TAKINGACLOSER LOOKATAGE-RELATEDMACULARDEGENERATION

Age-related macular degeneration(AMD) is the leading cause of irre-versible vision loss in Americans over65 years of age.1 It is a progressiveeye disease that causes deteriorationof the macula—the small, centralpart of the retina that allows us tosee fine details. While AMD rarelycauses total blindness, it often resultsin significant loss of central vision.

Close to 2 million Americans are esti-mated to have advanced AMD, and anadditional 7.3 million people are atsubstantial risk of losing vision fromthe disease.2 However, new therapiesthat help slow and even reverse visionloss are available.

“It’s like there arelittle holes in myvision. I can’t seestraight on verywell. But aroundthe edges are littleholes where I cansee quite clearly.”

Georgia O’Keeffe continuedto paint (including the coverimage) while suffering from AMD.

TAKINGACLOSERLOOKATAGE-RELATEDMACULARDEGENERATION

Cover: Georgia O'Keeffe,American, 1887-1986, BlackRock with Blue Sky andWhite Clouds, 1972, oil oncanvas, 36x30 1/2 in., AlfredStieglitz Collection, bequestof Georgia O'Keeffe, 1987.250.3, Reproduction, TheArt Institute of Chicago.

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AMD is an eye disease that causes thedeterioration, or breakdown, of themacula—the light-sensing, centralportion of the retina—resulting inthe loss of sharp, central vision.AMD is painless and usually progresses slowly. In fact, oncediagnosed with AMD some patientsmay go for years without any notice-able loss of vision. However, in othersthe disease may progress faster and canlead to significant vision loss in both eyes.

AMD almost always develops in both eyes,although one eye may be much more severely affected. The rate at which itdevelops usually depends on which of the two types of AMD you have—themore common “dry” AMD or the more severe “wet” AMD.

“Dry” AMD

“Dry” AMD is the most common typeof AMD, accounting for more than85%-90% of all cases.3 Dry AMDoccurs when small, yellowishdeposits called drusen start to formand collect beneath the macula. Whiledrusen can be harmless, in AMD thedeposits are related to the breakdownof the light-sensing cells in the mac-ula, which slowly blurs and distortscentral vision. Dry AMD usually pro-gresses slowing and in stages—early,intermediate, and advanced—and candevelop into wet AMD. While dry AMDaffects the ability to read, recognizefaces, and see fine details, it usuallyonly causes mild vision loss.

“Wet” AMD

“Wet” AMD occurs in around 10% ofindividuals with AMD4 and is causedby the growth of abnormal blood ves-sels under the macula. Because thesevessels are very fragile, they oftenleak blood and fluid, damaging themacula and causing visual cells todie. This damage results in distortionand loss of central vision. Unlike dryAMD, wet AMD does not have stagesbut is considered advanced—in fact,all people who have wet AMD haddry AMD first. With wet AMD severevision loss can occur rapidly, some-times in as little as 3 months, andwithout treatment results in legalblindness for most people.

WHAT ISAMD?Lens

Retina

Cornea

Iris

Vitreous Gel

Macula

Optic Nerve

Retinal Blood Vessels

AMD affects the ability to see centrally, both near and far.This loss of centralvision makes everyday tasks such as driving, reading, and watching television diffi-cult. You may also find it hard to recognize faces and adjust from dark to light con-ditions. However, most people with AMD keep a reasonable amount of their periph-eral vision and can learn to adapt and make the most of their remaining vision.

Dry AMD

In the early stage of dry AMD thereare usually no symptoms or visionloss, although you may find it hard toread in low light or see small elec-tronic screens. During this stagedrusen begin to collect and can bedetected during an eye exam. Ifdetected at this early stage, it may bepossible to slow down or preventfuture vision loss.

During the intermediate stage of dryAMD a blurred spot in the center ofyour vision may start to develop. Youmay also need more light or magni-fication for reading or seeing finedetails, and you may have a hard time recognizing faces.

With advanced dry AMD the drusendeposits start to cause the loss ofimportant cells in the center of yourretina. At this point the blurred spotin your central vision will get largerand darker, causing increasing visionloss. Dry AMD only rarely causesmajor vision loss, but can progressinto the more severe form—wet AMD.

