Evaluation of primary care physicians’ knowledge, attitudes, and awareness levels regarding age-related macular degeneration

Abstract

Purpose

Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss in individuals over the age of 50. This study aims to evaluate the knowledge and awareness of primary care physicians in Türkiye regarding AMD and to examine the impact of professional characteristics on this awareness.

Methods

This is a cross-sectional and descriptive study conducted online between August 2025 and September 2025. The participants included general practitioners, family medicine residents, and family medicine specialists working across Türkiye, who were divided into three groups. Data were collected through a Google Forms questionnaire consisting of demographic characteristics and 35 closed-ended questions about AMD. A p-value of < 0.05 was considered statistically significant.

Results

A total of 440 participants were included in the study, of whom 70.5% were male and 29.5% female, with a mean age of 38.8 ± 7.9 (26–68). Of the participants, 47% were general practitioners, 39.2% residents, and 13.8% specialists. While 86.0% of physicians knew the definition of AMD, deficiencies were identified regarding classification, risk factors, and access to treatment. Significant differences were observed among professional title groups in the following statements: “AMD is known as yellow spot disease among the public” (p = 0.016), “At what age range does AMD begin” (p = 0.013), “AMD is associated with iris color” (p < 0.001), “Invasive methods are used in the diagnosis of AMD” (p = 0.038), and “Anti-VEGF injections are covered by social security” (p = 0.003). Increased experience was associated with more accurate responses to “AMD is a progressive disease” (aOR = 1.14; p = 0.025). Gender had no significant effect (p > 0.05 for all items).

Conclusion

Primary care physicians demonstrated a basic level of awareness, corresponding to the middle tertile of the scoring system. However, important knowledge gaps remain, particularly regarding risk factors and treatment processes. Expanding in-service training and integrating updated clinical guidelines into primary care are recommended for earlier diagnosis and appropriate referral.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-026-03228-2.

Introduction

Age-related macular degeneration (AMD) is a chronic, progressive retinal disease that constitutes one of the most common causes of central vision loss, particularly in individuals over the age of 50, and significantly affects quality of life [1]. According to data from the World Health Organization, AMD is the leading cause of irreversible vision loss in developed countries, and its prevalence is rapidly increasing in parallel with the aging population [2]. In Türkiye, the proportion of elderly individuals within the total population is also rising, which further underscores the importance of early diagnosis and treatment of age-related diseases [3]. AMD is classified into two subtypes: non-neovascular (dry) and neovascular (wet). While the dry type is more prevalent and generally progresses slowly, the wet type advances more rapidly and can lead to severe vision loss [4]. Although intravitreal anti-VEGF therapy is currently the mainstay of treatment for wet AMD, management of dry AMD has also evolved with Age-Related Eye Disease Study (AREDS)/AREDS2 supplementation and recently approved complement-inhibiting therapies for geographic atrophy; nevertheless, no definitive curative treatment exists for either subtype [5, 7, 8]. Early initiation of treatment plays a critical role in slowing the progression of vision loss [5]. In recent years, advances in AMD have expanded management strategies beyond neovascular disease. AREDS and AREDS2 trials demonstrated that specific antioxidant and micronutrient supplementation may reduce the risk of disease progression in patients with intermediate dry AMD [6, 7]. In addition, complement-targeting therapies for geographic atrophy supported by the completed OAKS, DERBY, and GATHER1/2 trials and now approved for clinical use further emphasize the importance of early disease recognition and timely referral in primary care settings [8, 9]. Therefore, timely recognition of the disease and appropriate referral remain critical for effective disease management and treatment outcomes. Primary care physicians, who are primary healthcare providers, are typically the first point of contact for patients due to both the structure of the healthcare system and the accessibility of physicians. Consequently, primary care physicians have an important role in recognizing conditions such as AMD, identifying risk factors, detecting symptoms, and referring patients to ophthalmology specialists at the appropriate time [10]. In the literature, studies evaluating the knowledge, awareness, and attitudes of primary care physicians regarding AMD are limited [11].

