Sir,

We thank Woo et al for their insightful comments. Our study aimed to evaluate how many patients with age-related macular degeneration (AMD) are aware of their disease beore developing choroidal neovascularization (CNV) and to assess whether such awareness confers benefit. Unfortunately, we found that many patients were not aware that they had AMD, and that prior awareness did not confer benefit for patients who develop CNV.

With respect to the remarks of Woo et al, in Israel, AMD is diagnosed and treated by ophthalmologist and not by family physicians or optometrist. The study evaluated awareness from the patients’ perspective and its consequences; we did not focus on the different recommendations that different care providers might suggest. We agree with Woo et al that compliance may vary among patients; this is probably one of the major factors underlying poor benefit from awareness by itself. Finally, the referral pattern for photodynamic treatment in Jerusalem was not ‘peculiar’ as Woo et al state, but rather appropriate according to the national health insurance system in Israel.

Although the review by Woo and Au Eong1 is interesting, neither it nor the other two manuscripts that Woo et al mention2, 3 provide data suggesting visual benefit from early awareness to AMD. Our study delineated major limitations of the current treatment algorithm for AMD in the Jerusalem area as many patients are not diagnosed during the non-neovascular stage of the disease and as diagnosis by itself is not sufficient to improve the outcome. Conceivably, at least to a certain extent, our conclusions apply to other communities. As ophthalmologists, it is our role to optimize such treatment algorithms to maximize visual benefits. Identifying weaknesses of current algorithm is a first step towards improving it. We should not ignore miss concepts even if they are long-standing or backed by theories that were never supported by data.

We strongly believe that early awareness can be important given that patients use oral supplements according to the AREDS study recommendations and that they adhere to a routine follow-up examination schedule.4 Efforts must be invested in improving the number of patients that are diagnosed and who follow these recommendations, as according to our findings, awareness by itself is not sufficient to improve the outcome in patients who develop CNV.