Rapid Access Referral in the Management of Wet age related macular degeneration (AMD) Pathway Overview

Patients with exudative (‘wet’) AMD have a more rapid onset of symptoms than those with the dry form. Treatment with anti-VEGF therapy is available in Gloucestershire according to NICE guidance.

Most patients with wet AMD who have experienced recent progression of symptoms and whose vision falls within the guidelines are eligible for treatment for first and second eyes.

In a proportion of patients, treatment leads to an improvement in vision but in the majority it stabilizes vision so it is very important that patients should be seen as early as possible in the course of the disease process and ideally within a few days of onset of symptoms.

A fast-track referral system is in place to allow optometrists to refer suspected cases urgently to the retinal team. On receipt of the referral, the patient will be contacted directly and then assessed by a retinal specialist. If the diagnosis is confirmed using optical coherence tomography (OCT) and fluorescein angiography and if the patient falls within NICE guidance they will be offered treatment with anti-VEGF therapy.  Treatment is offered in Cheltenham General Hospital and in Gloucestershire Royal Hospital.

Patients presenting to their GP should be referred urgently to the retinal team. If there is some uncertainty, local optometrists are usually happy to advise at short notice and to make the appropriate referral.

Please click the relevant flowchart box to be taken directly to textual information.


Red Flags
  • Total vision loss
  • Headache or weakness in arm, face or leg
  • Speech disturbance
  • Nausea or vomiting
  • Ocular pain
  • History of trauma
  • Scalp tenderness or jaw claudication
  • Amaurosis fugax
  • Haloes
  • Flashing lights

Patients with exudative AMD have a more rapid onset of symptoms than those with the dry form. They notice central visual loss often accompanied by distortion developing over the course of a few days or weeks. Distortion may be the earliest sign. Patients may not notice early symptoms when only one eye is affected and it is not unusual for them to present at a late stage with their first eye.

  • Age > 60
  • Family history of AMD
  • Smoking
  • Previous diagnosis of AMD in either eye, (wet or dry)
  • High myopia
Differential Diagnosis
  • Macular hole
  • Epiretinal membrane
  • Diabetic maculopathy
  • Central serous chorioretinopathy (CSR)
  • Pathological myopia
  • Angioid streaks
  • Ocular histoplasmosis syndrome
  • Choroidal melanoma
Initial Primary Care Assessment/Investigations

Central visual acuity is usually reduced but may not be a reliable indicator of disease severity.

Often central visual distortion and/or scotoma is more indicative so testing for these with an Amsler Chart is recommended.

Examination of the macula, preferably with a binocular viewing technique looking for soft drusen, haemorrhage, exudate or sub-retinal fluid.

When to Refer

Referral to the Wet AMD Rapid Access Clinic is indicated when vision in the affected eye is > 6/96 and the patient reports a < 3month history of:

  • Visual loss AND/OR spontaneously reported distortion AND/OR missing patch /blurring of central vision
  • AND retinal signs of macular haemorrhage, exudate or sub-retinal fluid.

Please follow this link to the referral form.

Key Point

  • Only those with recent symptoms (< 3 months) of wet AMD should be referred using the fast track system.
  • Patients presenting with symptoms in their first or second eye should be referred  

If there is some uncertainty, local optometrists are usually happy to advise and to make the appropriate referral using the fast track wet AMD referral form.

If Wet AMD is not suspected following initial assessment / investigations consider routine referral to Ophthalmology.


Wet AMD Clinic - GHFT

  • Diagnosis is confirmed by the retinal team using optical coherence tomography (OCT) and fluorescein angiography.
  • If the patient falls within NICE guidance they will be offered treatment with anti-VEGF therapy.  Injections usually start the same day.
  • Patients with occult wet AMD but no evidence of recent progression will be monitored.

Anti-VEGF therapy has been shown to be extremely effective.  It remains vitally important that eligible patients should be referred as quickly as possible

  • Treatment consists of 3 intra vitreal injections at monthly intervals.
  • Further injections are given according to findings at subsequent assessment visits
  • Patients should expect to attend monthly for assessment and/or injection and it is very important that retreatment should not be delayed if it is necessary.
  • It is not certain how long monitoring and treatment needs to continue, but it will be for at least 2 years.
  • Generally, treatment is well tolerated and adverse events are rare, however patients need to be aware of the risks. Information and counselling are provided.

Key Point

In Gloucestershire, Ranibizumab for Wet AMD is funded subject to criteria based access. Please see the IFR policy for further information.


Ongoing Secondary Care / Primary Care Management

Those diagnosed with wet AMD will receive information about their condition. Low visual aid assessment and referral to social services (with or without registration) will be offered where appropriate.


Patient Resources

Please see the Patient & Carer Information & Leaflets and Community Resources sections.

Resources for Professionals

National Standards

Please see the National and NICE Guidance section.

Other Online Resources

Pathway Leads





Dr Graham Mennie


Gloucestershire Clinical Commissioning Group


Miss Emily Fletcher


Gloucestershire Hospitals Foundation Trust


Ian Sprigmore

Transformation Programme Manager

Gloucestershire CCG


Completion Date

Feb 2017

Review Date

Jan/Feb 2018