 to 2 years | Yes; repeat every year | Patient education; Recommend UVR protection antioxidant supplementation home Amsler every other day; Monitor for CNV |
| Patient at high risk with soft confluent drusen and granular pigmentary degeneration | 4 to 6 months | Every interim visit | Every interim visit | Annually | Annually | Patient education; Recommend UVR protection antioxidant supplementation home Amsler daily; Low vision consultation and evaluation |
| Patient with CNV within 2500 microns of center of FAZ every 2 to 3 months | 2 weeks after FA laser photocoagulation; at 6 weeks then after repeat FA | Every interim visit | Every interim visit | Semiannually | Semiannually | Patient education; Recommend UVR protection antioxidant supplementation home Amsler daily; immediate consultation for signs of recurrent CNV; Low vision consultation and evaluation |
| Patient with disciform scar in both eyes | 6 to 12 months | Not necessary | Every interim visit | Annually; consider central 30º AVF depending on central fixation | Annually | Review; Low vision consultation and evaluation |
Clinical Algorithm(s)
An algorithm is provided for Optometric Management of the Patient with AMD.
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
Until the means to prevent or cure age-related macular degeneration (AMD) are in place optometrists need to understand the etiopathogenesis of the disease in order to reduce patient's risk for severe vision loss by early identification and timely referral for laser photocoagulation. Optometrists should educate and inform patients about the natural history of the retinal abnormalities associated with AMD. In certain cases useful vision can be maintained if the patient is informed and educated to seek care promptly. Improved patient understanding of AMD will promote compliance and in some cases may help preserve useful vision.
Subgroups Most Likely to Benefit:
Patients within the following groups at risk should be screened for signs and symptoms of age-related macular degeneration:
- Persons over 60 years of age
- Persons with hypertension or cardiovascular disease
- Cigarette smokers
- Persons with a first-degree family (sibling or maternal) history of vision loss from AMD regardless of age
- Persons with aphakia or pre-1984 pseudophakia
- Persons whose history indicates significant cumulative light exposure
Potential Harms
Not stated
Qualifying Statements
Clinicians should not rely on this Clinical Guideline alone for patient care and management. Please refer to the references and other sources listed in the original guideline for a more detailed analysis and discussion of research and patient care information.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical Algorithm
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- American Optometric Association. Care of the patient with age-related macular degeneration. 2nd ed. St. Louis (MO): American Optometric Association; 1997. 47 p. (Optometric clinical practice guideline; no. 6). [73 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Funding was provided by the Vision Service Plan (Rancho Cordova California) and its subsidiary Altair Eyewear (Rancho Cordova California)
Guideline Committee
American Optometric Association Consensus Panel on Care of the Patient with Age-Related Macular Degeneration
Composition of Group that Authored the Guideline
Members: Anthony A. Cavallerano O.D. (Principal Author); John P. Cummings O.D.; Paul B. Freeman O.D.; Randall T. Jose O.D.; Leonard J. Oshinskie O.D.; John W. Potter O.D.
AOA Clinical Guidelines Coordinating Committee Members: John F. Amos O.D. M.S. (Chair); Kerry L. Beebe O.D.; Jerry Cavallerano O.D. Ph.D.; John Lahr O.D.; Richard Wallingford Jr. O.D.
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
According to the guideline developer this guideline has been reviewed on a biannual basis and is considered to be current. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the American Optometric Association Web site.
Print copies: Available from the American Optometric Association 243 N. Lindbergh Blvd. St. Louis MO 63141-7881
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This summary was completed by ECRI on December 2 1999. The information was verified by the guideline developer as of January 27 2000.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions as follows:
Copyright to the original guideline is owned by the American Optometric Association (AOA). NGC users are free to download a single copy for personal use. Reproduction without permission of the AOA is prohibited. Permissions requests should be directed to Jeffrey L. Weaver O.D. Director Clinical Care Group American Optometric Association 243 N. Lindbergh Blvd. St. Louis MO 63141; (314) 991-4100 ext. 244; fax (314) 991-4101; e-mail JLWeaver@AOA.org.
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