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Age-related macular degeneration

About

What is covered

This interactive flowchart covers diagnosing and managing age-related macular degeneration in adults. It aims to improve the speed at which people are diagnosed and treated to prevent loss of sight.

Updates

Updates to this interactive flowchart

11 February 2019 Serious eye disorders (NICE quality standard 180) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on age-related macular degeneration in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing and managing age-related macular degeneration in adults. It aims to improve the speed at which people are diagnosed and treated to prevent loss of sight.

Updates

Updates to this interactive flowchart

11 February 2019 Serious eye disorders (NICE quality standard 180) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Age-related macular degeneration (2018) NICE guideline NG82
Epiretinal brachytherapy for wet age related macular degeneration (2011) NICE interventional procedures guidance 415
Limited macular translocation for wet age-related macular degeneration (2010) NICE interventional procedures guidance 339
Transpupillary thermotherapy for age-related macular degeneration (2004) NICE interventional procedures guidance 58
Radiotherapy for age-related macular degeneration (2004) NICE interventional procedures guidance 49
Serious eye disorders (2019) NICE quality standard 180

Quality standards

Quality statements

Referral for cataract surgery

This quality statement is taken from the serious eye disorders quality standard. The quality standard defines clinical best practice for serious eye disorders and should be read in full.

Quality statement

Adults with cataracts are not refused surgery based on visual acuity alone.

Rationale

The decision to undertake cataract surgery should be based on discussions with the person about the effect of cataract on their quality of life, the risks and benefits of surgery and what may happen if they choose not to have surgery. Measurement of visual acuity often fails to detect vision problems that may benefit from cataract surgery (for example, glare and loss of colour vision). The decision should include consideration of a patient’s quality of life and symptoms such as difficulty with reading, night driving, work or home activities, glare and loss of contrast, despite appropriate optical correction. Restricting access to surgery based on visual acuity alone has an impact on quality of life for some people with cataracts. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.

Quality measures

Structure
Evidence of local agreements to include vision difficulties affecting quality of life in the criteria for referral and access to cataract surgery. The same criteria should be used for first- and second-eye cataract surgery.
Data source: Local data collection, for example, service specifications and local commissioning agreements for cataract surgery.
Process
a) Proportion of presentations of cataract where the person has a discussion about how their vision affects their quality of life.
Numerator – the number in the denominator where the person has a discussion about how their vision affects their quality of life.
Denominator – the number of presentations of cataract.
Data source: Local data collection, for example, patient records.
b) Proportion of presentations of cataract that are refused referral for surgery based on visual acuity alone.
Numerator – the number in the denominator that are refused referral for surgery based on visual acuity alone.
Denominator – the number of presentations of cataract.
Data source: Local data collection, for example, patient records or referral records.
c) Proportion of referrals for cataract surgery that are not accepted based on visual acuity alone.
Numerator – the number in the denominator that are not accepted based on visual acuity alone.
Denominator – the number of referrals for cataract surgery.
Data source: Local data collection, for example, patient records or referral records.
Outcome
Health-related quality of life for adults with cataracts.
Data source: Local data collection, for example, results from a questionnaire or patient-reported outcome measure on self-reported improvement after surgery, such as the Cat-PROM5 questionnaire (National Cataract Surgery Audit – Cat-PROM5 currently being piloted).

What the quality statement means for different audiences

Service providers (such as community optometry practices, referral management centres and NHS hospital trusts) ensure that referral pathways for cataract surgery are based on criteria that include vision difficulties affecting quality of life, and not just visual acuity alone. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.
Healthcare professionals (such as ophthalmologists, optometrists, orthoptists and advanced nurse practitioners) base decisions about cataract surgery on a discussion with the person of the impact of the cataract(s) on their quality of life and the risks and benefits of having, and not having, surgery. Visual acuity should not be used as the sole basis for deciding to refer for or perform surgery. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.
Commissioners (clinical commissioning groups and NHS England) commission services that provide access for adults to cataract surgery based on criteria other than visual acuity alone. The other criteria include vision difficulties affecting quality of life. They monitor services to ensure that this is happening. The decision to undertake cataract surgery should be made on the same basis for first and second eyes.
Adults with cataracts are involved in discussion of how cataracts affect their everyday life, how they affect their vision, the risks and benefits of surgery, and what would happen if they chose not to have surgery. Referral for cataract surgery is based on this discussion, and not only on the clarity and sharpness (particularly fine details) with which they can see objects. The decision to perform cataract surgery on the second eye should be made on the same basis.