Wet AMD

Damage to the macula occurs muchfaster in wet AMD, causing blurred oreven lost central vision. Early symp-toms of wet AMD include blurred cen-tral vision, straight lines appearingwavy, dark spots in the center of yourvision, and even objects appearing tomove or change shape or color.

As the disease progresses the blurredspot will get larger and darker. Becausethe cones (eye cells that detect color)are highly concentrated in the macula,color vision may also deteriorate. WetAMD can lead to legal blindness.

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HOWDOESAMD AFFECTMYVISION?

Normal vision

The same scene as viewed by a person with AMD

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Age

Age is the greatest risk factor forAMD. People over age 60 are atgreater risk than other age groups.

Genes

Individuals who have one or morefamily members with AMD, especiallyimmediate relatives such as a parentor sibling, are at increased risk.

Gender and Race

Women may have a greater risk ofdeveloping AMD than men do, andCaucasians are more likely thanBlacks to lose vision from AMD.

Eye Color

AMD is more common in people withlight colored eyes. While the reasonfor this is uncertain, it may bebecause of ethnicity or genetic pre-disposition, or because lighter eyeshave less protective pigment to blocksunlight.

Diet and Nutrition

Nutrition can have a huge impact onyour risk for AMD. A diet high in satu-rated fat and low in antioxidants canbe harmful to your eyes.

WHATARETHERISKFACTORSFORAMD?

Sunlight Exposure

The cells of the macula are highlysensitive to sun light. Exposure mayincrease risk, and people with lightcolored eyes are more likely to getdamage from the sun.

Smoking

Smoking reduces the protectiveantioxidants in the eye and canincreases the risk of AMD.

Heart Disease

High blood pressure and other riskfactors for heart disease raise therisk of AMD, possibly because of theimpact on blood vessels supplyingnutrition to the retina.

Obesity

Research has found a link betweenobesity and the progression of earlyor intermediate stage AMD to latestage AMD. Being overweight or obesecan also contribute to heart disease,which is harmful to your eyes.

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Improving your diet plays a veryimportant role in your visionhealth.There is growing evidencethat shows that the right diet mayimprove the health of your eyes, helpprevent the onset of AMD, and evenslow the rate of vision loss.

Free radicals—harmful molecules thatcan damage the fragile cells of themacula—occur naturally and are pro-duced by environmental insults suchas cigarette smoke, blue light, andharmful UV light. Antioxidants infoods help fight free radicals by neu-tralizing them and making them harm-less. The antioxidants you are proba-bly most familiar with are vitamin C,vitamin E, and beta-carotene. Many ofthese antioxidants are also plant pig-ments and give fruits and vegetablestheir vibrant colors.

The family of antioxidants thatappear to be highly protective to youreyes is carotenoids. Two of thesecarotenoids—lutein and zeaxanthin(pronounced loo-teen and zeeah-zan-thin)—are pigments found in a vari-ety of colorful fruits and vegetables.Researchers believe that they protectagainst AMD by collecting in themacula and blocking harmful light. Astudy sponsored by the NationalInstitutes of Health (NIH) found thatpeople who ate the highest amounts

of food rich in carotenoids, especiallylutein and zeaxanthin, had a 43%lower risk of developing AMD thanthose who ate food with the leastamounts.5 These antioxidants can befound in egg yolks, green leafy veg-etables, corn, oranges, squash, andmany other fruits and vegetables.

Another NIH study, the Age-RelatedEye Disease Study (AREDS), found alink between a certain combinationof vitamins and minerals, and a lowerrisk of AMD. In the study, individualswho were at high risk of developingadvanced stages of AMD took a sup-plement containing vitamin C, vita-min E, beta-carotene, zinc, and cop-per. These individuals reduced theirrisk of developing advanced AMD byup to 25%.6 A second AREDS study isnow underway and is looking at vari-ations of the original vitamin-mineralformula, including the addition oflutein and omega-3 fatty acids.

Omega-3 fatty acids have also beenfound to reduce a person’s risk ofgetting AMD. In at least two studies,people who ate 1-3 servings of fishper week were found to be less likelyto develop AMD.7 Foods that are highin omega-3 fatty acids include wildsalmon and other oily fish, walnuts,and flaxseed.

WHATROLEDOESNUTRITIONPLAYINPROTECTINGMYEYESIGHT?

