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Age-Related Macular Degeneration (AMD)

NICE guideline [NG82] Age-related macular degeneration. Published: Jan 2018. NICE CKS Macular degeneration - age-related. Last revised: Aug 2022.

Background Information

There 2 main types of AMD:
 
  Dry AMD (Atrophic) Wet AMD (Neovascular / Exudative)
Prevalence ~90% of AMD cases ~10% of AMD cases
Pathophysiology Gradual atrophy of retinal pigment epithelium (RPE) and photoreceptors Choroidal neovascularisation → leakage, haemorrhage, fibrosis

This is the classification system used by NICE, but is of excessive detail and unlikely to be examined.
 
AMD classification Definition

Normal eyes

  • No signs of age-related macular degeneration (AMD)

  • Small ('hard') drusen (less than 63 micrometres) only

Early AMD

Low risk of progression:

  • medium drusen (63 micrometres or more and less than 125 micrometres) or

  • pigmentary abnormalities

Medium risk of progression:

  • large drusen (125 micrometres or more) or

  • reticular drusen or

  • medium drusen with pigmentary abnormalities

High risk of progression:

  • large drusen (125 micrometres or more) with pigmentary abnormalities or

  • reticular drusen with pigmentary abnormalities or

  • vitelliform lesion without significant visual loss (best-corrected acuity better than 6/18) or

  • atrophy smaller than 175 micrometres and not involving the fovea

Late AMD (indeterminate)

  • Retinal pigment epithelial (RPE) degeneration and dysfunction (presence of degenerative AMD changes with subretinal or intraretinal fluid in the absence of neovascularisation)

  • Serous pigment epithelial detachment (PED) without neovascularisation

Late AMD (wet active)

  • Classic choroidal neovascularisation (CNV)

  • Occult (fibrovascular PED and serous PED with neovascularisation)

  • Mixed (predominantly or minimally classic CNV with occult CNV)

  • Retinal angiomatous proliferation (RAP)

  • Polypoidal choroidal vasculopathy (PCV)

Late AMD (dry)

Geographic atrophy (in the absence of neovascular AMD)

Significant visual loss (6/18 or worse) associated with:

  • dense or confluent drusen or

  • advanced pigmentary changes and/or atrophy or

  • vitelliform lesion

Late AMD (wet inactive)

  • Fibrous scar

  • Sub-foveal atrophy or fibrosis secondary to an RPE tear

  • Atrophy (absence or thinning of RPE and/or retina)

  • Cystic degeneration (persistent intraretinal fluid or tubulations unresponsive to treatment)

Note that eyes may still develop or have a recurrence of late AMD (wet active)

Guidelines

This article presents a high-yield summary of the NICE guideline and common clinical practice on AMD, created for educational purposes. It focuses on core diagnostic and treatment principles and may omit some details, eligibility thresholds, or procedural steps found in the full guideline.

Test Findings suggestive of AMD
Amsler grid
  • Metamorphopsia (straight lines appear wavy or distorted)
  • Scotomas (parts of the lines missing)
Fundoscopy
  • Dry AMD
    • Drusen - main finding
    • Retinal pigment epithelium atrophy / hypertrophy (mottling)
 
  • Wet AMD - indicated by choroidal neovascularisation
    • Subretinal / intraretinal fluid
    • Subretinal haemorrhage
    • Retinal pigment epithelial detachment
 

Slit lamp biomicroscopic fundus examination is the mainstay for diagnosis of both early and late AMD
  • If dry AMD is suspected, slit lamp alone is enough, no need for the below investigations

Further imaging for wet AMD:
  • 1st line: optical coherence tomography - detects subretinal / intraretinal fluid
  • 2nd line: fundus fluorescein angiography (FFA) - used to confirm choroidal neovascularisation (dye leaks out of vessels)

If AMD is suspected, refer urgently to ophthalmology
 

There are currently no pharmacological treatments for dry AMD.

Mainstay of management is active observation and supportive:
  • Stop smoking - proven to reduce risk of progression
  • Consider antioxidant vitamin and mineral supplementation (AREDS2 formula: vitamin C, vitamin E, zinc oxide, copper, lutein, and zeaxanthin)
  • Healthy balanced diet (low glycaemic index, rich in fruits, green leafy vegetables and fish high in omega-3 fatty acids)

Mainstay of management: intravitreal anti-VEGFVascular endothelial growth factor therapy (ranibizumab, aflibercept, bevacizumab)

 

NICE recomends not to offer photodynamic therapy and intravitreal corticosteroids as an adjunct to anti-VEGFVascular endothelial growth factor therapy.

References

Author: Adams Lau
Reviewer:
Last edited: 20/07/25