The aim of this study is to assess the level of knowledge, awareness, and clinical approaches of primary care physicians working in Türkiye regarding AMD. Furthermore, the study seeks to examine the potential effects of variables such as professional experience, academic titles, and educational background on this level of awareness. The findings may contribute to shaping in-service training programs for primary healthcare professionals, as well as guiding health policies aimed at enhancing the effectiveness of primary care in early diagnosis and treatment processes [12]. In this respect, the study aims to help address knowledge gaps and raise awareness about the prevention of age-related vision loss.

Materials and methods

This study was designed as a prospective, descriptive, and cross-sectional survey conducted between August 2025 and September 2025. Ethical approval was obtained from the Gazi Yaşargil Training and Research Hospital Ethics Committee (date: 25.07.2025, number: 566). The study was conducted in accordance with the principles of the Declaration of Helsinki. At the beginning of the online survey, participants were clearly informed about the aim and scope of the study, and it was emphasized that participation was voluntary. Completion of the questionnaire was considered as informed consent.

The study population consisted of three professional groups: general practitioners providing primary healthcare services in Türkiye, family medicine residents receiving specialty training at universities or training and research hospitals, and certified family medicine specialists. A convenience sampling method, one of the non-probability sampling techniques, was used, and participation was based on voluntariness. Inclusion criteria were active medical practice in Türkiye and complete submission of the online questionnaire. No personal identifiers were collected, and all data were obtained anonymously.

Questionnaire development and validation

The data collection tool was a self-administered online questionnaire developed by the researchers. The questionnaire was constructed by two ophthalmologists with expertise in medical retina and family medicine specialist. Content validity was evaluated by a panel of three ophthalmologists who assessed the relevance, clarity, and comprehensiveness of each item. The content validity index (CVI) was calculated as 0.82, indicating acceptable content validity.

A pilot study was conducted with 20 family physicians who were not included in the main sample. Based on the feedback received, minor wording adjustments were made. Internal consistency of the knowledge domain was assessed using Cronbach’s alpha, which was 0.78, demonstrating acceptable reliability.

Structure of the questionnaire and scoring system

The questionnaire consisted of two main sections. The first section collected demographic information (age, gender, professional title, and years of experience). The second section included 35 closed-ended questions assessing the participants’ knowledge, attitudes, and clinical approaches regarding AMD.

Each correct response in the knowledge section was scored as 1 point, while incorrect or “I have no idea” responses were scored as 0. The total score ranged between 0 and 35. Awareness levels were categorized using tertile distribution as follows:

• Low awareness: 0–11 points

• Basic awareness: 12–22 points

• Good awareness: 23–35 points

The term “basic level of awareness” reported in the abstract corresponds to the middle tertile (12–22 points).

For the item “Invasive diagnostic methods are used in the diagnosis of AMD,” the correct answer was defined as “No,” as AMD is primarily diagnosed using non-invasive methods such as fundus examination and optical coherence tomography. This item was designed to assess participants’ awareness of standard diagnostic approaches rather than advanced or invasive procedures.

Sample size calculation

Sample size was estimated using the G*Power 3.1 program. Assuming a medium effect size (d = 0.5), a 5% significance level, and 80% power, the minimum required sample size was calculated as 128 participants for two-group comparisons and 159 participants for three-group comparisons (ANOVA).

Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics version 24.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were presented as mean ± standard deviation, frequency, and percentage distributions. Comparisons between groups were performed using the chi-square test for categorical variables and ANOVA for continuous variables. Variables with p < 0.10 in univariate analyses were included in multivariable logistic regression models to identify independent predictors of correct responses. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported. A p-value < 0.05 was considered statistically significant.

