OPHTHALMOLOGYMACULA DEGENERATION

MBChB 4Prof P Roux

2012

AGE-RELATED MACULAR DEGENERATION (AMD)

1. Drusen

2. Drusen and AMD

3. Atrophic AMD

4. Exudative AMD• Pigment epithelial detachment (PED)• Choroidal neovascularization (CNV)

DrusenHistopathology

• Small well-defined spots• Usually innocuous

• Larger, ill-defined spots• May enlarge and coalesce

SoftHard

• Increased risk of AMD

FA of drusen

• Amount of staining • Lipid content

Degree of hyperfluorescence depends on:• Extent of overlying RPE atrophy (window defect)

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Drusen and AMD - progression

Atrophic AMD Exudative AMD

Atrophic AMD

Initially drusen and non-specific RPE changes

Late RPE (geographic) atrophy

Progression

Atrophic AMD

Hyperfluorescence from RPE window defect Low-vision aids if appropriate

ManagementFluorescein angiogram

Signs of Pigment epithelial detachment

Sub-RPE fluid may be clear or turbid Circumscribed, dome-shaped elevation

FA of pigment epithelial detachment

Early, well-defined hyperfluorescence

Progressive increase in hyperfluorescence

No increase in size of lesion

ICG angiogram of pigment epithelial detachment

Later, thin surrounding hyperfluorescent ring

No increase in size of lesion Early, well-defined hypofluorescence

Possible subsequent course of PED

Spontaneous resolution Geographic atrophy

CNV RPE rip

Choroidal neovascularization (CNV)• Metamorphopsia is initial symptom• Most lesions are not visible clinically

Suspicious clinical signs

Pinkish-yellow subretinal lesion with fluid

Subretinal blood or lipid

• Less common than atrophic AMD but more serious

• Extrafoveal > 200 m from centre of FAZ• Juxtafoveal < 200 m from centre of FAZ

Angiographic classification of CNV

Well-defined (classical)

• Subfoveal - involving centre of FAZ

• Poorly defined

• Obscured by PED, blood or exudate

Occult

Late staining

FA of classical CNV

Leakage into subretinal space and around CNV

Very early ‘lacy’ filling pattern

CNV is hyperfluorescent (hot spot) PED is hypofluorescent

ICG angiogram in PED with occult CNV

Subretinal (disciform) scarring

Massive subretinal exudation

Possible subsequent course of CNV

Haemorrhagic sensory and RPE detachment

Exudative retinal detachment

Potential indications for laser treatment of CNV• Classic extrafoveal CNV on FA• Occult extrafoveal CNV on ICG

Pre-treatment FA of classic CNV

• Perimeter is treated with overlapping 200 m (0.2-0.5 sec) burns• Entire area is covered with high energy burns

Technique of laser photocoagulation of CNV

Lack of leakage following successful treatmentLate staining around margin is normal

Treatment

• Anti VEGF intravitreal injection monthly x3– Avastin– Lucentis

• Triamcinolone intravitreal injection every 3-6 months

Amsler grid for follow up

Amsler grid

Prevention for patients with Drusen

• Anti oxidants, vitamins and minerals• Ocuvite with Lutein• Eye Rx

• Healthy diet of veggies and fruits• Stop smoking • Treat hypercholesterolemia

Prevention for general public

• Healthy diet of veggies and fruits• Stop smoking • Treat hypercholesterolemia