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) and social www.aao.org/smartsight w-up after Treatment for AMD Neovascular w-up after Treatment isual acuity and about the need for prompt notification to anand about the need for prompt notification promptly aftercally even in absence of symptoms, but onset of new or significant visual symptoms causal relationship between smoking and AMD and other considerable health benefits of smoking cessation Refer patients with reduced visual function for vision rehabilitation (see services mately 4 weeks after treatment mately 4 weeks after  and fluorescein angi  Subsequent examinations, OCT,  and potentialEducate patients about the prognosis their visual and value of treatment as appropriate for assess their ownEncourage patients with early AMD eye exams for and to have regular dilated early detection of intermediate AMD  phenotypeEducate patients with a high-risk AMD of CNV about methods of detecting new symptoms ophthalmologist  to monitorInstruct patients with unilateral disease return periodi their vision in their fellow eye and to suggestive ofInstruct patients to report symptoms endophthalmitis, including eye pain or increased dis Encourage patients who are currently smoking to stop because there are observational data that support a Changes in medications and nutritional supplements medications and Changes in systemic history ocular history and Changes in smoking especially social history, Changes in V examination of the fundus Stereo biomicroscopic with intravitreal injectionsExamine patients treated or ranibizumab approxi of aflibercept, bevacizumab, fluorescein angiography at leastExamine and perform stable after verteporfin PDT every 3 months until with thermal laser photo Examine patients treated angiography approximatelycoagulation via fluorescein at 4 to 6 weeks 2 to 4 weeks after treatment and then dependingography should be performed as indicated of the treatingon the clinical findings and the judgment ophthalmologist functional status comfort, worsening eye redness, blurred or decreased vision, increased sensitivity to light, or increased num- ber of floaters promptly

  ollow-up ollow-up Physical Exam • • • • • • • • • • F Follo • • • Patient Education • • •

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Age-Related Macular Age-Related Degeneration (Initial Evaluation) and Follow-up ests

Physical Exam elements) (Key of classic CNV Visual symptoms, including decreased vision and Visual or retina, subretinal blood, hard exudates or or retina, subretinal blood, hard exudates or consistingpercentage of the lesion composed of or verteporfin PDT) to assist in determining the cause of visual loss that is not explained by clinical exam metamorphopsia to detect persistent or recurrent CNV following  to guide treatment (laser photocoagulation surgeryto guide treatment (laser photocoagulation to detect the presence of and determine the extent,to detect the presence of and determine when patient has unexplained when patient has unexplained blurred of the RPEwhen clinical exam reveals elevation subretinal fibrosis calculate the type, size, and location of CNV and to treatment when patient complains of new metamorphopsia Stereo biomicroscopic examination of the macula Stereo biomicroscopic Comprehensive eye examination Comprehensive eye  Systemic history (any hypersensitivity reactions) Systemic history (any of AMD especially family history Family history, especially smoking Social history, scotoma, photopsia, difficulties in dark adaptation) photopsia, difficulties scotoma, supplements and nutritional Medications Ocular history  Symptoms (metamorphopsia, decreased vision, (metamorphopsia, Symptoms

Follow-up Exam Follow-up History • • and manage any complications. • • Each angiographic facility must have a care plan or an emergency plan and a protocol to minimize the risk • • • Diagnostic T Optical coherence tomography is important in diagnos- Optical coherence AMD, particularly with respect toing and managing fluid and in docu- determining the presence of subretinal Optical coher menting the degree of retinal thickening. Initial • • • • • • • architectureence tomography defines the cross sectional with anyof the retina in a manner that is not possible It may reveal the presence of other imaging technology. alone. It alsofluid that is not apparent on biomicroscopy retina and RPEassists in evaluating the response of the to be followedto therapy by allowing structural changes accurately. in theIntravenous fundus fluorescein angiography clinical setting of AMD is indicated: • Initial Exam History elements) (Key • RETINA VIP =Verteporfin inPhotodynamicTherapy OCT =opticalcoherencetomography;PDT =photodynamictherapy;TAP =Treatment of Age-RelatedMacularDegenerationwithPhotodynamicTherapy; AMD =Age-RelatedMacularDegeneration; AREDS=Age-RelatedEyeDiseaseStudy;CNVchoroidalneovascularization; MPS=MacularPhotocoagulationStudy; MPS reports surgery asrecommendedinthe Thermal laserphotocoagulation VIP reports recommended intheTAP and PDT withverteporfinas ranibizumab literature 0.5 mgasrecommendedin Ranibizumab intravitrealinjection label status consent withrespecttotheoff- provide appropriateinformed The ophthalmologistshould reports 1.25 mgasdescribedinpublished Bevacizumab intravitrealinjection reports 2.0 mgasdescribedinpublished Aflibercept intravitrealinjection reports the originalAREDSandAREDS2 supplements asrecommendedin Antioxidant vitaminandmineral surgical therapies Observation withnomedicalor Recommended Treatment Age-Related (Management Recommendations)(Management Degeneration Age-RelatedMacular TreatmentDegeneration Age-RelatedMacular Follow-upfor Recommendationsand Plans