Results

A total of 440 participants were included in the study. Of these, 70.5% were male (n = 310) and 29.5% were female (n = 130). The mean age was 38.8 ± 7.9 years (range: 26–68). In terms of professional titles, 47% were general practitioners working in primary care (n = 207), 39.2% were family medicine residents (n = 173), and 13.8% were family medicine specialists (n = 60). Table 1 shows the demographic distribution. Regarding years of professional experience, the largest subgroup consisted of those with 15 years of practice (n = 42; 9.7%), and the majority of participants had between 5 and 20 years of experience. Responses to questions 1–35 are presented in Table 2 and 3. Table 2 summarizes the responses to questions using the Yes/No/I have no idea format, whereas Table 3 presents the distribution of selected options for the multiple-choice questions. For the multiple-choice questions assessing age of onset, legal blindness rate, and dry-type proportion (Questions 6, 9, and 11), the response options considered correct according to current epidemiological evidence were selected by 56.2%, 48.4%, and 37.1% of participants, respectively (Table 3). In comparisons between groups, no significant difference in knowledge level was found based on gender (p > 0.05 for all questions). However, statistically significant differences were observed among the professional title groups in responses to several questions. Notably, significant differences emerged regarding the following statements: “AMD is commonly known as macular disease in the general population” (p = 0.016), “At what age does AMD begin?” (p = 0.013), “AMD is associated with iris color” (p < 0.001), “Invasive diagnostic methods are used in the diagnosis of AMD” (p = 0.038), and “Anti-VEGF injections are reimbursed by the social security system” (p = 0.003) (Table 4). In particular, family medicine specialists demonstrated higher knowledge levels compared with general practitioners and residents.

Table 1.

Demographic and professional characteristics of participants

Variable	n (%) or Mean ± SD
Total participants	440
Age (years)	38.8 ± 7.9 (26–68)
Gender	Male 310 (70.5%) / Female 130 (29.5%)
Professional title	GP 207 (47%) / Resident 173 (39.2%) / Specialist 60 (13.8%)
Years of professional experience	Majority between 5–20 years (detailed distribution available in text)

Table 2.

