Commissioning Guidance - Age Related Macular Degeneration Services

  • 16 Jun 2021
  • RCOphth

The macula is the centre of the retina that is responsible for high quality central vision. Age related macular degeneration (AMD) is a chronic progressive degenerative disease of the macula typically affecting people over the age of 50 years. There are two types of advanced forms of the disease, commonly called dry and wet AMD. Whilst the dry form is a slowly deteriorating condition with no treatment at present, the wet form presents acutely and needs both urgent and chronic treatment over years.

This condition is the most common cause of visual impairment in the older population significantly affecting their quality of life and independence. Other than the cost incurred by social services, the cost of providing care for wet AMD is very high due to the cost of the drugs and the treatment burden of frequent visits to ophthalmology departments over several years. Moreover, as treatment must be initiated urgently, fast-track services need to be implemented. The demand for this service has already affected the capacity of several ophthalmology departments and is projected to rise as the ageing population increases, highlighting the need to continually plan for the chronic management and the growing need. New and existing drugs are being evaluated to reduce burden, ensure cost effectiveness, and improve outcomes. There is a need to incorporate them into these services.

People with advanced forms of AMD also require low visual aids, counselling on coping with their vision, advice on available support and have associated conditions and risk of falls that may also require treatment. Most patients with AMD are elderly, and many have other chronic diseases and mobility issues. Therefore, transport needs should be considered, and services should be readily accessible in terms of location, parking, public transport, and hours of opening. Stable treated AMD patients may be evaluated in the community. Psychological counselling regarding the loss of vision is also required. Eye Clinic Liaison Officers (ECLOs) are essential throughout a patient journey and people need the help of family/friends to attend appointments.
It is important to establish joint care with optometry services for diagnosis, referral, and monitoring of stable patients. Particularly as an ageing population increases demand upon healthcare services, pathway design must consider efficiency and cost-effectiveness of services and treatments to deliver the best possible care to patient within the resources available to the NHS. However, a patient focused approach should be the overarching principle when designing local pathways. New ways of delivering care such as telemedicine, clinical decision tools incorporating artificial intelligence and diagnostic hubs and treatment centres are to be evaluated to benefit the patients, NHS, and the wider society.

Read the Editorial in Eye Chandra, S., McKibbin, M., Mahmood, S. et al. The Royal College of Ophthalmologists Commissioning guidelines on age macular degeneration: executive summary. Eye (2022).