Neovascular age-related macular degeneration: decision making and optimal management.
OBJECTIVE
To review the decision-making processes and dilemmas in the delivery of services for neovascular age-related macular degeneration (nAMD) and describe its optimal management.


METHODS
Review of literature and presentation of illustrative cases.


RESULTS
Guidelines are available to aid commissioners and providers of services but with important gaps in advice. Increasing awareness of variants and diseases that mimic nAMD means that clinicians need to carefully assess lesions at presentation, using stereo imaging, fluorescein and indocyanine green angiography, and new generation optical coherence tomography. Current evidence supports the use of ranibizumab as first-line therapy. Evidence is unclear on the most appropriate treatment regime, especially in protocols relying on clinician-determined re-treatment. Current consensus recommends initiation with monthly injections for 3 months followed by maintenance comprising regular monthly visits with clinician-determined re-treatment. Further evidence on treatment protocols and the comparison with bevacizumab is awaited.


CONCLUSIONS
Owing to incomplete evidence base health professionals face a large number of controversies and dilemmas in care pathways for patients with nAMD. Treatment should be delivered against protocols developed locally in a systematic manner with consensus and a cautious approach to change.
Harding
S P
SP
Unit of Ophthalmology, School of Clinical Sciences, University of Liverpool, Liverpool, UK. s.p.harding@liverpool.ac.uk
D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized; D000068258:Bevacizumab; D019091:Critical Pathways; D003657:Decision Making; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use*; D008268:Macular Degeneration / Q000175:diagnosis / Q000188:drug therapy*; D017410:Practice Guidelines as Topic; D000069579:Ranibizumab; D042461:Vascular Endothelial Growth Factor A / Q000627:therapeutic use
D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D007155:Immunologic Factors; D042461:Vascular Endothelial Growth Factor A; D000068258:Bevacizumab; D000069579:Ranibizumab