Why early diagnosis matters
Macular disease is progressive and largely irreversible: once the macular cells have atrophied or scarred, the damage cannot be recovered. However, prompt treatment can slow or halt progression. For this reason early diagnosis — clinical and instrumental — is crucial.
The Amsler grid test — monitoring at home
The Amsler grid is a simple and effective tool that people use at home, regularly, as advised by their ophthalmologist: perpendicular lines with a central dot that help detect distortions, wavy lines or dark spots (scotomas) early — the first signs of macular oedema or atrophy. It is the simplest way to monitor your vision between appointments.
- General population
- After the age of 50 — regular eye examinations with fundus examination, at the interval advised by the ophthalmologist.
- High-risk individuals
- Family history, high myopia, smoking, diabetes, high blood pressure — closer monitoring, often with OCT, as advised by the ophthalmologist.
- Wet AMD or oedema under treatment
- Closer check-ups with OCT, at the interval set by the ophthalmologist, to assess the response to anti-VEGF treatment.
- What is needed
- Eye examination with fundus examination, macular OCT, Amsler grid test, fluorescein angiography if indicated.
The 6 main tests
The diagnostic pathway for macular disease starts with home monitoring using the Amsler grid test and the fundus examination. It is supplemented by high-resolution imaging (OCT) and — when necessary — by a dynamic study of the retinal circulation.
- 01
Amsler grid test
Monitoring at homeThe Amsler grid test is a grid of perpendicular lines with a central fixation point. The person does it at home, covering one eye at a time from a distance of 30 cm, wearing their usual reading glasses.
The pathological changes that the test can detect are: lines that appear wavy or broken (metamorphopsia — typical of macular oedema), and areas where lines seem to be missing or are blurred (scotomas). It should be done once a week by people over 50 or with risk factors.
How to use the test
- Wear your usual reading glasses and hold the grid 30 cm away
- Cover one eye at a time; the other looks at the central dot
- Check whether the lines are straight or wavy, and whether there are missing or blurred areas
- Do the test once a week, always at the same time of day
- Contact your ophthalmologist straight away if you notice new distortions, spots or broken lines
- 02
Fundus examination with dilation
Essential basic testIt is the core clinical examination. It requires the pupil to be dilated with eye drops (the effect lasts 4-6 hours), it is painless, and it allows the ophthalmologist to look directly at the macula for drusen, atrophy, abnormal new blood vessels and signs of oedema.
It is combined with colour fundus photography (high-resolution photographs of the back of the eye) to record the condition of the macula over time and track the course of the disease through comparisons over time.
What the ophthalmologist looks for
- 03
OCT — Optical Coherence Tomography
Gold standardOCT is the gold standard in the diagnosis and follow-up of macular disease. It works like a ‘CT scan of the eye’: it uses light waves to create extremely high-resolution images (5 micrometres) of the retina, section by section. It is non-invasive and painless, and takes just a few minutes.
It is the essential test for identifying macular oedema, drusen, retinal atrophy, macular holes and vitreomacular traction. Essential for monitoring the response to anti-VEGF injections over time.
What OCT detects
- Drusen and sub-retinal deposits (early dry AMD)
- Geographic atrophy of the macula (advanced dry AMD)
- Intra- or sub-retinal fluid (wet AMD)
- Epiretinal membranes and vitreomacular traction
- Full-thickness or lamellar macular holes
- Response to drug treatment over time
- 04
OCT angiography
Vessels without contrastAn advanced version of OCT that shows the network of retinal and choroidal blood vessels without the need to inject a contrast dye. It allows the different vascular layers to be studied separately, down to the level of the choriocapillaris (the most important vascular layer for nourishing the photoreceptors).
It is particularly useful for identifying the choroidal neovascularisation (CNV) typical of wet AMD and for monitoring it over time without repeated invasive tests.
Advantages
Non-invasive and quick — excellent for patients who cannot cooperate fully or are allergic to the dye. Limitation: it does not show leakage (fluid escaping from the vessels), so in some cases fluorescein angiography remains complementary.
- 05
Fluorescein + indocyanine green angiography
Dynamic studyFluorescein angiography (FA) requires an intravenous injection of a dye that shows the retinal circulation in real time. It shows the leakage (fluid escaping) typical of abnormal new blood vessels and outlines active lesions precisely.
Indocyanine green (ICG) angiography completes the diagnosis by exploring the deep choroidal circulation — not visible with fluorescein alone. It is particularly useful in atypical forms of wet AMD, in polypoidal choroidal vasculopathy (PCV) and in central serous chorioretinopathy.
When both tests are used
Fluorescein and indocyanine green angiography complement each other: the first shows the retina, the second shows the deeper choroid. Together they guide treatment decisions in atypical cases or cases that resist standard treatment.
- 06
Microperimetry
Point-by-point retinal functionA functional test that measures the sensitivity of the retina point by point, overlaying the results on an image of the back of the eye. It allows assessment of how well each small area of the macula can see, in far more detail than a classic visual field test.
It is particularly useful for quantifying visual loss in advanced stages of AMD or in forms with geographic atrophy, to plan visual rehabilitation and monitor the course of the disease over time.
When it is used
It is not a first-line test — it is carried out in selected cases when it is necessary to measure the functional deficit precisely, assess the effectiveness of experimental treatments or plan visual aids for low vision.
Diagnostic criteria
The diagnosis of macular disease is based on the combination of clinical examination, OCT and — when indicated — fluorescein angiography. The stage and type (dry or wet AMD, myopic, diabetic) determine the treatment strategy.
Established macular disease
The diagnosis is certain when typical structural changes are present, even in the absence of symptoms:
- Confluent drusen, atrophy or scarring at the macula visible on fundus examination
- Changes in retinal thickness or sub-retinal fluid on OCT
- Leakage or choroidal new vessels on fluorescein angiography or OCT angiography
- Positive distortions on the Amsler grid corresponding to the lesions
When closer monitoring is needed
In some cases more frequent follow-up is needed to detect progression to advanced or wet forms:
- Large or confluent drusen (high risk of progression)
- Known genetic predisposition (family history of wet AMD)
- Intermediate AMD with recent visual symptoms
- Macular disease in one eye and a healthy fellow (contralateral) eye
Check-up frequency
The schedule of eye check-ups depends on age, risk factors and the stage of macular disease. The ophthalmologist sets it case by case, with the person doing the Amsler grid test at home regularly.
Adults aged 50-65 without risk factors
Regular eye examinations with fundus examination, at the interval advised by the ophthalmologist. Amsler grid test at home.
Adults over 65 or with risk factors
More frequent check-ups, with fundus examination and often macular OCT. Amsler grid test at home.
Large drusen (intermediate AMD)
Periodic OCT check-ups, at the interval set by the ophthalmologist, to detect conversion to the advanced form.
Wet AMD under anti-VEGF treatment
Close examination and OCT, at the interval set by the ophthalmologist, to decide whether to go ahead with the next injection.
Myopic macular disease with CNV under treatment
Similar to wet AMD: close check-ups until the condition is stable.
New symptoms or a worsening Amsler grid test
Urgent eye examination — straight away, without waiting for the scheduled check-up.
Early diagnosis can protect central vision
Macular disease is largely irreversible, but early diagnosis can radically change the outcome: anti-VEGF medicines in the wet forms can help preserve vision if started before extensive damage has occurred. Do not wait until you notice poor vision before getting checked: the Amsler grid test and regular eye examinations are the best protection for your fine vision.