Participants’ responses to questions about age-related macular degeneration

No	Question / Information	Yes%	No%	I have no idea%
1	Is the term AMD referred to as “yellow spot”?	86%(n = 378)	14%(n = 62)	–
2	Is AMD a cause of vision loss in old age?	66.7%(n = 293)	6.8%(n = 30)	26.5%(n = 117)
3	Do you have a family member with AMD?	11.8% (n = 52)	88.2%(n = 388)	–
4	Is AMD progressive?	80.5% (n = 354)	2.8% (n = 13)	16.7% (n = 73)
5	Does AMD prevalence increase with age?	81.4% (n = 358)	2.2% (n = 10)	16.4% (n = 72)
7	Is AMD irreversible?	57.3%(n = 252)	16.8%(n = 74)	25.9%(n = 114)
8	Does AMD affect the macula and central vision?	88.1% (n = 388)	0.5% (n = 8)	11.4% (n = 50)
10	Is AMD classified into dry/wet types?	70.1% (n = 309)	0.9% (n = 3)	29% (n = 128)
12	Is blindness caused by dry type?	40.6% (n = 178)	16.4% (n = 72)	42.9%(n = 190)
13	Is AMD associated with diabetes/hyperglycemia?	55.2% (n = 243)	18.6% (n = 82)	26.2%(n = 115)
14	Is AMD associated with hypertension/CVD?	64.5% (n = 283)	9.5% (n = 42)	25.9%(n = 114)
15	Does smoking increase risk?	73.6% (n = 324)	4.5% (n = 20)	21.8% (n = 96)
16	Is there a genetic inheritance?	42.3% (n = 186)	20.5% (n = 90)	37.3%(n = 164)
17	Does family history increase risk?	71.1% (n = 313)	3.7% (n = 16)	25.2%(n = 111)
18	Does increased BMI increase risk?	51.4% (n = 226)	10.1% (n = 44)	38.5%(n = 170)
19	Is AMD associated with refractive error?	48.2% (n = 212)	23.2%(n = 102)	28.6%(n = 126)
20	Is AMD associated with iris color?	19.6% (n = 86)	35.6%(n = 157)	44.7%(n = 197)
21	Is light eye color protective?	13.6% (n = 60)	28.5%(n = 125)	57.9%(n = 255)
22	Does cataract surgery reduce risk?	23.2% (n = 102)	21.8% (n = 96)	55% (n = 242)
23	Is AMD associated with nutrition?	21.8% (n = 96)	44.1%(n = 194)	34.1%(n = 150)
24	Is African descent at higher risk?	18.2% (n = 80)	22.7%(n = 100)	59.1%(n = 260)
25	Does sunlight increase risk?	62.4% (n = 274)	5% (n = 22)	32.6%(n = 144)
26	Are diagnostic methods invasive?	19.2% (n = 85)	48.9%(n = 215)	32% (n = 140)
27	Are you familiar with the Amsler Grid test?	22.6% (n = 99)	51.1%(n = 225)	26.2%(n = 115)
28	Is intravitreal injection used in AMD treatment?	52.5% (n = 231)	27.6%(n = 121)	19.9% (n = 88)
29	Does medical education provide sufficient knowledge on AMD?	16.8% (n = 74)	69.1%(n = 304)	14.1% (n = 62)
30	Does dry AMD progress to wet type?	29.1% (n = 128)	8.2% (n = 36)	62.7%(n = 276)
31	Does early anti-VEGF provide benefit?	65.2% (n = 287)	0.9% (n = 4)	33.9%(n = 149)
32	Does AMD require lifelong follow-up?	82.3% (n = 362)	2.3% (n = 10)	15.5% (n = 68)
33	Can AMD be completely cured?	20.8% (n = 92)	49.3%(n = 217)	29.9%(n = 131)
34	Are anti-VEGF treatments covered by health insurance?	28.1% (n = 124)	10.4% (n = 46)	61.5%(n = 270)
35	Is injection treatment outpatient and rapid?	60% (n = 264)	8.2% (n = 36)	31.8%(n = 140)

Questions 6, 9, and 11 were intentionally designed and administered as multiple-choice questions (not Yes/No/I have no idea), as they assess age of onset, prevalence estimates, and subtype distribution, respectively. Their results are therefore presented in categorical form. All other questions in the table use Yes/No/I have no idea response options

Table 3.

Multiple-choice knowledge questions and distribution of selected options

No	Question	Selected options n (%)
6	What is the typical age of onset of AMD?	50–60 years: 56.2% (n=247)
		60–70 years: 33.8% (n=149)
		70–80 years: 7.8% (n=34)
		80+ years: 2.3% (n=10)
9	What do you think the rate of legal blindness is in AMD?	0–10%: 48.4% (n=213)
		10–20%: 35.8% (n=158)
		20–30%: 15.8% (n=69)
11	What is the approximate proportion of dry-type AMD?	0–30%: 33.8% (n=149)
		30–60%: 29.1% (n=128)
		60–90%: 37.1% (n=163)

For scoring purposes, one option for each question was predefined as correct based on current evidence. The correct response rates were 56.2% (Q6), 48.4% (Q9), and 37.1% (Q11)

Table 4.

