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Assessment and
management of AMD
hyper-reective material underlying the
RPE is clearly visible on the tomogram.
Furthermore, the local elevations of
the RPE caused by drusen are also
apparent on an OCT image (Figure 3).
When a patient is referred to the
hospital with suspected wet AMD,
uorescein angiography is carried out
as a standard procedure to conrm
the presence and type of choroidal
neovascularisation. Fluorescein
angiography is also an important
tool in differentiating between
neovascularisation attributable
to AMD and that caused by other
conditions such as myopia and
birdshot choroidopathy, which may
require different treatment strategies.
2
VA is often relatively unaffected in
early AMD, but there is evidence to
suggest decits in other aspects of visual
function when fundus changes are still
mild. Reduced sensitivity to icker
3

and elevated cone and rod thresholds
4

have been reported in individuals
with ARM before marked VA loss has
occurred. There is substantial evidence
that the rod and cone adaptation are
also delayed in very early macular
disease.
5,6
The macular photostress test
is one way that cone adaptation may
be assessed quickly and easily in the
REFERRAL REFINEMENT PART 4 COURSE CODE: C-16276 O/D
Dr Alison Binns, BSc (Hons), PhD, MCOptom
The previous article in this series outlined the key features of age-related macular
degeneration (AMD), a condition that is responsible for more than half of all
registrations as sight-impaired or severely sight-impaired in the UK.
1
A review
of treatments showed that medical intervention is currently only available
for those with the active, wet form of the disease. Although those with early
AMD (also known as age-related maculopathy - ARM), dry AMD (geographic
atrophy), and end stage wet AMD are not responsive to current medical
treatments, they still present at optometric practices requiring management.
This article provides an overview of the optometric assessment of patients with
suspected ARM and AMD, and appropriate management of these patients.
Clinical Assessment of ARM
and AMD
Diagnosis and monitoring of AMD in the
clinic has historically been based on the
assessment of visual acuity (VA), Amsler
chart, and fundus examination of retinal
signs. Fundus examination in recent
years has expanded to include not only
direct and indirect ophthalmoscopy,
but also imaging techniques such as
(stereo) fundus photography and optical
coherence tomography (OCT). Intra-
retinal or sub-retinal uid accumulation
or sub-retinal pigment epithelium (RPE)
neovascular membranes will cause a
raised area of the retina, which may not
be immediately appreciated without a
three dimensional view of the fundus.
Binocular indirect ophthalmoscopy
(Volk or BIO headset) and stereo
fundus photography provide a means
of accurately identifying elevations of
the retina. OCT, which provides a cross-
sectional view of the retinal layers, not
only allows the clinician to identify
raised or thickened areas of the retina,
but also allows some visualisation of the
nature of the material that is causing the
elevation. For example, Figure 1 shows
a serous pigment epithelial detachment
(PED), where the uid under the RPE
is seen as black due to its low relative
optical reectivity, whilst Figure 2 shows
a brovascular membrane, where the
Figure 1
Fundus photograph (left) and OCT image (right) of serous PED. Black arrow indicates location of OCT scan.
Note the bright band of OCT image corresponding to the RPE (marked with a green arrow) shows dome-
shaped elevation with accumulation of uid beneath, seen as a dark region due to its low relative optical
reectivity. Images courtesy of Ashley Wood, Cardi University


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clinic. Margrain and Thomson
7
found
the technique to be most repeatable
after exposure of the macula to an
ophthalmoscope light for 30 seconds,
followed by assessment of the time taken
for VA to return to within one line of its
pre-bleach level. Their data suggest that
a healthy 60-year-old person should
have a recovery time of less than about
60 seconds, and that any delay beyond
this may be considered abnormal.
There is also evidence that patients
who are at higher risk of developing
choroidal neovascularisation will
have more marked delays on the
macular photostress test.
8
This may
provide a useful adjunct to the Amsler
chart, which is commonly used to
look for central visual distortions in
patients at risk of wet AMD (Figure 4).
Optometric management of
ARM and AMD
Age-related maculopathy
On identifying drusen or pigmentary
changes in the retina, a key role of
the optometrist is to exclude the
possibility of neovascular changes
through thorough fundus examination
and checking for marked central visual
eld distortions using the Amsler chart
(bearing in mind that drusen may
themselves cause small distortions).
These patients should be referred for
urgent ophthalmological assessment
if they have noticed a sudden onset
of blurring or distortion of the central
vision. Not all patients with drusen will
imminently develop severe visual loss
(one study observed that nine out of 49
patients with bilateral drusen developed
severe sight loss in at least one eye
over a period of about ve years).
9