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Individuals with intermediate AMDin one or both eyes, or with advancedAMD in one eye, should consider theAREDS formula of antioxidants andzinc. Visit the National Eye Institute’swebsite at www.nei.nih.gov for moreinformation on the formulation.However, before making any changesto your diet and supplements, be sureto discuss them with your eye care

professional to determine what isbest for you. In addition to thinkingabout things you should add to yourdiet, you should also make sure youavoid saturated fats and drink onlyin moderation. Alcohol depletes thebody of protective antioxidants andsaturated fats can harm blood ves-sels and produce free radicals thatcan damage the macula.

�� Beta-carotenecarrots, green leafyvegetables, sweetpotatoes, cantaloupes

�� Calcium*dairy products, greenleafy vegetables, tofu

�� Folic Acidgreen leafy vegetables,oranges, bananas, liver,dried beans, peas

�� Iron*meat, poultry, fish,eggs, vegetables, tofu

�� Lutein & Zeaxanthingreen leafy vegetables,eggs, corn, oranges,mangos, carrots

�� Lycopenetomatoes, watermelons,pink grapefruits, red grapes

�� Seleniumseafood, kidney, liver, meats

�� Vitamin A*dairy products, egg yolks,margarine, fish oil

�� Vitamin B6whole grains, poultry,fish, pork, dried beans,bananas, avocados

�� Vitamin B12meat, dairy products,eggs, liver, fish

�� Vitamin C*citrus fruits, melons,berries, bell peppers,potatoes, broccoli,tomatoes

�� Vitamin D*egg yolks, saltwaterfish, liver

�� Vitamin Ewhole grains, greenleafy vegetables, nuts,vegetable oil, wheatgerm

�� Zinc*meat, liver, eggs,seafood

FOOD SOURCES FOR EYE-HEALTHYNUTRIENTSThere are many foods that are good for your eyes and a number of them are included in the table below. If you are unable to get enough nutrients directly from your food,you may want to talk to your eye care professional about taking supplements.

*These nutrients can also be found in some fortified foods such as cereal and milk.

While you can’t change your age,your sex, or your family tree, thereare a number of things you can doto help protect your eyes:

�� Wear sunglasses or brimmed hatsto shield your eyes from sunlight—contact lenses also offer aprotective benefit

�� Eat a diet full of fruits, vegetables,and other foods that containvision protecting vitamins andminerals—see the earlier sectionfor more information

�� Talk to your eye care professionalabout taking supplements

�� Limit your intake of saturated fats

�� Don’t smoke

�� Exercise regularly and maintainan ideal weight

�� Work with your health careprofessional to control high bloodpressure and other cardiovascularrisk factors

�� Get regular eye exams—especiallyif you are at increased risk

WHATCAN I DOTOPROTECTMYEYES?

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It’s very important for you to get regular eye exams because the earlier eye dis-eases like AMD are detected, the more treatment options are possible. The NationalEye Institute recommends that people over the age of 50 get an eye exam everyyear—or as recommended by your eye care professional. You should also contactyour eye care professional immediately if you notice any changes in your vision.Listed below are many of the tests that may be used to detect and monitor AMD.

WHATTESTSWILLDETECTANDMONITORMYAMD?

Risk Assessment

Your risk for AMD can be evaluatedwith the risk factors listed on page 3.

Visual Field Test

A series of lights test your centraland peripheral vision, detectingimpaired areas of vision.

Dilated Eye Exam

Enlarging your pupils with eye dropsallows your eye care professional toexamine your retina and the back ofyour eye, detecting any drusen depositsand fluid or blood accumulation.

Visual Acuity / Function

The common eye chart measures how well you see at various dis-tances. Questions about your visionduring tasks such as driving andreading can assess visual function.

Amsler Grid

If you notice anydistortions of thelines on this checker-board-like grid (seeback cover) it maybe a sign of AMD.However, ONLY atrained professionalshould diagnoseAMD and the gridshould not substituteregular eye exams.

Fluorescein Angiogram and ICG Angiography

Dye injected into your arm circulatesthrough your bloodstream and into your retina, allowing a detailed picture to be taken and identifying any leaky blood vessels or other retinal changes.

Optical Coherence Tomography (OCT)

In a similar way to how ultrasounduses sound, OCT uses light to create aclear picture of the macula and retina.A comparison of pictures over time can show disease progression.

