AMD is the leading cause of visual impairment and blindness among older adults in Ireland. On completion of this module, it is expected the reader will have an enhanced understanding of the two primary forms of AMD, including risk factors, presentation and diagnosis. This module also discusses management and monitoring strategies, as well as the role of the pharmacist.
Introduction
Age-related macular degeneration (AMD) is a progressive, degenerative condition of the central retina that results in the gradual loss of central vision. It primarily affects the macula — the central part of the retina responsible for sharp, detailed vision — leading to difficulties with everyday activities such as reading, driving, and recognising faces. While peripheral vision is typically preserved, the loss of central vision can significantly impact independence and overall quality of life.
AMD is the leading cause of visual impairment and blindness among older adults in Ireland. More than 100,000 people in Ireland are currently living with AMD, with approximately 7 per cent of individuals over the age of 50 affected. As the population continues to age, the prevalence of AMD is expected to rise, posing increasing challenges for both patients and the healthcare system.
There are two primary forms of AMD: Dry (atrophic) and wet (neovascular). Dry AMD is the more common type, accounting for approximately 85- to-90 per cent of cases. It involves the gradual degeneration of macular retinal cells over time and typically progresses slowly. Wet AMD is
less prevalent but more severe. It is characterised by the growth of abnormal blood vessels beneath the retina that leak fluid or blood, which can cause sudden and significant central vision loss if left untreated.
Public awareness of AMD remains limited, and early symptoms are often overlooked. Pharmacists, as accessible healthcare professionals, are well positioned to support early identification, provide
patient education, and recommend management strategies that may delay disease progression and help preserve vision.
This CPD module will provide an overview of AMD, including its pathophysiology, risk factors, clinical presentation, diagnosis, evidence- based treatment guidelines, and the pharmacist’s role. Raising awareness among older adults and primary care providers is a key public health objective. Enhanced education initiatives and early screening efforts can lead to earlier diagnosis and improved clinical outcomes.
Pathophysiology
AMD is a complex, multifactorial disease that primarily affects the macula. Although the exact pathogenesis is not fully understood, it is believed to involve a combination of oxidative stress and chronic inflammatory processes. Understanding the underlying pathophysiology is essential to inform prevention, diagnosis, and treatment strategies.
A hallmark of early AMD is the accumulation of drusen – extracellular deposits that form between the retinal pigment epithelium (RPE) and Bruch’s membrane. These deposits interfere with nutrient and waste exchange, leading to oxidative damage and chronic inflammation. In dry AMD, progressive atrophy of the RPE and photoreceptors results in geographic atrophy, leading to a slow but irreversible decline in central vision.
In contrast, wet AMD is marked by the formation of abnormal choroidal blood vessels that leak fluid or blood into the retina. This leakage causes acute retinal damage and can result in rapid vision loss. Vascular endothelial growth factor (VEGF) plays a central role in promoting this abnormal vessel growth (neovascularisation), which forms the basis for the use of anti- VEGF therapies in the management of wet AMD.
Risk factors
There are several well-established non-modifiable and modifiable risk factors that contribute to the development and progression of AMD. Non-modifiable factors include age and genetics. Genetic predisposition plays
a role in AMD development. Variations in genes related to the complement system, such as CFH and ARMS2, have been linked to increased susceptibility, highlighting the complex genetic influence. Age is one of the most significant risk factors, with incidence rising sharply after age 60. A family history of AMD or having the condition in the other eye significantly increases the risk of developing the disease.
Smoking is the most significant modifiable risk factor, associated with both the onset and progression of AMD. Smokers have up to four times the risk compared to non-smokers.
A mild to moderate association between hypertension and AMD has been observed. Obesity and a lack of physical activity are also modifiable risk factors. In addition, a diet high in fat and low in omega-3 and omega-6 fatty acids, vitamins, carotenoids, and minerals is associated with an increased risk of AMD.
A comprehensive risk assessment should therefore include lifestyle habits, systemic health status, and family history. Pharmacists play an important role in identifying modifiable risks and offering tailored lifestyle advice, particularly in relation to smoking cessation, weight management, and nutrition.