However, patients should be made
aware of the risks of developing late
AMD and the symptoms of wet AMD.
Patients with risk factors for developing
choroidal neovascularisation (eg,. lots of
large soft and conuent drusen and/or
focal hyperpigmentation, or wet AMD
in the fellow eye) should be monitored
particularly closely. Amsler charts
may be given to patients to take home
so that they can check for distortions
in their vision on a daily basis. It is
important that the patient understands
how to carry out the test (for example,
the importance of checking each eye
separately), and it is also vital that
they understand the need for prompt
assessment should any changes
in their vision become apparent.
The optometrist should consider
giving advice to patients with ARM
about lifestyle changes which may
reduce their risk of developing
advanced AMD. Epidemiological
10

and longitudinal
11
studies have
consistently reported that smoking is
the strongest modiable risk factor for
the development of late AMD, which
gives a rm basis for recommending
that patients with ARM stop smoking.
Some population-based studies have
indicated that increased light exposure,
especially to short wavelength (blue)
light, may also be a risk factor for
AMD.
12-17
Although this nding has
not been universal,
18,19
it may be wise
to advise individuals at risk of AMD
and those with early fundus changes
to wear protective sunglasses when
outdoors, especially on bright days.
Other nominated modiable risk factors
such as elevated body mass index
(BMI), lack of physical activity and
excessive alcohol consumption are less
consistently signicant across studies.
20

Nutritional supplements
The efcacy of nutritional supplements
in preventing or delaying the onset of
late AMD has been a matter of some
debate. The rst large randomised
controlled trial of the benets of
supplementation for people with early
ARM was the Age-Related Eye Disease
Study (AREDS).
21
This study reported
a 28% risk reduction in progression
from intermediate to late AMD over ve
years in people taking a combination of
zinc plus antioxidants (high dosage of
vitamins C, E and beta carotene). There
was evidence of a benecial effect in
those who had at least one large druse,
multiple intermediate sized drusen,
parafoveal geographic atrophy in one or
both eyes, or unilateral advanced AMD
(individuals with only small drusen
did not benet). There is, therefore, a
strong case for recommending vitamin
supplements conforming to the AREDS
formulation for people who fall into
this intermediate AMD category.
Figure 2
Fundus photograph (left) and OCT image (right) of choroidal neovascular membrane resulting in PED.
Black arrow indicates location of OCT scan. Note disruption of RPE on OCT image, and reective material
beneath (red arrow). Images courtesy of Ashley Wood, Cardi University


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advanced AMD.
22
There was also an
apparent decrease in the risk of early
AMD with regular sh consumption.
The carotenoids lutein and
zeaxanthin, which are the main
constituents of macular pigment, have
also been the subject of much interest
given their protective antioxidant
and short wavelength absorption
characteristics. Large epidemiological
studies have found a reduced incidence
of intermediate and advanced AMD
in those individuals with the highest
dietary intake of these dietary factors,
suggesting that they may indeed have
a protective effect in individuals
predisposed to AMD.
23
Green, leafy
vegetables such as kale and spinach
are a particularly good source of
these carotenoids. On the basis of the
evidence, advising patients to include
regular sh and green, leafy vegetables
in their diet is a reasonable precaution
to take, but it should be noted that
the protective effect cannot be fully
determined until large, randomised
controlled trials have been carried out.
Wet AMD
Patients who require urgent referral
to the hospital eye service (HES) by
the optometrist are those who present
with newly developed wet AMD. These
patients are at risk of rapid development
of visual loss, and are also the patients
who could potentially benet from
medical intervention, particularly
the anti-VEGF therapy ranibizumab
(Lucentis; Novartis Pharma AG,
Switzerland and Genentech, California).
There are guidelines provided by the
College of Optometrists for referral of
AMD cases, but these were published
in 2005, pre-dating the widespread use
of therapies based on growth factor
inhibitors.
24,25
Other referral guidelines
have been published since, for example
by Novartis, with specic reference to
anti-VEGF treatments.
26
The key features
of these documents are the same; newly
developed wet AMD warrants urgent
attention by an ophthalmologist. Delayed
treatment for wet AMD has been strongly
associated with a poorer visual outcome,
so time is of the essence.
27
Some health
authorities now employ a direct referral
scheme for these patients,
for example hospitals in
Wales use an AMD direct
referral pad, adapted
from the Thames Valley
Macular Group Referral
Pad, which allows urgent
and direct referral straight
to the local macular
specialist. In a different
scheme, Manchester
Royal Eye Hospital
runs an optometry-led
Contraindications for the AREDS
supplements include smoking, anaemia
and Alzheimers disease.
20
Some
supplements that are currently available
commercially lack beta carotene and so
are less hazardous to current smokers.
However, there is less rigorous
evidence available regarding the efcacy
of such non-AREDS formulations.
Evidence for the benecial effects
of other dietary factors is less robust.
Omega-3 long chain polyunsaturated
fatty acids are required to maintain
healthy photoreceptor outer segments,
and may be associated with preventing
oxidative, inammatory and age-related
damage to the retina. Oily sh such as
salmon and tuna are rich in omega-3
fatty acids, and other sources include
nuts, seeds and olive oil. A recent
systematic review of nine studies that
had evaluated
the benets of
omega-3 fatty
acid intake (and
included a total
of 88,974 people)
found that a high
dietary intake
of omega-3 was
associated with
a 38% reduction
in the risk of
d e v e l o p i n g
Figure 3
Fundus photograph (left) and OCT image (right) of drusen. Black arrow indicates location of OCT scan. Note
bright band of OCT image corresponding to RPE (marked with a green arrow) is raised by underlying drusen
(red arrows). Images courtesy of Ashley Wood, Cardi University
Figure 4
Image showing the Amsler chart as it may be perceived by a patient with distortions due to wet AMD.
Images courtesy of National Eye Institute, National Institute of Health


