OCTA in age-related macular degeneration: consensus on practical guidelines for optimal imaging strategies across different clinical scenarios

Purpose: To provide expert-driven, practical guidelines for the optimal use of optical coherence tomography angiography (OCTA) in the clinical management of age-related macular degeneration (AMD). Given the heterogeneity of AMD and the versatility of OCTA, clinicians require scenario-specific recommendations to navigate imaging strategies effectively across various stages and phenotypes of the disease. Methods: An expert panel from the European Young Retinal Imaging and Retina Study Group conducted a consensus-based review integrating the latest evidence and extensive clinical experience. The panel focused on developing OCTA-based protocols tailored to distinct clinical scenarios in AMD, including neovascular subtypes, geographic atrophy, non-exudative neovascularization, and ambiguous fluid accumulations. Recommendations emphasize appropriate scan sizes, slab selections, and strategies for interpreting flow signals across disease presentations. Results: The expert panel delineated structured OCTA protocols for a range of AMD phenotypes to enhance diagnostic accuracy and clinical decision-making. In neovascular AMD, OCTA enables detailed characterization of macular neovascularization (MNV) subtypes—types 1, 2, and 3—through high-resolution, depth-resolved imaging. Recommendations include the use of cross-sectional OCTA to localize flow and appropriate selection of en face slabs to optimize lesion visualization. In geographic atrophy (GA), while structural OCT remains the primary modality, OCTA may assist in identifying subclinical or complicating MNV and in assessing choriocapillaris perfusion in the peri-atrophic zone, which may have prognostic implications. In cases of early and intermediate AMD, OCTA plays a critical role in detecting non-exudative MNV—particularly type 1 and type 3 lesions—providing valuable prognostic information given the risk of exudative conversion. Additionally, OCTA contributes to the differential diagnosis of pseudovitelliform lesions, detection of deep retinal age-related microvascular anomalies (DRAMAs), and exclusion of neovascularization in cases presenting with atypical intraretinal or subretinal fluid. Conclusions: This expert consensus offers a pragmatic framework for applying OCTA in AMD clinics, advocating for individualized imaging approaches based on lesion type and anatomical complexity. By enhancing diagnostic precision and enabling tailored monitoring strategies, OCTA integration into clinical workflows may significantly improve patient outcomes across the AMD spectrum.