Source guidance

Cataracts in adults: management (2017) NICE guideline 77, recommendations 1.2.1 and 1.2.2

Definitions of terms used in this quality statement

Based on visual acuity alone
The decision to refer an adult with cataracts for surgery should be based on a discussion with the person of the issues listed below, not on visual acuity alone:
  • how the cataract affects the person's vision and quality of life
  • whether 1 or both eyes are affected
  • what cataract surgery involves, including possible risks and benefits
  • how the person's quality of life may be affected if they choose not to have cataract surgery
  • whether the person wants to have cataract surgery.
[NICE’s guideline on cataracts in adults, recommendation 1.2.1]

Certificate of vision impairment

This quality statement is taken from the serious eye disorders quality standard. The quality standard defines clinical best practice for serious eye disorders and should be read in full.

Quality statement

Adults with serious eye disorders are given a certificate of vision impairment (CVI) as soon as they are eligible.

Rationale

A CVI allows easier access to services and support for adults with serious eye disorders. Making a person aware of the benefits associated with a CVI, and giving them the choice of having a CVI as soon as they are eligible, rather than waiting for treatment to finish, allows earlier access to services and support. This can help people retain or regain their independence and improve their wellbeing and quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with serious eye disorders are given information about the CVI and those meeting the eligibility criteria are given a certificate.
Data source: Local data collection, for example, a service protocol.
Process
Proportion of adults with serious eye disorders that meet the eligibility criteria for a CVI who are given a CVI.
Numerator – the number in the denominator who are given a CVI.
Denominator – the number of adults with serious eye disorders that meet the eligibility criteria for a CVI.
Data source: Local data collection, for example, patient records.
Outcome
Health-related quality of life for adults with serious eye disorders.
Data source: Local data collection, for example, a questionnaire.

What the quality statement means for different audiences

Service providers (NHS hospital trusts and community optometry practices) have systems in place to ensure that adults with serious eye disorders are given information about the support and services associated with certification. They ensure that adults can engage in the process as soon as they meet the eligibility criteria, including while they are having treatment. Services make sure people know about the benefits of certification, and know that they have a choice to have a CVI or not.
Healthcare professionals (optometrists, and ophthalmologists, orthoptists and nurses working in secondary care) make sure that people with serious eye disorders know about the benefits of certification and that they can have a CVI if they choose as soon as they are eligible. This includes while they are having treatment. Professionals give information about the support and services associated with certification. Ophthalmologists sign the certificate to formally certify adults with serious eye disorders as visually impaired.
Commissioners (clinical commissioning groups) ensure that providers have the capacity and resources to give information about the support and services associated with certification to adults with serious eye disorders as soon as they meet the eligibility criteria.
Adults with serious eye disorders are given a certificate of vision impairment as soon as they are eligible. This may be while they are still having treatment. They are also told about support and services, which can help them improve or regain their independence and wellbeing.

Source guidance

Definitions of terms used in this quality statement

Certificate of vision impairment
See the Department of Health and Social Care’s Certificate of vision impairment: explanatory notes for consultant ophthalmologists and hospital eye clinic staff in England, executive summary, sections 4, 9, 21, 29 to 34 inclusive.

Equality and diversity considerations

Healthcare professionals should adapt their communication to the needs of adults with sight difficulties so that they have the opportunity to be involved in decisions relating to certification of vision impairment. This includes being made aware of the benefits associated with having a CVI.
Physical or learning disabilities, hearing problems and difficulties with reading or speaking English, which may affect the patient's involvement in the consultation, should also be considered.
For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

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
  • continue to attend routine sight-tests with their community optometrist.
People with low vision have visual impairments that cause restriction in their everyday lives and that cannot be corrected by surgery, medicine, or glasses or contact lenses. This definition includes, but is not limited to, those who are registered as sight impaired or severely sight impaired. It can include blurred vision, blind spots or tunnel vision. A low-vision service provides a range of services for people with low vision to enable them to make use of their eyesight to achieve maximum potential.

Glossary

age-related macular degeneration
classic choroidal neovascularisation
fundus fluorescein angiography
(services set in secondary care providing diagnosis or treatment of the eye or vision-related conditions)
optical coherence tomography
photodynamic therapy
polypoidal choroidal vasculopathy
pigment epithelial detachment
retinal angiomatous proliferation
retinal pigment epithelial
vascular endothelial growth factor

Paths in this pathway

Pathway created: January 2018 Last updated: February 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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