MACULAR DEGENERATION

Definition: MACULA (Lt: spot, stain) is the area in which the lens focuses and contains the FOVEA which has the highest concentration of cones (C for colour) and point of highest visual acuity. MACULAR DEGENERATION (MD) is the age related degeneration of the macula. There are two main forms: DRY MD is more common and a result of deposits of DRUSDEN around the macula in the retina. They appear as small yellow discrete lesions around the macula; with time they may enlarge, become confluent & result in localised detachment & atrophy of the retina [See image]. WET MD is due to neovascularisation into the retina resulting again in localised detachment and atrophy of the retina. Bleeding from these vessels can cause an acute loss in vision, but is otherwise gradual. This can also occur on top of dry MD. Epidemiology: Most common cause of visual impairment amongst over 50s in the developed world. In Australia, 1 in 7 people over the age of 50 are affected. Risk Factors: Age > 50, White, Female, Smoking (3x risk), Hypertension, Hypercholesterolaemia, Obesity, FHx (50% developing?) Aetiology & Pathophysiology Multifactorial aetiology; exact pathophysiology not fully understood. Due to a combination of genetics (FHx, mutations in various genes) + Age related changes + Presence of risk factors (mostly cardiovascular related). Deposition of drusden/vasculature with age Disrupts barrier retina atrophies, detaches, blood vessels grow visual loss. Clinical Presentation: Gradual, painless, bilateral central visual loss in the elderly difficulty reading not being able to recognise faces changes in colour brightness/intensity

requiring more light to read/harder to read in poor lighting visual distortion (See grid image) o metamorphopsia

maintained peripheral vision.

Commonly bilateral, but unilateral forms are often harder to diagnose because good eye often compensates and visual changes harder to notice. Advanced disease may include a central area of blurriness or loss of vision & visualing geometric shapes/people. Investigations & Diagnosis

Ophthalmoscopy o o Drusden Neovascularisation often difficult to see. Haemorrhages from neovasculature

of the grid lines around centre).

Fluorescein Angiography (See image below). o Neovascularisation, as difficult to assess using ophthalmoscope

Amsler Grid (See Image below) o Central loss/blurring with metamorphopsia (i.e. bending

Optical Coherence Tomography

Essentially optical ultrasound, used to determine thickness of retina/choroid)

Management No treatment for MD, but progression is slow and many can live well with the condition. Regular eye exams are recommended. For slowing progression of Dry MD: Vitamins A, C, E; Zinc & Copper may help. + Increased coloured fruit and vegatables (that include those vitamins) & stop smoking. ?Fish oils.
Evans & Henshaw, Cochrane Review (2008): Authors identified three large, high quality randomised controlled trials based in Australia, Finland and USA which had investigated the effects of vitamin E and beta-carotene supplementation. This review found no evidence that people in the general population should take antioxidant vitamin or mineral supplements in order to delay the onset of AMD. The results of ongoing trials are awaited.

?Telescopic lens implant for severe cases, may improve vision to some degree by focusing on what is left of the fovea. ?Injection of vascular endothelial growth factor antagonists for wet MD Complications & Prognosis Usually progressive decline to blindness with age; rate varible w genetics & RF. Secondary wet MD on top of dry MD can cause acute change. IMAGES:
A) Amsler Grid showing wet MD. B) Haemorrhage in wet MD C) Dry MD w Drusden deposits D) Fluoroscein Angiography