• Oct 2014
    AAO Retina PPP Panel, Hoskins Center for Quality Eye Care

    Introduction

    These are summary benchmarks for the Academy’s Preferred Practice Patterns® (PPP) guidelines. The Preferred Practice Patterns series of guidelines has been written on the basis of three principles.

    • Each Preferred Practice Pattern should be clinically relevant and specific enough to provide useful information to practitioners.
    • Each recommendation that is made should be given an explicit rating that shows its importance to the care process.
    • Each recommendation should also be given an explicit rating that shows the strength of evidence that supports the recommendation and reflects the best evidence available.

    Preferred Practice Patterns provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. They physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.

    The Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein.

    For each major disease condition, recommendations for the process of care, including the history, physical exam and ancillary tests, are summarized, along with major recommendations for the care management, follow-up, and education of the patient. For each PPP, a detailed literature search of PubMed and the Cochrane Library for articles in the English language is conducted. The results are reviewed by an expert panel and used to prepare the recommendations, which they rated in two ways.

    The panel first rated each recommendation according to its importance to the care process. This “importance to the care process” rating represents care that the panel thought would improve the quality of the patient’s care in a meaningful way. The ratings of importance are divided into three levels.

    • Level A, defined as most important
    • Level B, defined as moderately important
    • Level C, defined as relevant but not critical

    The panel also rated each recommendation on the strength of evidence in the available literature to support the recommendation made. The “ratings of strength of evidence” also are divided into three levels.

    • Level I includes evidence obtained from at least one properly conducted, well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.
    • Level II includes evidence obtained from the following:
      • Well-designed controlled trials without randomization
      • Well-designed cohort or case-control analytic studies, preferably from more than one center
      • Multiple-time series with or without the intervention
    • Level III includes evidence obtained from one of the following:
      • Descriptive studies
      • Case reports
      • Reports of expert committees/organizations (e.g., PPP panel consensus with external peer review) 

    PPPs are intended to serve as guides in patient care, with greatest emphasis on technical aspects. In applying this knowledge, it is essential to recognize that true medical excellence is achieved only when skills are applied in a such a manner that the patients’ needs are the foremost consideration. The AAO is available to assist members in resolving ethical dilemmas that arise in the course of practice. (AAO Code of Ethics)

    Initial and Follow-up Evalution

    Initial Exam History (Key elements)

    • Symptoms (metamorphopsia, decreased vision, scotoma, photopsia, difficulties in dark adaptation)
    • Medications and nutritional supplements
    • Ocular history
    • Systemic history (any hypersensitivity reactions)
    • Family history, especially family history of AMD
    • Social history, especially smoking

    Initial Physical Exam (Key elements)

    • Comprehensive eye examination
    • Stereo biomicroscopic examination of the macula

    Diagnostic Tests

    Optical coherence tomography is important in diagnosing and managing AMD, particularly with respect to determining the presence of subretinal fluid and in documenting the degree of retinal thickening. Optical coherence tomography defines the cross sectional architecture of the retina in a manner that is not possible with any other imaging technology. It may reveal the presence of fluid that is not apparent on biomicroscopy alone. It also assists in evaluating the response of the retina and RPE to therapy by allowing structural changes to be followed accurately.

    Intravenous fundus fluorescein angiography in the clinical setting of AMD is indicated:

    • when patient complains of new metamorphopsia
    • when patient has unexplained blurred vision
    • when clinical exam reveals elevation of the RPE or retina, subretinal blood, hard exudates or subretinal fibrosis
    • to detect the presence of and determine the extent, type, size, and location of CNV and to calculate the percentage of the lesion composed of or consisting of classic CNV
    • to guide treatment (laser photocoagulation surgery or verteporfin PDT)
    • to detect persistent or recurrent CNV following treatment
    • to assist in determining the cause of visual loss that is not explained by clinical exam

    Each angiographic facility must have a care plan or an emergency plan and a protocol to minimize the risk and manage any complications.

    Follow-up Exam History

    • Visual symptoms, including decreased vision and metamorphopsia
    • Changes in medications and nutritional supplements
    • Interval ocular history and systemic history
    • Changes in social history, especially smoking

    Follow-up Physical Exam

    • Visual acuity
    • Stereo biomicroscopic examination of the fundus

    Follow-up after Treatment for Neovascular AMD

    • Examine patients treated with intravitreal ijections of aflibercept, bevacizumab, or ranibizumab approximately 4 weeks after treatment
    • Examine and perform fluorescein angiography at least every 3 months until stable after verteporfin PDT
    • Examine patients treated with thermal laser photocoagulation via fluorescein angiography approximately 2 to 4 weeks after treatment and then at 4 to 6 weeks
    • Subsequent examinations, OCT, and fluorescein angiography should be performed as indicated depending on the clinical findings and the judgment of the treating ophthalmologist

    Patient Education

    • Educate patients about the prognosis and potential value of treatment as appropriate for their visual and functional status
    • Encourage patients with early AMD to assess their own visual acuity and to have regular dilated eye exams for early detection of intermediate AMD
    • Educate patients with a high-risk AMD phenotype about methods of detecting new symptoms of CNV and about the need for prompt notification to an ophthalmologist
    • Instruct patients with unilateral disease to monitor their vision in their fellow eye and to return periodically even in absence of symptoms, but promptly after onset of new or significant visual symptoms
    • Instruct patients to report symptoms suggestive of endophthalmitis, including eye pain or increased discomfort, worsening eye redness, blurred or decreased vision, increased sensitivity to light, or increased number of floaters promptly
    • Encourage patients who are currently smoking to stop because there are observational data that support a causal relationship between smoking and AMD and other considerable health benefits of smoking cessation 
    • Refer patients with reduced visual function for vision rehabilitation (see www.aao.org/smartsight) and social services

    Management Recommedations

    Treatment Recommendations and Follow-up Plans for Age-Related Macular Degeneration -- REFER TO PAGE 2 OF PDF FOR TABLE