macular degeneration

Macular DegenerationMacular Degeneration

Nicholas J. Silvestros, ODClinical Instructor

Department of Ophthalmology and Vision SciencesWashington University St. Louis

School of Medicine

Retinal AnatomyRetinal Anatomy

• Key Anatomical Features:• Macula – oval area at posterior pole measuring 5 mm

in diameter

• Fovea – is a depression in the inner retinal surface at the center of the macula

• Foveola – central area of the fovea containing only cones and thinnest part of the retina

• Retinal pigment epithelium (RPE) – single layer supporting photoreceptors

• Bruchs membrane – separates RPE from choriocapillaris

Retinal AnatomyRetinal Anatomy

Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)

• Prevalence• Leading cause of irreversible severe vision loss in

Western world over 60 yrs old• In USA 10% between 65-75 have lost some central

vision

• In USA 30% older than 75 have lost some central vision

• Two Types of ARMD:• Atrophic (dry) – 90% of cases, slow progression

• Exudative (wet) – 10% but frequently devastating vision loss

• Risk Factors for of ARMD• Smoking – research shows two-fold increase in

risk for ARMD

• Race – caucasians more likely than African American descent

• Family history – increased risk with family history

• Diet – poor, fatty diet associated with increase risk

• Signs of ARMD• Drusen – earliest clinically detectable feature• Asymptomatic yellow excrescence beneath the RPE

• Rarely clinically visible before 45 yrs

• Not uncommon between 45-60 yrs

• Universally present >60 yrs

• With age drusen increase in size and number

• Types of Drusen• Hard drusen – small, round, yellow-white spots• Associated with focal dysfunction of RPE

• Soft drusen – larger with indistinct edges• Can coalesce, become confluent

• Diffuse dysfunction of the RPE

• Increases the risk of wet ARMD

• Pathogenesis:• Drusen are discrete deposits of abnormal

material in the RPE. Failure to clear this material which moves to inner portion of Bruch membrane. This relationship has been postulated as a determinant to progressing of ARMD

• The exact pathogenesis of drusen in ARMD is unclear

• Atrophic (dry) ARMD• Slow progressive atrophy of RPE and

photoreceptors

• Three stages • Early - small to few medium size drusen with no

symptoms or vision loss

• Intermediate – many medium size drusen with one or more larger drusen symptoms of decreased central vision noted

• Advanced dry – in addition to drusen, a breakdown of photoreceptors in macular causes reduced central vision

• All people who have wet form had intermediate stage of dry form first

• No way to tell if dry form will turn into the more severe wet form

• Dry ARMD can turn into wet ARMD at any time

• Exudative (Wet) ARMD• Fibrovascular tissue growing from

choriocapillaris, through defects in Bruch membrane, into sub-RPE and subretinal space.

• Means abnormal new blood vessels grow behind the retina/macula. Fragile and leak blood and fluid.

• Sudden meta-morphopsia or changes to present defects early sign of progression to Wet form

• Exudative (Wet) ARMD• Course:• Hemorrhagic RPE detachment

• Hemorrhagic sensory retina

• Vitreous hemorrhage

• Disciform scarring

• Massive exudation

• Exudative retinal detachment

• Exudative (Wet) ARMD• Treatment:• Injections – anti-VEGF

• Blocks vascular endothelial growth factor (VEGF) which promotes new abnormal vessel growth

• Usually multiple injections monthly

• Photodynamic therapy• IV with active laser destroying new blood vessel growth

• Laser surgery• Focal laser to stop leaking of new blood vessel growth

• Amsler Grid• Still best way to screen for macular disease

• Tests central 10 degrees/central fixation

• Patient complains of obstructing central vision scotoma (positive scotoma)• Wavy/distorted lines

• Optic nerve disease presents as a hole in central vision (negative scotoma)• Missing lines

• Age-Related Eye Disease Study (AREDS)• Studied population for 10 years

• High levels of antioxidants and zinc significantly reduce the risk of advanced ARMD and its associated vision loss

• High risk of developing advanced ARMD lowered their risk by about 25%

• First demonstrated treatment for people at high risk developing advanced ARMD• Not a cure, will not restore vision already lost just delay

onset of advanced ARMD

• Age-Related Eye Disease Study (AREDS)• No reduction in progression of no ARMD to

early or early to intermediate ARMD

• Diet alone will not provide same high levels of minerals

• Multivitamins do not contain same high levels of minerals

• Age-Related Eye Disease Study (AREDS)• Multivitamins can be taken with AREDS

formulation with physicians approval

• Eating a diet rich in green, leafy vegetables and fish showing lower risk of developing ARMD

• AREDS II – release date 2013• Added lutein, zeaxanthin and omega -3 fatty

acids DHA and EPA

Question:Question:

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