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include metamorphopsia, recent onset
blurred central vision, VA loss and
uniocular hyperopic shift. Clinical
trials suggest that baseline VA does not
inuence the outcome of ranibizumab
treatment within the range of 6/12 to
6/48, and NICE guidelines support
medical intervention if presenting VA
is within the range of 6/12 to 6/96.
2
Advanced AMD
When AMD has advanced to a stage
where VA is markedly reduced (to less
than 6/96), as a result of geographic
atrophy or advanced wet AMD including
brosis or disciform scarring, treatment
is unlikely to result in a positive
outcome.
2
These patients should still be
referred to the HES on a non-urgent basis
for assessment of the fellow eye, and also
to determine whether they may benet
from other services available. A low
Fundus Features Functional Status Optometric Action
Dry ARM
Drusen (several small hard drusen are
considered a normal ageing change)
Focal Hyperpigmentation
Slight distortion on Amsler grid,
corresponding to location of drusen
Gradual reduction in VA
Monitor, advise on lifestyle
changes (eg, stopping smoking
and nutritional supplements)
and provide Amsler grid for self-
assessment.
Wet AMD
(Suitable
for
Treatment)
Haemorrhage (sub-RPE, sub-retinal, intra-
retinal)
Exudates (requires urgent referral as it is a
sign of leakage from new vessels)
Visible retinal elevation
Sub-retinal uid or pigment epithelial
detachment
Sub-retinal neovascular membrane may be
seen as greenish grey lesion
Presence of markedly distorted,
blurred, or absent lines on Amsler grid
Recent onset marked reduction in VA
(6/12 to 6/96)
Hyperopic shift in Rx
REFER URGENTLY
(via rapid access referral route if
available locally)
Advanced
AMD
Geographic atrophy
Disciform scar
Extensive exudates, haemorrhage, brosis,
macular elevation
Central scotoma on Amsler chart
VA reduced to below 6/96
Refer non-urgently to assess
fellow eye, and consider LVA
assessment and training, visual
impairment counselling and
registration.
Table 1
Summary of the clinical features of ARM, wet AMD and advanced AMD, and appropriate action for optometrists
vision assessment, visual impairment
counselling and/or registration as sight
impaired or severely sight impaired may
be appropriate. If they have only early
changes in the fellow eye, provision
of an Amsler grid for self-assessment,
and advice on lifestyle changes
should also be given (eg, stopping
smoking, nutritional supplements).
For patients with an AMD-related
visual impairment who are not
amenable to treatment, the optometrist
can also give useful advice on
household modications that may help
with performance of daily activities.
Generally increased lighting levels,
with directional lighting when reading,
can be particularly benecial. Advice
on improving contrast can also be
helpful, for example suggesting that
the patient use a thick black felt tip
pen when writing. Later articles in this
fast-access direct referral clinic, in
which optometrists and GPs may refer
patients directly to a referral renement
optometrist, who can then re-direct
either to the retinal specialist clinic
for treatment, or to alternative clinics/
discharge.
24
It is of great importance
that all optometrists familiarise
themselves with the local protocols for
normal referrals and fast track referrals.
Signs and symptoms of wet AMD
requiring urgent treatment are
summarised in Table 1. The key retinal
features are: intra-retinal/sub-retinal
or sub-RPE haemorrhage, the presence
of exudates (which suggests leakage
from the vessels, indicating a need
for urgent treatment), intra-retinal or
sub-retinal uid, PED, raised central
retina, and/or visible neovascular
membrane (often seen as a greenish
or greyish lesion). Functional changes

