Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 7-16: AGE-RELATED MACULAR DEGENERATION + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Older age group Acute or chronic deterioration of central vision in one or both eyes Distortion or abnormal size of images in one or both eyes, sometimes developing acutely No pain or redness Macular abnormalities seen by ophthalmoscopy +++ General Considerations ++ Age-related macular degeneration is classified as dry ("atrophic," "geographic") or wet ("neovascular," "exudative") Both are progressive and usually bilateral; however, manifestations, prognosis, and management differ Although dry age-related macular degeneration is much more common, wet age-related macular degeneration accounts for about 90% of all cases of legal blindness due to age-related macular degeneration +++ Demographics ++ Leading cause of permanent visual loss in the older population in developed countries Prevalence progressively increases over age 50 years (to almost 30% by age 75) Occurrence and response to treatment are likely influenced by genetically determined variations, many of which involve the complement pathway Other associated factors Race (usually white) Sex (slight female predominance) Family history Hypertension Hypercholesterolemia Cardiovascular disease Farsightedness Light iris color Cigarette smoking + Clinical Findings Download Section PDF Listen +++ ++ Age-related maculopathy that is characterized by retinal drusen is precursor to age-related macular degeneration Hard drusen appear ophthalmoscopically as discrete yellow subretinal deposits Soft drusen are larger, paler, and less distinct Large, confluent soft drusen are risk factors for neovascular (wet) age-related macular degeneration Age-related macular degeneration results in loss of central vision in the majority of patients Peripheral fields, and hence navigational vision, are maintained, except in patients with severe wet age-related macular degeneration Dry age-related macular degeneration Gradual progressive bilateral visual loss due to atrophy of the Outer retina Retinal pigment epithelium Choriocapillaris, which supplies blood to both the outer retina and the retinal pigment epithelium Wet age-related macular degeneration Onset of visual loss is more rapid and more severe than in atrophic degeneration New choroidal vessels grow under either the retina or the retinal pigment epithelial cells, leading to accumulation of exudative fluid, hemorrhage, and fibrosis The two eyes are frequently affected sequentially over a period of a few years + Diagnosis Download Section PDF Listen +++ ++ On ophthalmoscopic examination, various abnormalities are visualized in the macula Fundal photography after intravenous fluorescein (fluorescein angiography) is often required + Treatment Download Section PDF Listen +++ ++ Dry age-related macular degeneration: No specific treatment Wet age-related macular degeneration Rehabilitation including low-vision aids is important Inhibitors of vascular endothelial growth factors (VEGF), such as ranibizumab (Lucentis), bevacizumab (Avastin), and aflibercept (VEGF Trap-Eye, Eylea), cause regression of choroidal neovascularization with resorption of subretinal fluid and improvement or stabilization of vision Long-term repeated intraocular injections are required and must be administered in the eye clinic several times a year, if not monthly No dietary modification has been shown to prevent the development of age-related maculopathy However, progression may be reduced by oral treatment with antioxidants (vitamins C and E), zinc, copper, and carotenoids (lutein and zeaxanthin, rather than vitamin A [beta-carotene]) Oral omega-3 fatty acids do not provide additional benefit Patients should be advised to stop smoking + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Treatment is well tolerated with minimal adverse effects, but there is a risk of infection (1/2000), retinal detachment (1/10,000), vitreous hemorrhage and cataract A certain percentage of patients do not respond to anti-VEGF injections and up to one-third of eyes lose vision despite regular treatment +++ When to Refer ++ Older patients with sudden visual loss, particularly paracentral or central distortion or scotoma with preservation of central acuity, should be referred urgently to an ophthalmologist + References Download Section PDF Listen +++ + +Evans JR et al. Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration. Cochrane Database Syst Rev. 2017 Jul 30;7:CD000253. [PubMed: 28756617] + +Evans JR et al. Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration. Cochrane Database Syst Rev. 2017 Jul 31;7:CD000254. [PubMed: 28756618] + +Jonas JB et al. Updates on the epidemiology of age-related macular degeneration. Asia Pac J Ophthalmol (Phila). 2017 Nov–Dec;6(6):493–7. [PubMed: 28906084] + +Kandasamy R et al. New treatment modalities for geographic atrophy. Asia Pac J Ophthalmol (Phila). 2017 Nov–Dec;6(6):508–13. [PubMed: 28905539] + +Kataja M et al. Outcome of anti-vascular endothelial growth factor therapy for neovascular age-related macular degeneration in real-life setting. Br J Ophthalmol. 2018 Jul;102(7):959–65. [PubMed: 29074495] + +Layana AG et al. Vitamin D and age-related macular degeneration. Nutrients. 2017 Oct 13;9(10). [PubMed: 29027953] + +Westborg I et al. Treatment for neovascular age-related macular degeneration in Sweden: outcomes at seven years in the Swedish Macula Register. Acta Ophthalmol. 2017 Dec;95(8):787–95. [PubMed: 28834299]