The Finnish national guideline for diagnosis, treatment and follow‐up of patients with wet age‐related macular degeneration

I ncreasing incidence and prevalence of age-related eye diseases including age-related macular degeneration (AMD) together with the limited healthcare resources pose significant challenges for the provision and development of cost-effective eye care in developed countries (Tuulonen et al. 2016). For people 65-years or older, AMD accounts for 59% of all cases with permanent visual disability by the annual report of the Finnish Register of Visual Impairment (2014). In 2015, the Finnish chief ophthalmologists in public eye hospitals initiated and sponsored to create an evidence-based guideline for wet form of AMD (wAMD) to standardize and improve diagnostics, treatment, follow-up and cost-effectiveness of wAMD care in Finland. This Editorial sums up the main principles of the complete Guidelines (Tuuminen et al. 2016). The link to Evidence Summaries are found at www.actaophthalmologica.com, written by Tuuminen et al. (2017). The writing group consisted of three editors of Current Care Guidelines from the Finnish Medical Society Duodecim (responsible for development of over 100 national guidelines since 1994) and the ophthalmic Expert Panel from the eye departments of five university hospitals and 15 central hospitals. For the literature search carried out and evaluated by the Editors, the Expert Panel framed eight key questions confronted in everyday ophthalmic practices: (1) What methods are required for the diagnosis of wAMD, (2) What are the indications for treatment of wAMD, (3) Which clinical findings may predict poor treatment effect, (4) Are there differences in effectiveness, adverse effects and safety between anti-vascular endothelial growth factor (anti-VEGF) agents, (5) What kind of expertise is required for carrying out anti-VEGF therapy, (6) Is there a difference in the outcomes, adverse effects and costeffectiveness between different treatment protocols, (7) What methods are required for the follow-up of wAMD, and (8) When and by what criteria the treatment should be discontinued and/ or patient be taken off control visits and switched to self-monitoring? Similar to the Finnish guidelines for glaucoma (Tuulonen et al. 2015), the practical evidence-based recommendations are provided for different levels of care (very good, good and satisfactory). The diagnosis of wAMD should always be carried out by or under the surveillance of an ophthalmologist specialized in its diagnostics and treatment. The presence of other eye diseases, risk factors for AMD and systemic diseases should always be considered. Excellent level of diagnostics requires clinical examination including visual acuity (VA) testing, slit lamp microscopy, evaluation of the fundus of both eyes, fluorescein angiography and optical coherence tomography (OCT). The fundus image (colour, red-free or autofluorescent) is encouraged to be taken to aid the diagnostics and documentation. In diagnostically challenging cases, indocyanine green angiography (ICGA) may be helpful as a complementary method for diagnosing wAMD. According to the Expert Panel, in case of diagnostic uncertainty, a trial dose with anti-VEGF treatment is encouraged instead of waitand-see when the risk of vision loss is obvious (Tuuminen et al. 2016). Considering different wAMD treatment protocols, anti-VEGF injections should be discontinued in case of no expected benefit on the clinical parameters, patient’s ability to function or quality of life, or if the adverse effects and risks associated with treatment are estimated to be greater than the expected benefits. The decision to discontinue treatment should be made in one accord by the patient and the ophthalmologist. The Expert Panel suggests treatment to be discontinued at the latest when the VA in the treated eye permanently drops below 0.0625 (Tuuminen et al. 2016). Development and promotion of cost-effective ophthalmic interventions are vitally important for being able to ensure appropriate care to all eye diseases, including wAMD (Tuulonen et al. 2016). In Finland, injection treatments for wAMD can be administered in an appropriate setting by ophthalmologists, residents in ophthalmology, or special-trained nurses as recent prospective and retrospective studies have reported that the risks and side effects of injections were not dependent on the healthcare professional administering the anti-VEGF drug (Tuuminen et al. 2016). The Council of Choices for Health Care (COHERE) in Finland, which is a permanent