When should patients with macular degeneration be referred to a specialist?

When to Refer Macular Degeneration

Patients with age-related macular degeneration should be referred to an ophthalmologist immediately when they have any degree of macular edema, severe nonproliferative changes, any neovascular (wet) AMD, visual acuity worse than 20/40, unexplained vision loss, or symptomatic visual complaints. 1

Immediate Referral Criteria

Refer urgently (within days to weeks) for:

• Any neovascular (wet) AMD - Anti-VEGF therapy must be initiated immediately upon diagnosis, as early treatment within 2 years significantly reduces legal blindness and visual impairment 1, 2
• Visual acuity worse than 20/40 (6/12) in either eye 3
• Any symptomatic vision reports including metamorphopsia (distorted vision), blurred central vision, or central scotomas 1
• Unexplained visual acuity loss regardless of fundus findings 3
• Sudden vision changes or acute symptoms 1

Prompt Referral (Within 1-3 Months)

Refer for specialist evaluation when:

• Center-involved diabetic macular edema with retinal thickening affecting the central 1mm zone 3
• Severe nonproliferative diabetic retinopathy meeting any of: ≥20 intraretinal hemorrhages in each quadrant, definite venous beading in ≥2 quadrants, or prominent intraretinal microvascular abnormalities in ≥1 quadrant 3
• Proliferative diabetic retinopathy with neovascularization or vitreous/preretinal hemorrhage 3
• Inadequate retinal assessment during screening unless obviously no retinopathy or only microaneurysms present 3

Referral for Vision Rehabilitation Services

Refer to low vision specialists when patients experience:

• Difficulty with reading despite best correction 1, 4
• Mobility problems or difficulty with activities of daily living 1, 4
• Inability to recognize faces 4
• Emotional distress or depression related to vision loss 1, 4
• Visual acuity worse than 20/40 in the better eye, even without wet AMD 4

Early referral to vision rehabilitation leads to improved outcomes and should not be delayed until vision is severely impaired 4. Approximately 48% of patients with intermediate AMD who are not referred have visual function scores as poor as those who were referred, suggesting significant under-referral 5.

Special Populations Requiring Referral

Pregnant diabetic patients should be monitored every 3 months during pregnancy and for 1 year postpartum, with referral based on degree of retinopathy progression 3

Patients with intermediate AMD or advanced AMD in one eye should be referred for AREDS2 supplementation counseling and aggressive monitoring of the fellow eye every 6-12 months, as they remain at exceptionally high risk for progression 1, 2

Critical Pitfalls to Avoid

• Do not delay referral waiting for additional vision loss in patients with known wet AMD - every week matters for visual outcomes 1
• Do not assume normal vision means no referral needed - patients with intermediate AMD and normal acuity may still benefit from AREDS2 supplementation and monitoring 1
• Do not overlook functional vision complaints - VFQ-25 scores in general vision, driving, and mental health domains predict need for referral independent of visual acuity 5
• Do not wait for bilateral involvement - unilateral wet AMD requires immediate treatment and aggressive monitoring of the fellow eye 1, 2