Age-related macular degeneration

DEFINITION
 Describes a common degenerative condition
of the retina that may affect central vision.
 LINK KE VIDEO
Age-related macular degeneration (AMD)

 Ageing changes that occur in the macula in people aged

50 years & above

 Characterized by ≥ 1 of the following:

 drusen formation
 RPE ( Retinal Pigment Epithelium) abnormalities 
hypopigmentation/hyperpigmentation, PED ( Pigment Epitelium
Detachment)
 geographic atrophy of the RPE & choriocapillaris
 Neovascular (exudative) maculopathy
AMD classification
 Dry AMD (non-neovascular form) vs wet AMD (neovascular form)
 The International Age Related Maculopathy Study Group1

1Bird AC. Surv ophthalmol. 1995

The Age Related Eye Disease Study (AREDS)

 No AMD (AREDS category 1)

 None or <5 small drusen (<63µm)
 Early AMD (AREDS category 2)
 Multiple small drusen, few intermediate drusen (63-124µm), RPE
abnormalities
 Intermediate AMD (AREDS category 3)
 Extensive intermediate drusen, ≥1 large drusen (≥125µm), geographic
atrophy not involving the center of the macula
 Advanced AMD (AREDS category 4)
 Geographic atrophy involving the center of the macula
 Neovascular maculopathy (CNV, serous/hemorrhagic PED,retinal hard
exudate,subretina/subRPE fibrovascular proliferation, disciform scar)
Epidemiology
 WHO (2002)  3rd leading cause of blindness globally
after cataract and glaucoma1
 Incidence, prevalence, & progression of AMD increase
with advancing age
 Female > male
 Whites > black
 80% of AMD patients  dry form
 Almost 90% of severe visual loss due to AMD  wet
form
1WHO: Magnitude and causes of visual impairment. Factsheet 282; Nov 2004
Prevalence
 US  late AMD: 1.47%
 Early vs late AMD
 The Beijing Eye Study  1.4% vs 0.2%
 The Shihpai Eye Study (Taiwan)  9.2% vs 1.9%
 The Funagata Study (Japan)  3.5% vs 0.5%
 The Singapore Malay Eye Study  4.9% vs 0.7%
 Indonesia  Yogyakarta : 1.11%, Jakarta (Urban Eye
Health Study): 4.3%
Anatomy & physiology of RPE
Physiology of RPE & AMD
 RPE functions
 Active transport of materials in and out of RPE
 Phagoctytosis photoreceptor outer segments
 Retinal & PUFA metabolism
 Vitamin A metabolism
 Absorption of light
 Outer blood-retina barrier
Risk factors
Non-modifiable: Modifiable:
Age Smoking
Genetic/family history Hypertension & CV disease
Sex Obesity
Race Light exposure
Iris color Low level of antioxidant
Refractive error High cholesterol
Inflammation
Pathogenesis of AMD
 Not well understood
 Factors that may contribute to the development of AMD:
 retinal pigment epithelium (RPE) dysfunction
 alterations in Bruch’s membrane
 oxidative stress
 inflammatory processes
 ischaemia

Spaide RF et al. Retina. 2003;23:595–614.

Zarbin MA. Arch Ophthalmol. 2004;122:598–614.
Morphology of AMD
 Drusen
Drusen

(A) Hard drusen; (B) soft drusen; (C) coalescence of soft drusen; (D) calcified drusen
Drusen
Geographic atrophy
Choroidal neovascularization (CNV)
Natural history
 Early AMD (AREDS category 2)
 1.3% risk of progression to advanced AMD at 5 years
 Intermediate AMD (AREDS category 3)
 18% risk of progression to advanced AMD at 5 years
 Advanced AMD (AREDS category 4)
 ± 22% risk of the fellow eye developed advanced MD at 5 years
Diagnosis
 Anamnesis: it occurs in individuals 50 years
and older with blur or distortion of central
vision.
 Fundus examinations
 OCT ( Optical Coherence Tomography)
 FFA ( Fundus Fluorescence Angiography)
CNV
Modalities for treatment
 Antioxidant, vitamins, and mineral supplements
 Intravitreal injection of anti-VEGF/VEGF trap
 Intravitreal injection of steroid
 Photodynamic therapy
 Laser photocoagulation
 Transpupillary thermotherapy
 Radiotherapy
 Surgery
Dry AMD
 No effective curative treatment
 Stop smoking
 High levels of antioxidants & minerals reduce
progression to advanced AMD & vision loss  AREDS
 Follow-up patient with Amsler grid monitoring
 Monitor fellow eye
 Low vision aid if necessary
Wet AMD
 FFA to detect & localize CNV
 Extrafoveal CNV  direct laser
 Juxtafoveal & subfoveal:
 Intravitreal injection of anti-VEGF/VEGF trap
 Combination therapy with PDT if PCV is present
 No proven benefit in treating disciform scar
 Lifestyle changes: cessation of smoking, vitamin
supplementation (AREDS)
 Low vision aid
Wet AMD

Using CIRRUS HD 21 Line Scan

Case courtesy of Dr. Scott Lee, East Bay Retina Consultants, Oakland, CA, USA
Neovascular AMD and
associated Pigment
Epithelial Detachment
Thank You