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For further information, see CMDT Part 7-16: AGE-RELATED MACULAR DEGENERATION

Key Features

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

  • 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

  • On ophthalmoscopic examination, various abnormalities are visualized in the macula

  • Fundal photography after intravenous fluorescein (fluorescein angiography) is often required

Treatment

  • 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 ...

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