Monitoring and Follow-up
Self-monitoring
Once diagnosed, age-related macular degeneration (AMD) needs to be regularly monitored for progression both before treatment or rehabilitation is initiated (to guide the initiation decision) and afterward (to assess the effectiveness of the interventions). The American Academy of Ophthalmology (AAO) recommends that patients with early AMD (and even patients with no AMD but with family history of AMD) be encouraged to monitor their visual acuity at home to ensure that any vision changes are detected early.
A long-established tool for at-home assessment is the Amsler grid – a 10 cm × 10 cm sheet with a grid of 400 equal squares with a central dot (Figure 4-1A). The user fixes their sight (one eye at a time, covering the other eye) on the central dot and reports visual anomalies, such as line distortions, blurring or disappearance, which may indicate development of AMD (Figure 4-1B).
The advantage of the Amsler grid is that it is a low-cost option available to…
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Self-monitoring
Once diagnosed, age-related macular degeneration (AMD) needs to be regularly monitored for progression both before treatment or rehabilitation is initiated (to guide the initiation decision) and afterward (to assess the effectiveness of the interventions). The American Academy of Ophthalmology (AAO) recommends that patients with early AMD (and even patients with no AMD but with family history of AMD) be encouraged to monitor their visual acuity at home to ensure that any vision changes are detected early.
A long-established tool for at-home assessment is the Amsler grid – a 10 cm × 10 cm sheet with a grid of 400 equal squares with a central dot (Figure 4-1A). The user fixes their sight (one eye at a time, covering the other eye) on the central dot and reports visual anomalies, such as line distortions, blurring or disappearance, which may indicate development of AMD (Figure 4-1B).
The advantage of the Amsler grid is that it is a low-cost option available to nearly all patients. However, patients should still be trained to use it effectively – making sure to maintain the appropriate distance (12-15 inches) from the grid and to use only one eye at a time. Overall, the Amsler grid is a useful quantitative screening tool, but its lack of precision and a quantitative aspect makes it a poor option for monitoring disease progression.
Recent years have seen the expansion of electronic at-home monitoring tools, particularly mobile applications. Compared to the (physical) Amsler grid, the tests in these options have increased sensitivity and accuracy, the software allows for automated tracking and may include immediate alerts for disease progression. Some of the currently available software-based monitoring options are presented in Table 4-1.
Dilated Eye Examinations
In addition to self-monitoring, the AAO recommends that patients with early AMD should also have regularly scheduled dilated eye examinations to monitor for progression to intermediate AMD. For patients with early AMD, the AAO recommends a follow-up period of 6 months to 24 months for asymptomatic patients or as soon as symptoms of choroidal neovascularization appear. A panel of 11 United States-based expert eye care providers (ECPs; including optometrists, comprehensive ophthalmologists and retina specialists) recommends a follow-up interval of 12 months for early AMD.
For patients with intermediate AMD, especially those at high risk of progression to advanced AMD, the AAO recommends education on the methods of detecting symptoms of choroidal neovascularization and to report any such symptoms immediately. Furthermore, these patients should be offered education on the possible benefits of Age-Related Eye Disease Study 2 supplementation, which has a demonstrated benefit in this patient group (see Treatment Options and Therapies).
Follow-up testing may involve fundus photography, fluorescein angiography, optical coherence tomography (OCT) or optical coherence tomography angiography (as appropriate). The 11-expert United States panel considers OCT the preferred imaging modality because of its facility of use and widespread accessibility. Another United States-based panel of 15 expert ECPs (also composed of optometrists, comprehensive ophthalmologists and retina specialists) agreed that fundus autofluorescence and OCT are the preferred methods for monitoring progression to geographic atrophy, and that dilated fundoscopic examination is not sufficient on its own. Both panels consider a follow-up frequency of 6 months ideal in patients with intermediate or advanced AMD.
References
- Abdelsalam A, Del Priore L, Zarbin MA. Drusen in age-related macular degeneration: pathogenesis, natural course, and laser photocoagulation-induced regression. Surv Ophthalmol. 1999;44(1):1-29.
- Age-Related Eye Disease Study 2 Research Group. Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA. 2013;309(19):2005-2015.