As Viewed bySomeone With AMD

Normal Vision

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Although there is no cure for either type of AMD,there are exciting new therapies for wet AMD thatcan slow its progression and even restore vision insome patients. These anti-VEGF drugs are injectedinto the eye and work by blocking a protein that pro-motes new blood vessel growth. One of these drugs—Lucentis—has been found to stabilize vision in mostand restore vision in around 40% of patients.8

Avastin is another anti-VEGF that is similar toLucentis but is not FDA-approved for treatment of

wet AMD—it is approved for colorectal cancer. Many doctors use it forwet AMD anyhow—a practice called off-label use. Although it has notbeen through the FDA approval process, a recent clinical trial foundAvastin to be as effective as Lucentis in treating wet AMD9; however,safety trials are still being conducted, and at the time this brochurewas printed some Avastin patients were experiencing serious eyeinfections. Be sure to do your research if you are considering Avastin.

Whichever drug you and your physician decide to use, it’s critical thatyou receive all of your scheduled injections. Wet AMD is chronic andprogressive—like high blood pressure—and must be proactively treated.Once your vision stabilizes or improves, it may be tempting to skip atreatment or two—don’t! Without regular treatments, any improvementsto your vision will likely reverse and future vision loss will becomemore difficult to reverse.

There are new treatments expected soon that may require fewer injec-tions and further reduce the burden of AMD. Also, although not usedfrequently, there are a small number of people with wet AMD thatcould benefit from laser photocoagulation.

There are no-FDA approved treatments for dry AMD yet, although nutri-tional intervention can play a role in slowing the disease. For thosewith severe dry AMD, low-vision aids such as magnifying devices andlarge-print reading materials can be used to help with everyday activities,and trained professionals can help you adapt to your vision loss.

WHATHELP ISAVAILABLEFORPEOPLEWITHAMD?

RESOURCES FORMORE INFORMATIONONAMD ANDLOW-VISIONSERVICES

Alliance for Aging Researchwww.agingresearch.org202.293.2856

AMD Alliance Internationalwww.amdalliance.org877.AMD.7171

American Academy of Ophthalmologywww.aao.org415.561.8500

American Foundation for the Blindwww.afb.org800.AFB.LINE

American MacularDegeneration Foundationwww.macular.org888.MACULAR

American OptometricAssociationwww.aoa.org800.365.2219

American RetinaFoundationwww.americanretina.org904.998.0356

Foundation Fighting Blindnesswww.blindness.org800.683.5555

Lighthouse Internationalwww.lighthouse.org800.829.0500

Macular DegenerationPartnershipwww.amd.org888.430.9898

National Association for Visually Handicappedwww.navh.org212.889.3141

National Eye Institutewww.nei.nih.gov301.496.5248

1 National Eye Institute. 2006. Progress in Eye and Vision Research: 1999-2006.2 David S. Friedman, et al. 2004. Prevalence of Age-Related Macular Degeneration in the United States. Arch Ophthalmol 122(4):564-72.

3 AMD Alliance International. Basic Facts About AMD. www.amdalliance.org/information_overview_basic_facts.html.

4 Id.5 Johanna M. Seddon, et al. 1994. Dietary Carotenoids, Vitamins A, C, and E, and Advanced Age-Related Macular Degeneration. JAMA 272(18):1413-20.

6 Age-Related Eye Disease Study Research Group. 2001. AREDS report no. 8. Arch Ophthalmol 119(10):1417-36.

7 Arch Ophthalmol. 2006. 124(7):938-1070.8 National Eye Institute. Press Release. www.nei.nih.gov/news/pressreleases/042811.asp9 Rosenfeld et al. 2006. Ranibizumab for Neovascular Age-Related Macular Degeneration. NEJM355:1419-31

750 17th Street, NW, Suite 1100, Washington, DC 20006

Reviewed by National Eye Institute principal investigators.

AMSLERGRID

Directions for the Amsler Grid

Hold the grid at a comfortable reading distance (use glasses if needed). Cover one eye and look at the dot in the center of the grid. Note how the linesand squares appear. Do they look straight and even, or do any seem wavy ordistorted? Are any of the pieces of the grid missing? Now cover your other eyeand follow the same directions. If the lines do not appear straight and even,contact your eye care professional immediately.