Clinical presentation
The clinical presentation of AMD varies depending on the type and stage of the disease. Symptoms can differ significantly between individuals, and progression may be gradual or sudden. In early and intermediate dry AMD, patients are often asymptomatic or may notice mild blurring or difficulty reading in dim light. As the disease progresses to late AMD, patients may experience a gradual loss of detail or the appearance of a blank patch in the centre of their visual field. In contrast, wet AMD is often associated with a sudden onset of more severe symptoms.
Patients with wet AMD may report central distortion (metamorphopsia), blurred vision, or dark patches (scotomas), affecting tasks like reading, driving, and recognising faces. Although AMD often begins in one eye, bilateral involvement is common as the disease progresses, particularly in older adults. Ongoing monitoring of the unaffected eye is therefore essential. Prompt identification and referral are critical, especially in cases of wet AMD, where early treatment can significantly reduce the risk of irreversible vision loss.
Diagnosis
Diagnosis of AMD typically involves clinical history, visual function testing, and a detailed ocular examination, supported by imaging. Patients, typically over the age of 50, may present with central visual distortion, blurred vision, and difficulty reading, and should be referred to ophthalmology. Visual acuity testing is a useful initial tool for identifying central visual impairment.
Fundus examination, following pupil dilation, is important to detect hallmark features of AMD. In dry AMD, fundoscopy may reveal drusen and RPE changes. In wet AMD, findings may include subretinal fluid, haemorrhage, and pigment epithelial detachment, which are signs of choroidal neovascularisation.
Advanced imaging, particularly
The clinical presentation of AMD varies depending on the type and stage of the disease
optical coherence tomography (OCT),
are important in diagnosing and disease monitoring. OCT provides cross-sectional retinal images, allowing for the detection of intraretinal or subretinal fluid and RPE disruptions.
NICE guidance advises performing a fundus examination as part of the ocular assessment for patients presenting with visual changes or disturbances. Referral to hospital services is generally not required unless there are new symptoms suggestive of wet AMD. If wet AMD is suspected, urgent referral is essential, and OCT should be used to confirm the diagnosis. Early intervention can help preserve vision.
Management of AMD
The management of AMD depends on the disease subtype, with differing approaches to treatment and prognosis. While there is currently no curative therapy for either form, timely diagnosis and intervention are essential for slowing progression, preserving visual function and supporting patient independence. Patient education and involvement in shared decision-making are also vital for successful long-term disease control.
Management is tailored to the stage of disease, individual patient needs, and risk factors, underscoring the importance of early recognition and appropriate intervention. The goals of AMD management include optimising modifiable risk factors, preventing further vision loss, and helping patients adapt to visual impairment. A multidisciplinary approach is key to delivering effective care, with pharmacists having an important role to play in supporting these efforts.
Dry AMD is primarily managed through lifestyle modification, nutritional support, and monitoring for progression to wet AMD. Wet AMD, by contrast, requires urgent referral and prompt pharmacological therapy to control choroidal neovascularisation, as outlined in NICE guidelines.
Management of dry AMD
The management of dry AMD focuses on lifestyle modification, nutritional support, and regular monitoring to help slow disease progression. Due to its strong association with both onset and progression, smoking cessation remains a top priority. NICE guidelines recommend structured cessation interventions in all patients with AMD who smoke. These may include behavioural counselling and pharmacological aids such as nicotine replacement therapy (NRT), varenicline, or bupropion, which have been shown to improve cessation rates.
Nutritional supplementation is recommended for patients with intermediate or advanced dry AMD, particularly when drusen and/or pigmentary abnormalities are present. The Age-Related Eye Disease Study
2 (AREDS2) demonstrated that the following combination of antioxidants and minerals can reduce the risk of progression to late-stage AMD:
- Vitamin C: 500mg
- Vitamin E: 400IU
- Zinc oxide: 80mg
- Cupric oxide: 2mg
- Lutein: 10mg
- Zeaxanthin: 2mg
These nutrients target oxidative stress and inflammation – two central mechanisms involved in
AMD pathogenesis. Lutein and zeaxanthin are macular carotenoids that help protect photoreceptors by filtering blue light and neutralising free radicals. These replaced beta- carotene from the original AREDS formula, due to its association with increased lung cancer risk in smokers. NICE supports the use of AREDS2 supplementation in patients with intermediate or advanced AMD but does not recommend them for individuals without retinal changes, as there is no evidence of benefit in early AMD.