Questions Showing Statistically Significant Differences by Professional Title

Question	Gender p	Professional Title p
1. AMD is commonly known as “yellow spot disease” among the public.	0.1484	0.016*
6. What age range does AMD usually start?	0.1276	0.013*
20. Is AMD associated with iris color?	0.9073	< 0.001*
26. Are invasive diagnostic methods used for AMD diagnosis?	0.7878	0.038*
34. Are anti-VEGF injections covered by the social security system?	0.4774	0.003*

*Chi-square (χ²) test; p < 0.05 was considered statistically significant

In multivariate logistic regression analysis, age, gender, years of professional experience, and professional title were included as independent variables, and all odds ratios are presented as adjusted odds ratios (aORs). Professional experience was categorized into three groups: ≤5 years, 6–10 years, and > 10 years. In this analysis, the term “longer professional experience” refers to physicians with more than 10 years of professional practice. Gender was not found to have a significant effect on knowledge level (p > 0.05 for all questions). Conversely, professional title was observed to have an independent and significant effect on some questions. Family medicine specialists were significantly more likely than general practitioners to correctly respond to the statement “AMD is the leading cause of severe vision impairment in the elderly in developed countries” (aOR = 3.02; 95% CI: 1.03–8.88; p = 0.045). For the statement “AMD is classified as dry/wet type,” residents were significantly less likely than general practitioners to provide a correct response (aOR = 0.41; 95% CI: 0.21–0.79; p = 0.010). Similarly, in the question “Dry AMD can progress to wet AMD,” residents again had a lower likelihood of responding correctly compared with general practitioners (aOR = 0.45; 95% CI: 0.22–0.91; p = 0.029) (Fig. 1). Additionally, years of professional experience were associated with knowledge level. For the statement “AMD is a progressive disease,” the probability of a correct response increased significantly with longer professional experience (aOR = 1.14; 95% CI: 1.02–1.27; p = 0.025).

Fig. 1.

Results of multivariable logistic regression analysis showing statistically significant differences among professional title groups (adjusted odds ratios, aORs). Note: Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) are shown. The red dashed line represents the reference value of aOR = 1

Discussion

AMD is among the leading causes of vision loss in older adults in developed countries [1, 2]. The disease not only results in visual impairment but also significantly affects the social and psychological lives of individuals. In advanced stages, the risk of depression and social isolation increases, and patients experience serious limitations in daily living activities [13]. Moreover, the increasing prevalence of AMD imposes a substantial economic burden on healthcare systems, further highlighting the importance of preventive health services and early disease recognition [14]. In the context of the primary healthcare system in Türkiye, primary care physicians serve as the first point of contact for most patients, including elderly individuals at risk for AMD. Although primary care units generally do not have direct access to ophthalmic imaging tools such as fundus photography or optical coherence tomography, primary care physicians play a crucial role in identifying risk factors, recognizing early visual complaints, and ensuring timely referral to ophthalmology services. Therefore, adequate knowledge and awareness of AMD among primary care physicians are essential for early detection and appropriate patient management, supporting the relevance and rationale of the present study.

