International Council of Ophthalmology

ICO International Clinical Guidelines:

Intravenous fundus fluorescein angiography in the clinical setting of AMD is indicated: [A:I]

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 CVN 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. [A:III]

Discuss risks, benefits and complications with the patient and obtain informed consent [A:III]
For thermal laser surgery and PDT, treat within 1 week after fluorescein angiography [A:I]
Examine at 2 to 4 weeks after initial thermal laser surgery to confirm that CVN has been obliterated and perform fluorescein angiography [A:I]
Examine at 4 to 6 weeks after thermal laser surgery and perform fluorescein angiography, and thereafter, depending on clinical findings and judgment [A:I]
Examine and perform fluorescein angiography at least every 3 months for up to 2 years after verteporfin PDT [A:I]
Examine with retreatments as indicated every 4 to 8 weeks after intravitreal injections (see table) [A:III]

Educate patients about the prognosis and potential value of treatment as appropriate for their ocular and functional status. [A:III]
Encourage patients with early AMD to have regular dilated eye exams for early detection of intermediate AMD. [A:III]
Educate patients with intermediate AMD about methods of detecting new symptoms of CVN and about the need for prompt notification to an ophthalmologist. [A:III]
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. [A:III]
For patients with CVN for whom treatment may be indicated, counsel as follows: [A:III] treatment will reduce, but not eliminate the risk of severe visual loss; thermal laser surgery will produce permanent scotomas and explain anticipated effect of scotoma on central visual function; verteporfin PDT and pegaptanib sodium treatment will reduce risk of moderate and severe visual loss, but most patients will still lose some vision over 2 years, and improvement in visual acuity is unusual; there is a high risk of CNV persistence or recurrence after thermal laser surgery that could require additional laser surgery, and this risk is greatest in the first year; and multiple fluorescein angiograms are necessary for appropriate follow-up.
Refer patients with reduced visual function for vision rehabilitation (see www.aao.org/smartsight) and social services. [A:III]