AMD -testing patients and management

Question 1

What is important in history when detecting AMD or recognising if px is at risk?

Answer 1

Diet, systemic conditions like diabetes, htn, high cholesterol, overweight px, smoker, FH of AMD, previous cataract sx

Question 2

What symptoms should you look out for?

Answer 2

Reduced vision, distortion, gradual or sudden onset, 1 eye or both, difficulty performing tasks like reading, cooking, any dietary supplements?

Question 3

How can questions about vision onset help with management?

Answer 3

Only those with recent onset wet AMD are suitable for medical intervention.

Question 4

How can questions about daily tasks help with management?

Answer 4

May indicate that they need extra help around the house i.e. consider referral for low vision rehabilitation and/or to social care.

Question 5

Which chart is it better to measure VA with and why?

Answer 5

EDTRS logMAR

because there are far more letters in the 6/24 – 6/60 range, where many patients with AMD will see. This enables more precise measurement of visual acuity in these people.

It is also encouraging for someone with 6/60 vision to be able to read 5 letters on the logMAR chart rather than just 1 letter on a Snellen chart.

Question 6

How does VA play a role in management of AMD patients?

Answer 6

Treatment decisions for intravitreal injections are also made on the basis of the number of letters read on a logMAR chart in most hospitals.

NICE guidelines recommend Lucentis treatment only for those with VA between 6/12 and 6/96, so VA testing is important to determine whether they are eligible for treatment.

Also, in patients not suitable for medical intervention, VA helps to guide on referral for registration as SI or SSI.

Question 7

What other tests should be done to give important info about their VA?

Answer 7

Amsler

Contrast sensitivity

Colour vision

Microperimetry

Question 8

What is the purpose of an amsler test?

Answer 8

The amsler chart is a test of the central visual field.

The purpose is to plot areas of distortion and scotomas, which may indicate the presence of underlying neovascular changes.

Question 9

How can you use an amsler to monitor a patient?

Answer 9

Monitoring scotomatous areas is also useful in patients with established AMD and vision loss, as it helps the practitioner to give guidance on maximising the use of residual vision, for example using an eccentric viewing strategy.

(used to monitor pxs at risk of developing into wet amd)

Question 10

How is an amsler done?

Answer 10

Instructed to look at the chart daily to check for the distortions which may indicate the onset of wet AMD.

33cm, monocularly with reading spex
1. Do any of the lines in the grid appear wavy, blurred or distorted?
2. Do all the boxes in the grid look square and the same size?
3. Are there any “holes” (missing areas) or dark areas in the grid?
4. Can you see all corners and sides of the grid (while keeping your eye on the central dot)?
(30cm)
•

Question 11

What do you do if a patient stuggles with amsler instructions?

Answer 11

If a px struggles with procedure, you may suggest something simpler, like looking at some blinds, or a particular window frame each day.

Question 12

How can colour vision tests help?

Answer 12

Measurements of RedGreen and YellowBlue colour thresholds can provide a sensitive measure of functional change in AMD.

Question 13

What colour vision test can you use for AMD px?

Answer 13

Blue-yellow defects are commonly seen in early AMD, so Ishihara is not an appropriate test to use for assessing this condition.

Recent tests, such as the colour assessment and diagnosis (CAD) test, allow a more precise assessment of chromatic thresholds, which has been shown to be sensitive to early AMD.

Question 14

What can central visual fields detect?

Answer 14

In patients with central visual loss due to AMD, microperimetry can be useful to plot scotomas, monitor disease progression, and assess fixation stability.

Question 15

How can the info from central visual field tests help you manage px?

Answer 15

Training patients with central visual loss to use a non-foveal location to fixate (so-called ‘eccentric viewing’).

Question 16

Why is a dilated fundus exam important and using volk after?

Answer 16

In elderly patients with small pupils and media opacities, examination through the dilated pupil facilitates a thorough stereoscopic examination of the macular region.

A stereoscopic view (for example, using volk) will help substantially with the identification of elevations of the retina caused by subretinal or intraretinal fluid and fibrovascular membranes.

Question 17

What is the gold standard for identifying AMD at the hospital?

Answer 17

Fluorescein Angiography – gold standard for identifying wet AMD in hospital eye clinic.

Fundus autofluorescence – useful for evaluating geographic atrophy (usually in hospitals)

Question 18

Does px need to tell DVLA if they have AMD?

Answer 18

Px must inform DVLA if:
AMD in one eye (bus, coach, lorry drivers)

AMD in both eyes (car drivers)

(Bus, coach and lorry drivers need to inform the DVLA if they have AMD in one eye only)

Question 19

How do you as an optician manage dry AMD?

Answer 19

DON’T REFER asymptomatic early AMD OR late dry AMD
▪ No treatment for dry AMD

Reassurance as atm dry AMD doesn’t have any proven treatment so nothing we can do to reverse the changes of the drusen

Low vision aids
NB High adds

Prevention advice: quit smoking, diet of fruit and veg, AREDS supplement

Question 20

When do you refer DRY AMD?

Answer 20

Only refer LATE dry AMD to HES for certification of SI or to access low vision services OR if new symptoms develop suggesting wet AMD

Question 21

What is AREDS?

Answer 21

AREDS trial looked at the ability of antioxidants + zinc to prevent progression in people who already had AMD.