Ongoing monitoring of disease is essential. Regular eye examinations and the use of self-monitoring tools such as an Amsler grid can help detect signs of progression or conversion to wet AMD at an earlier stage, improving the likelihood of timely treatment and better clinical outcomes.
Management of wet AMD
Wet AMD progresses rapidly and accounts for most cases of severe vision loss linked to the condition. Prompt diagnosis and treatment are critical, as irreversible central vision damage can occur within weeks without treatment. The primary objective of management is to halt or reverse disease activity by targeting choroidal neovascularisation, aiming to preserve functional vision and maintain independence.
Advances in pharmacological therapies have greatly improved visual outcomes in recent years, transforming a previously untreatable condition into one that can often be stabilised or improved. Treatment success depends on early diagnosis, appropriate follow- up, and patient adherence to therapy and monitoring schedules. NICE guidelines emphasise a patient-centred approach, supporting multidisciplinary collaboration to ensure patients receive sight-preserving treatment alongside support for wellbeing and independence.
Anti-vascular endothelial growth factor (anti-VEGF) agents
The cornerstone of pharmacological treatment for wet AMD is anti-VEGF therapy. VEGF plays a central role in abnormal blood vessel growth, making it a key therapeutic target. These agents reduce the formation of fragile new vessels beneath the retina, limit fluid leakage, and help stabilise or improve vision. Anti-VEGF agents licensed for use in Ireland include ranibizumab and aflibercept.
According to NICE guidelines, anti- VEGF therapy should be offered to patients with active wet AMD who have best corrected visual acuity
(BCVA) between 6/12 and 6/96, along with evidence of recent disease progression. In eyes with vision worse than 6/96, treatment may still be considered if some visual function benefit is expected. Aflibercept and ranibizumab are first-line options, both administered via intravitreal injection and shown to improve visual outcomes. As there are no clinically significant differences in efficacy or safety between these drugs, choice may be influenced by factors such as cost, dosing schedule, or patient preference. Bevacizumab is sometimes used off- label, though it is not recommended in NICE guidelines.
Anti-VEGF treatment is generally well tolerated. Local adverse effects may include eye discomfort, inflammation, increased intraocular pressure or, rarely, endophthalmitis. Systemic risks are minimal, though there may be a small theoretical risk of arterial thromboembolic events, particularly in patients with a history of stroke or cardiovascular disease.
Treatment typically begins with a loading phase of three consecutive monthly injections, followed by a maintenance phase tailored to the patient’s response. Two common approaches are ‘pro re nata’ (PRN) and treat-and-extend. PRN involves regular monitoring and re-treatment when signs of recurrence appear on OCT or fundoscopy.
In the treat-and-extend model, intervals between injections are gradually lengthened if disease activity remains controlled, helping reduce treatment burden while maintaining visual outcomes. NICE guidelines recommend that intravitreal injections be administered by appropriately trained healthcare professionals. However, frequent injections can
be burdensome, especially for older patients or those with limited mobility or access to transport, potentially leading to under-treatment or non-adherence.
Emerging therapies – including longer-acting anti-VEGF agents, gene therapies, and port delivery systems – are under investigation and may offer future solutions to reduce treatment burden while maintaining efficacy.
Adjunctive therapies
Photodynamic therapy should not be used as monotherapy for wet AMD. It is reserved as a second-line adjunct to anti-VEGF therapy in the context of a randomised controlled trial. NICE recommends against the use of intravitreal corticosteroids as an adjunct to anti-VEGF treatment.
While anti-VEGF therapy remains the cornerstone of wet AMD treatment, non-pharmacological
and supportive strategies also play a critical role in preserving quality of life and promoting independence. Lifestyle adjustments, similar to those for dry AMD, should be encouraged, including smoking cessation and nutritional support. Patient education is vital, particularly around symptom recognition and disease progression.
