Neovascular AMD
At a glance
New macular neovascularisation can cause rapid central visual loss. New distortion requires prompt assessment.
CAVE
- Do not wait for substantial acuity loss.
- A dry OCT alone may not explain new symptoms; examine for haemorrhage and alternative disease.
Clinical presentation
- Metamorphopsia, central blur or scotoma, macular haemorrhage and intraretinal or subretinal fluid.
Diagnosis & investigations
- Record symptoms, duration, best-corrected acuity and a dilated fundus examination in both eyes. Obtain macular OCT and compare with previous scans for fluid, pigment epithelial detachment, subretinal material, atrophy and fibrosis.
- Use fluorescein angiography when OCT does not exclude neovascularisation or the diagnosis is uncertain; ICGA may clarify suspected polypoidal choroidal vasculopathy. OCT angiography can demonstrate a vascular network, but a network alone does not establish exudative activity.
Differential diagnosis
- Central serous chorioretinopathy, myopic or inflammatory macular neovascularisation and non-neovascular AMD.
- Consider polypoidal choroidal vasculopathy when the phenotype or treatment response is atypical.
Treatment
- Use an authorised anti-VEGF regimen selected for the eye and available service; record any off-label use explicitly. Explain loading, expected visit burden and the purpose of maintenance even when vision feels unchanged. Do not use a single extension schedule for all drugs.
- Before switching for apparent non-response, confirm adequate dosing and exclude irreversible structural loss or an alternative diagnosis. Decisions to suspend treatment require documented inactivity or lack of expected benefit and a clear return plan.
| Finding | Action | Timing / detail |
|---|---|---|
| New suspected active nAMD | Urgent macular referral, OCT and angiography when diagnosis is uncertain; initiate anti-VEGF promptly when indicated | NICE: referral normally within 1 working day, treatment as soon as possible and within 14 days of referral when indicated |
| New/increasing intraretinal fluid, subretinal fluid, haemorrhage or disease-related visual decline | Treat active disease and shorten the interval relative to the interval at recurrence | Distinguish degenerative cysts and stable non-exudative spaces from active leakage |
| Stable acuity and controlled exudation on treat-and-extend | Extend in small, protocol-defined steps; administer the scheduled injection in a true treat-and-extend regimen | Minimum/maximum intervals and loading differ by drug and label; extension is not discharge |
| Persistent fluid or falling vision despite adequate treatment | Check adherence, interval, segmentation and alternative diagnoses; consider PCV, fibrosis/atrophy or another maculopathy before switching | Large recent submacular haemorrhage needs urgent retinal discussion of displacement/surgical options |
Follow-up
- At each treatment visit record acuity, symptoms, OCT activity and new haemorrhage; reassess the fellow eye. Teach monocular self-monitoring and rapid access for new distortion or loss. After injection, increasing pain, redness or reduced vision requires urgent assessment for endophthalmitis or inflammation, not waiting for the next injection.
Risk factors & context
- Age, smoking, family history and AMD in the fellow eye inform risk.
- Symptoms are more useful for urgent triage than risk factors alone.
Complications
- Submacular haemorrhage, fibrosis and atrophy can limit recovery despite control of exudation.
- Injection-related infection needs emergency assessment.
When to refer
- New distortion or macular haemorrhage warrants urgent macular assessment; post-injection pain with visual loss requires emergency review.
References 2
- AAO · Age-Related Macular Degeneration Preferred Practice Pattern ↗2025 · Diagnosis; management; patient education
- NICE · Age-related macular degeneration ↗NG82 · 23 January 2018 · 1.4 Referral; 1.5 Diagnosis; 1.7 Management
UK guidance: referral pathways and funding criteria may differ elsewhere.