Macular Degeneration
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Transcript of Macular Degeneration
Macular DegenerationMacular Degeneration
Nicholas J. Silvestros, ODClinical Instructor
Department of Ophthalmology and Vision SciencesWashington University St. Louis
School of Medicine
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
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
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• 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
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• 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
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• 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
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (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
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• 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
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• 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
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• 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
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• Exudative (Wet) ARMD• Course:• Hemorrhagic RPE detachment
• Hemorrhagic sensory retina
• Vitreous hemorrhage
• Disciform scarring
• Massive exudation
• Exudative retinal detachment
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• 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
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• 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 Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
Age Related Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• 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 Macular Degeneration (ARMD)Age Related Macular Degeneration (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 Macular Degeneration (ARMD)Age Related Macular Degeneration (ARMD)
• 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:
Nicholas J. Silvestros, ODClinical Instructor
Department of Ophthalmology and Vision SciencesWashington University St. Louis
School of Medicine
Nicholas J. Silvestros, ODClinical Instructor
Department of Ophthalmology and Vision SciencesWashington University St. Louis
School of Medicine