Patients should be advised to monitor for signs of recurrence, such as metamorphopsia, blurred central vision, or dark patches in the visual field – and to report these changes promptly. Tools like the Amsler grid can assist with home monitoring. Low- vision aids, such as handheld magnifiers and enhanced lighting, can help patients with near-vision tasks and adapting to vision loss. Timely referral to low-vision rehabilitation services can improve functional outcomes and quality of life.
Psychosocial support is another key aspect of care. Visual impairment can lead to social isolation, reduced independence, and depression. NICE recommends that depression in patients with AMD be identified and managed according to guidance for adults with chronic physical health conditions. Pharmacists should be alert to signs of psychological distress and offer signposting to mental health or vision support services where appropriate.
In eyes with vision worse than 6/96, treatment may still be considered if some visual function benefit is expected
Monitoring and adherence
Effective long-term management of wet AMD depends on consistent medical monitoring and strong patient engagement. Most patients undergo regular OCT imaging to assess for subretinal or intraretinal fluid, pigment epithelial detachment, or retinal thickening. Fundus examination, visual acuity testing, and symptom review are also used to guide ongoing care.
Long-term adherence to treatment and scheduled monitoring is essential, as untreated wet AMD can result in irreversible central vision loss. Educating patients about the chronic nature of the disease and
the importance of consistent follow- up is key. Shared care protocols and collaboration between healthcare professionals can improve access to services and support better outcomes.
Pharmacists can help facilitate continuity of care by maintaining accurate medication records, identifying gaps in treatment, and reinforcing the importance of attending ophthalmology appointments.
Warning signs
Patient education is crucial in AMD management, particularly in recognising symptoms that may indicate disease progression or conversion from dry to wet AMD. Warning signs that warrant urgent ophthalmology referral include sudden changes in central vision, new metamorphopsia, or rapid visual decline. These symptoms may signal the development of choroidal neovascularisation and require prompt anti-VEGF treatment to prevent irreversible vision loss. Pharmacists play a vital role in identifying patients with visual complaints and signposting them to appropriate services.
Pharmacist’s role
Pharmacists are increasingly central to the multidisciplinary care of patients with AMD, particularly as accessible healthcare professionals who interact regularly with older adults. Their role spans public health promotion, early recognition, optimisation of pharmacological management, and ongoing patient education. Community pharmacists can contribute to awareness campaigns, especially during national eye health initiatives, and through pharmacy-based leaflets or consultations.
Pharmacists have a key role in promoting lifestyle changes that reduce AMD risk. Smoking is the most significant modifiable risk factor, and pharmacists are well positioned to provide cessation support. This includes counselling on nicotine replacement therapy, varenicline, or bupropion and referring patients to structured cessation programmes. Pharmacists can advise on maintaining a balanced diet and using appropriate nutritional supplements to support retinal health. Familiarity with the AREDS2 formulation and its evidence-based use in intermediate or advanced AMD is essential.
Given their accessibility, pharmacists are often the first point of contact for patients who report vision changes. Routine interactions provide opportunities to identify early signs
Given their accessibility, pharmacists are often the first point of contact for patients who report vision changes
of AMD or progression from dry to wet forms. Pharmacists should refer patients promptly to GPs or optometrists when red flags are identified. Clear communication about vision loss, treatment expectations, and the need for follow-up is essential, and messages should be tailored to patients’ health literacy to support understanding and engagement.
Pharmacists also support patients undergoing intravitreal anti-VEGF treatment by counselling on potential side-effects, promoting adherence, and encouraging regular follow-up. They can reassure and educate patients about the differences between dry and wet AMD, the role of self-monitoring, and the symptoms that need urgent review. For those with advanced AMD, pharmacists can offer guidance on low- vision aids, local support services, and mental health resources to help reduce isolation and maintain quality of life.
Finally, pharmacists have an important role in supporting multidisciplinary care. By collaborating with GPs, optometrists, and ophthalmology services, pharmacists help ensure that AMD care is coordinated, timely, and consistent. This integrated approach enhances patient outcomes and supports more effective long-term management.
References available upon request