Found a significant reduction in the Odds ratio in people who took the anti-oxidants plus zinc. Zinc is concentrated in the retina and is required for the functioning of many enzymes, including ones with antioxidant functions.
Reduction in risk only applied to those with intermediate AMD, or advanced AMD in the fellow eye.

In other words, advising patients with untreatable advanced AMD in one eye to take the AREDS formulation of nutritional supplements, is supported by the literature as a way of potentially slowing progression in the fellow eye.

No evidence that it prevents AMD in people who don’t have it to start with.

ALWAYS TELL PX TO FIRST CHECK WITH GP BEFORE TAKING SUPPLEMENTS

Question 22

How would you tell patient they have AMD?

Answer 22

AMD is an eye condition which affects the central part of your retina which is called the
macula. It causes changes to your central vision.

Talk about what problems they may face, treatment, prevention, progression, give amsler

Question 23

How do you as an optician manage Wet AMD?

Answer 23

Urgent referral is warranted if there is a marked distortion, blurring or scotoma seen on Amsler, which is of RECENT onset, if there is a recent onset reduction in VA (whilst treatment will only be given to those in the range 6/12-6/96, newly developed CNV should still be referred urgently if the VA is outside of this range), or if a hyperopic shift in Rx has occurred.

Question 24

WHEN do you refer Wet AMD?

Answer 24

VA 6/12-6/96

No permanent structural damage to fovea

Lesion size < 12 disc areas

Evidence of disease progression.

Blood < 50% lesion area

Longstanding wet AMD with scar tissue formation, and nAMD with VA worse than 6/96 is not suitable for medical treatment, however best to refer all newly diagnosed wet AMD for ophthalmological opinion.

Question 25

What are the currently used treatments for Wet AMD?

Answer 25

Anti-VEGF antibody binds to & inhibits all forms VEGF-A:

Ranibizumab (Lucentis)
Bevacizumab (Avastin) and Pegaptanib (Macugen) are all anti-VEGF intravitreal injections used in treatment of wet AMD

Question 26

How does anti-vegf help wet amd?

Answer 26

In wet AMD, vascular endothelial growth factor molecules bind to VEGF receptors. This starts a cascade of chemical reactions, which leads to proliferation of vascular endothelial cells, and increased permeability and migration of vessels, all of which results in angiogenesis (the development of new vessels). Anti VEGF therapy attempts to disrupt this cycle, thereby providing a way of treating all types of neovascular AMD.

Question 27

Which anti-VEF is the treatment of choice

Answer 27

Ranibizumab

Question 28

Why is ranibizumab better than the other 2?

Answer 28

Pegaptanib less effective than Ranibizumab

Bevacizumab Not licensed for intraocular use, therefore not recommended by NICE

Question 29

What is Aflibercept (Eylea)?

Answer 29

Not an antibody, but a fusion protein made of two parts of VEGF-receptor molecule

Question 30

How does eyelea work and how often is it needed?

Answer 30

Blocks VEGF-A and B & Placental Growth Factor

3 x 4-weekly loading dose. 8-weekly maintenance dosing.

Question 31

What is NICE’s opinion on eylea?

Answer 31

2013: NICE approved for use in same patients eligible for Ranibizumab.
Effectiveness very similar.

Question 32

What is another treatment that’s rarely used for Wet AMD?

Answer 32

Photodynamic Therapy (PDT)

Question 33

What is PDT?

Answer 33

Intravenous injection of a photosensitizer, verteporfin- binds to low density lipoproteins in the blood, taken up by cells in new blood vessels. A low powered laser is directed onto the area of CNV to activate the photosensitizer.

Question 34

What is the disadvantage of PDT?

Answer 34

It leaves a scotoma as the choroid and retina in this region are also destroyed.

Retreatment required

Question 35

When might ophthalmologist decide to stop treating a WET AMD px?

Answer 35

Criteria for discontinuation: persistent deterioration VA; identification of anatomical changes in retina indicating inadequate response to therapy.

Question 36

3 signs of early AMD?

Answer 36

Soft Drusen

Focal Hyperpigmentation

Question 37

2 symptoms of early AMD?

Answer 37

Slight distortion on Amsler grid, corresponding to location of drusen
Gradual reduction in VA

Question 38

Management of early AMD?

Answer 38

Monitor, advise on lifestyle changes (e.g. stopping smoking and nutritional supplements) and provide Amsler grid for self-assessment.

Question 39

5 signs of WET amd?

Answer 39

Haemorrhage
Exudates
Visible retinal elevation
Sub-retinal fluid or pigment epithelial detachment
Sub-retinal neovascular membrane may be seen as greenish grey lesion

Question 40

3 symptoms of early AMD?

Answer 40

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

Question 41

Management of WET AMD?

Answer 41

REFER URGENTLY

via rapid access referral route if available locally

Question 42

5 signs of advanced AMD (Not suitable for treatment)

Answer 42

Geographic atrophy

Disciform scar

Extensive exudates,
haemorrhage, fibrosis, macular elevation

Question 43

2 symptoms advanced AMD

Answer 43

Central scotoma on Amsler chart

VA reduced to below 6/96

Question 44

Management of advanced AMD

Answer 44

Refer non-urgently to assess fellow eye, and consider LVA assessment and training, visual impairment counselling and registration.

Refer urgently if in any doubt Re. treatment suitability.

Question 45

What should always be given with verbal info to the px

Answer 45

WRITTEN INFO

Can also tell them about macular society or other helpful online sources of info