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series will look at the management of
patients with low vision at greater depth.
Summary
Patients with active wet (neovascular)
AMD require urgent medical treatment to
prevent rapid visual loss occurring. It is
important that all optometrists are aware
of the urgent referral pathway for these
patients in their area. Those individuals
with early AMD may benet from
guidance about modiable risk factors,
particularly with respect to smoking and
the potential positive effect of dietary
supplements. Even if the presence of
wet AMD has been excluded, advice on
monitoring for symptoms of choroidal
neovascularisation and the provision of
Amsler charts is advisable, especially
for those patients with risk factors for
development of wet AMD (such as
choroidal neovascularisation in the fellow
eye, or lots of large soft and conuent
drusen or focal hyperpigmentation of
the retina). Patients with end stage AMD
(geographic atrophy/disciform scarring)
should be referred non-urgently to check
the status of the fellow eye, and for low
vision aid provision and training, or
registration as sight impaired or severely
sight impaired. As new treatments
become available, referral guidelines
are likely to be reviewed in the future.
Five key points to remember:
Patients with early AMD should
be thoroughly examined to exclude
possibility of wet AMD and given
an Amsler chart to self-monitor.
Stopping smoking, taking AREDS
formulation dietary supplements
(to non-smoking patients only),
and the use of sunglasses on bright
days should be recommended.
If a patient has any signs of wet AMD
(Table 1), has noticed a sudden onset
of blurring or distortion of the central
vision, or shows marked distortion
on the Amsler grid, refer urgently
for ophthalmological assessment.
Referral pathways vary between
areas, and it is important for all
optometrists to know their local system.
When AMD has advanced to end-
stage disciform scarring or geographic
atrophy, refer non-urgently for low
vision assessment and evaluation of the
fellow eye. Advise on the importance
of improving lighting and contrast.
About the author
Dr Alison Binns is an optometrist
and a lecturer at the School of
Optometry and Vision Sciences, Cardiff
University. Her main research interests
include the early detection and monitoring
of age-related macular degeneration and
electrophysiology of the visual system.
References
See http://www.optometry.co.uk
clinical/index. Click on the article title
and then download "references".
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Course code: C-16276 O/D
1) Which of the following is NOT an advantage of OCT when
assessing AMD?
a) It allows visualisation of changes to dierent retinal layers
b) It helps dierentiation between dierent types of PED
c) It allows dierential diagnosis of classic and occult choroidal
neovascularisation
d) It helps to identify areas of retinal thickening due to oedema
2) The macular photostress test provides a rapid
assessment of:
a) Speed of cone adaptation
b) Speed of rod adaptation
c) Cone absolute threshold
d) Rod absolute threshold
3) If a patient presents with bilateral soft drusen in the
macular area and VA of 6/6 in both eyes, what is the MOST
appropriate course of action?
a) Refer for urgent ophthalmological assessment
b) Advise on lifestyle changes and monitor
c) Refer for non-urgent ophthalmological assessment
d) Refer for low vision assessment
4) If a patient presents with recent loss of central vision in their right
eye, accompanied by haemorrhage and oedema in the macular region,
and the best VA is 6/36, what is the MOST appropriate course of action?
a) Refer for urgent ophthalmological assessment
b) Advise on lifestyle changes and monitor
c) Refer for non-urgent ophthalmological assessment
d) Refer for low vision assessment

5) Which of the following statements about dietary supplements for
AMD is TRUE?
a) Low dose vitamin C and E taken daily reduces risk of progression from early to
late AMD
b) High dose vitamin C and E and beta carotene plus zinc taken daily reduces risk
of developing early AMD within ve years, in healthy individuals
c) High dose vitamin C and E and beta carotene plus zinc taken daily reduces risk
of progression from intermediate to late AMD within ve years
d) High dose vitamin C and E and beta carotene plus zinc taken daily reduces risk
of further visual loss in those patients with bilateral wet AMD

6) Which of the following statements about the referral of patients with
wet AMD is FALSE?
a) Urgent referral is only necessary if VA is poorer than 6/18
b) Urgent referral is not necessary if VA is poorer than 6/96
c) Sudden onset report of central scotoma should be referred urgently
d) Sudden onset report of blurred central vision should be referred urgently even
in the absence of choroidal neovascularisation
PLEASE NOTE There is only one correct answer. All CET is now FREE. Enter online. Please complete online by midnight
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