Management of Wet Age-related Macular Disease (AMD) and Rapid Access Referral (updated Jan 2017)
Patients with exudative AMD have a more rapid onset of symptoms than those with the dry form. They notice central visual loss often accompanied by distortion developing over the course of a few days or weeks. Distortion may be the earliest sign. Patients may not notice early symptoms when only one eye is affected and it is not unusual for them to present at a late stage with their first eye.
Treatment with ranibizumab (Lucentis) is now available in Gloucestershire according to NICE guidance. Most patients with wet AMD who have experienced recent progression of symptoms and whose vision falls within the guidelines are now eligible for treatment for first and second eyes.
In a proportion of patients, treatment leads to an improvement in vision but in the majority it stabilizes vision so it remains very important that patients should be seen as early as possible in the course of the disease process and ideally within a few days of onset of symptoms. In order not to overload the service and to prevent disappointment, it is also important that only those patients with any hope of benefiting from the treatment should be referred urgently. As most patients are referred via their optometrists, a rapid access referral system is now well established to allow optometrists to refer directly.
Wet AMD Rapid Access Referral (updated Nov 2016)
The new fax number for the wet AMD referral service is 0300 422 5995. Version 5 of the referral form incorporating this change is now available for download. Please see the link at right of this page or our 'Forms and Leaflets to Download' page. Please now use this version of the form when necessary and ensure you retain a copy of the referral for your records and send a copy to the patient's GP.
After referral the patient should expect to be contacted by the hospital within 2-3 days. It is good practice to explain this to the patient and ask them to contact you if they have not heard within this time. In these circumstances contact the Central Booking Office on 0300 4226878 to confirm they have received the faxed referral.
On receipt of the referral, the patient will be contacted directly and then assessed by a retinal specialist. If the diagnosis is confirmed using optical coherence tomography (OCT) and fluorescein angiography and if the patient falls within NICE guidance (see below), they will be offered treatment with ranibizumab. Treatment is offered in Cheltenham General Hospital and in Gloucestershire Royal Hospital.
Copies of our patient information leaflet are available from the Hospital website www.gloshospitals.org.uk.
Management of wet age-related macular disease (AMD) in Gloucestershire
Ranibizumab (Lucentis), within its marketing authorisation, is recommended as an option for the treatment of wet age-related macular degeneration if all of the following circumstances apply in the eye to be treated
the best-corrected visual acuity is between 6/12 and 6/96
there is no permanent structural damage to the central fovea
the lesion size is less than or equal to 12 disc areas in greatest linear dimension
there is evidence of recent presumed disease progression (blood vessel growth, as indicated by fluorescein angiography, or recent visual acuity changes)
Lucentis has been shown to improve vision in approximately 30% of patients and to maintain vision in over 90%. It remains vitally important that eligible patients should be referred as quickly as possible.
Routes of referral
Patients usually present to their optometrist.
Only those with recent symptoms of wet AMD should be referred using the fast track system.
The existing guidelines should be followed and the existing form completed and faxed as before.
Patients presenting with symptoms in their first or second eye should be referred
Patients presenting to their GP should be referred urgently to the retinal team.
If there is some uncertainty, local optometrists are usually happy to advise at short notice and to make the appropriate referral.
At risk patients under the care of the Eye Department or who have been discharged on an open appointment and who are aware of symptoms to look out for can contact the eye department directly.
Patients will be assessed in the retinal clinic. Investigations will usually include optical coherence tomography and fluorescein angiography.
Those falling within the guidelines for treatment with Lucentis will then be seen in a designated assessment clinic. Those eligible for treatment will usually start their injections the same day.
Patients with occult wet AMD but no evidence of recent progression will be monitored.
OCT (optical coherence tomography) is a non invasive investigations which is an essential tool in monitoring change. It allows quantification of macular thickness and demonstrates intraretinal and subretinal fluid
Treatment consists of 3 intra vitreal injections at monthly intervals.
Further injections are given according to findings at subsequent assessment visits
Patients should expect to attend monthly for assessment and/or injection &ndash it is very important that retreatment should not be delayed if it is necessary.
It is not certain how long monitoring and treatment needs to continue, but it will be for at least 2 years.
Generally, treatment is well tolerated and adverse events are rare, however patients need to be aware of the risks. Information and counselling are provided. Trust based information booklets are available.
Low visual aid assessment and referral to social services (with or without registration) will be offered where appropriate.
Copies of the referral form can be downloaded from this site - please see the link at right of this page or our 'Forms and Leaflets to Download' page.
Other useful information:
Nutritional supplementation in ARMD - advice written by Mrs Barbara Harney - see link to the right of this page.