May beconsideredforjuxtapapillaryCNV CNV, neworrecurrent May beconsideredforextrafovealclassic PDT, butmaybeconsideredinselectcases. Juxtafoveal CNVisanoff-labelindicationfor areas insizewhenthevisionis>20/50 vision <20/50oriftheCNVis<4MPSdisc Occult CNVmaybeconsideredforPDTwith linear diameter the entirelesionis classic componentis>50%ofthelesionand Macular CNV, neworrecurrent,wherethe Macular CNV Macular CNV Macular CNV Advanced AMDinoneeye(AREDScategory4) Intermediate AMD(AREDScategory3) geographic atrophyordisciformscars Advanced AMDwithbilateralsubfoveal Early AMD(AREDScategory2) No clinicalsignsofAMD(AREDScategory1) Diagnoses EligibleforTreatment

5400 microns in greatest 5400 micronsingreatest

Monitoring ofmonocularnearvision (reading/Amslergrid) Retreatments asindicated depending ontheclinicalandangiographicfindings 4 weeksaftertreatment,andthenatto6thereafter Return examwithfluoresceinangiographyapproximately2to Monitoring ofmonocularnearvision(reading/Amslergrid) retreatments asindicated Return examapproximatelyevery3monthsuntilstable,with Monitoring ofmonocularnearvision(reading/Amslergrid) treating ophthalmologist follow-up dependsontheclinicalfindingsandjudgmentof Return examapproximately4weeksaftertreatment;subsequent increased sensitivitytolight,ornumberoffloaters discomfort, worseningeyeredness,blurredordecreasedvision, of endophthalmitispromptly, includingeyepainorincreased Patients shouldbeinstructedtoreportanysymptomssuggestive Monitoring ofmonocularnearvision(reading/Amslergrid) treating ophthalmologist follow-up dependsontheclinicalfindingsandjudgmentof Return examapproximately4weeksaftertreatment;subsequent increased sensitivitytolight,ornumberoffloaters discomfort, worseningeyeredness,blurredordecreasedvision, of endophthalmitispromptly, includingeyepainorincreased Patients shouldbeinstructedtoreportanysymptomssuggestive Monitoring ofmonocularnearvision(reading/Amslergrid) results toevery4weeksinthefirstyearoftherapy. maintenance treatmentregimenhasbeenshowntohavecomparable and judgmentofthetreatingophthalmologist.Anevery8-week subsequent follow-upandtreatmentdependsontheclinicalfindings Return examinationapproximately4weeksaftertreatmentinitially; increased sensitivitytolight,ornumberoffloaters discomfort, worseningeyeredness,blurredordecreasedvision, suggestive ofendophthalmitis,includingeyepainorincreased Patients shouldbeinstructedtoreportpromptlysymptoms Fluorescein angiographyand/orOCTforsuspicionofCNV Fundus photographyand/orfundusautofluorescenceasappropriate for newsymptomssuggestiveofCNV Return examat6to18monthsifasymptomaticorprompt Monitoring ofmonocularnearvision(reading/Amslergrid) Fundus photosorfluoresceinangiographyasappropriate for newsymptomssuggestiveofCNV Return examat6to24monthsifasymptomaticorprompt OCT, fluoresceinangiography, orfundusphotosasappropriate for newsymptomssuggestiveofCNV Return examat6to24monthsifasymptomaticorprompt Evaluation PPP As recommendedintheComprehensiveAdultMedicalEye Follow-up Recommendations