In our study, the overall knowledge level of primary care physicians regarding AMD was found to be moderate to high; however, significant knowledge gaps were identified, particularly in disease classification, risk factors, and access to treatment. These results are largely consistent with previous findings reported in the literature. Alemu et al., in their multicenter study, reported that only 40% of primary care physicians were able to correctly define AMD, and awareness of treatment options was markedly low [15]. Similarly, a large-scale study conducted by Ewumi et al. revealed that while most primary care physicians were aware that AMD is common in the elderly, they lacked sufficient knowledge regarding recognition of advanced clinical findings and appropriate referral timing [16]. Our study confirms these findings within the context of Türkiye, clearly demonstrating deficiencies in knowledge particularly related to treatment accessibility, recognition of risk factors, and patient management. No significant differences in knowledge level regarding AMD were found between male and female physicians in our study, which is consistent with prior literature [17]. However, knowledge levels were significantly higher with increasing professional title. Specifically, family medicine specialists showed greater awareness of AMD compared to general practitioners and residents, suggesting that both the training process and professional experience directly contribute to knowledge acquisition. Previous studies have similarly reported that physicians with higher clinical experience were more successful in early recognition of AMD, differentiating symptoms, and making referral decisions [18, 19]. This finding emphasizes the tangible contribution of continuous medical education and specialty training to patient care and management. Nevertheless, a considerable proportion of physicians in our study reported that their medical education was insufficient regarding AMD. This underscores the need for updating medical curricula and ensuring more comprehensive coverage of retinal diseases during undergraduate education, in order to strengthen preventive health services. The literature similarly highlights substantial knowledge gaps among primary care physicians regarding AMD and points to inadequacies in current educational processes [20–22]. Another noteworthy finding in our study was the knowledge deficit among physicians regarding certain controversial topics. High levels of uncertainty were observed concerning issues such as the association of AMD with iris color and whether cataract surgery reduces AMD risk. The lack of consensus in the literature on these issues aligns with our findings. While some epidemiological studies have reported an increased risk of AMD in individuals with lighter iris colors, others have found no such association [23, 24]. Similarly, a recent meta-analysis examining the relationship between cataract surgery and AMD progression reported that undergoing cataract surgery did not significantly alter the course of the disease, nor did it increase or decrease risk [23]. These findings highlight the importance of primary care physicians keeping up to date with current literature and the necessity of regular training to address clinical uncertainties. Awareness of treatment options was also found to be limited in this study. Notably, a large proportion of participants responded “I have no idea” regarding whether anti-VEGF injections are covered by the social security system. This indicates that physicians experience knowledge gaps not only in clinical aspects but also in healthcare system applications. The literature also emphasizes that the costs and reimbursement processes of anti-VEGF treatments constitute major barriers in clinical practice [25, 26]. Therefore, physicians need to be informed not only about pharmacological treatments but also about accessibility and integration of these therapies within the healthcare system. The observed positive association between years of professional experience and correct responses regarding the progressive nature of AMD further suggests that clinical experience enhances knowledge. Similarly, Colijn et al. reported that physicians with longer clinical practice were better able to recognize AMD symptoms and were more effective in patient referral [27]. This finding underscores the critical role of professional experience in the management of diseases in primary care.

Limitations of the study

This study has several limitations. Due to its cross-sectional design, causal relationships cannot be established. In addition, data were collected using self-reported questionnaires, which may be subject to reporting bias, and voluntary participation may have resulted in selection bias, limiting the generalizability of the findings. Furthermore, as the study was conducted in Türkiye, the results may not be directly applicable to countries with different healthcare systems and socioeconomic conditions. Another limitation relates to the construct validity and scope of the questionnaire. Although the 35-item instrument assessed basic knowledge and awareness of AMD, it did not evaluate key clinical decision-making skills such as diagnosis, differential diagnosis, referral decisions, recognition of early clinical symptoms (e.g., visual distortion), or knowledge regarding the management of high-risk dry AMD, including oral antioxidant supplementation. Therefore, the findings should be interpreted as reflecting general awareness rather than comprehensive clinical competence.

Authors’ contributions

Clinical Practices: H.Ö, B.DK, M.Ç, MF.A, U.D, C.T, ES.U Concept: H.Ö, B.DK, C.T, ES.U Design: H.Ö, B.DK, C.T, ES.U Data Collection or Processing: H.Ö, B.DK, M.Ç, MF.A, U.D, C.T, ES.U Analysis or Interpretation: H.Ö, B.DK, M.Ç, MF.A, U.D, C.T, ES.U Literature Search: H.Ö, B.DK, M.Ç, MF.A, U.D, C.T, ES.U Writing: H.Ö, B.DK, ES.U.

Funding

Not applicable.

Data availability

Raw data were generated at Gazi Yasargil Training and Research Hospital. Derived data supporting the findings of this study are available from the corresponding authors H.Ö and B.DK on request.

Declarations

Ethics approval and consent to participate

Gazi Yaşargil Training and Research Hospital Ethics Committee (dated 25.07.2025 and numbered 566).

At the beginning of the survey, participants were clearly informed about the aim and scope of the study, and it was emphasized that participation was voluntary. Completion of the survey was accepted as informed consent.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.