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Age- Related Macular Degeneration

  • INTRODUCTION: Macular Degeneration
  • Types of Macular Degeneration
  • Risk factors/Diagnosis
  • Treatment & Management

What is Macular Degeneration?

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Age-related macular degeneration (AMD) is a deterioration or breakdown of the eye’s macula. The macula is a small area in the retina — the light-sensitive tissue lining the back of the eye. The macula is the part of the retina that is responsible for your central vision, allowing you to see fine details clearly

The macula makes up only a small part of the retina, yet it is much more sensitive to detail than the rest of the retina (called the peripheral retina). The macula is what allows you to thread a needle, read small print, and read street signs. The peripheral retina gives you side (or peripheral) vision. If someone is standing off to one side of your vision, your peripheral retina helps you know that person is there by allowing you to see their general shape.

Many older people develop macular degeneration as part of the body’s natural aging process. There are different kinds of macular problems, but the most common is age-related macular degeneration.

With macular degeneration, you may have symptoms such as blurriness, dark areas or distortion in your central vision, and perhaps permanent loss of your central vision. It usually does not affect your side, or peripheral vision. For example, with advanced macular degeneration, you could see the outline of a clock, yet may not be able to see the hands of the clock to tell what time it is.

Causes of macular degeneration include the formation of deposits called drusen under the retina, and in some cases, the growth of abnormal blood vessels under the retina. With or without treatment, macular degeneration alone almost never causes total blindness. People with more advanced cases of macular degeneration continue to have useful vision using their side, or peripheral vision. In many cases, macular degeneration’s impact on your vision can be minimal.

When macular degeneration does lead to loss of vision, it usually begins in just one eye, though it may affect the other eye later. Many people are not aware that they have macular degeneration until they have a noticeable vision problem or until it is detected during an eye examination.

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NORMAL VISION
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ARMD VISION

An eye disease that causes vision loss

  • Very common More than 10 million cases per year (India)
  • Can’t be cured, but treatment may help
  • Requires a medical diagnosis.
  • Lab tests or imaging rarely required.
  • Chronic: can last for years or be lifelong

Macular degeneration causes loss in the centre of the field of vision. In dry macular degeneration, the centre of the retina deteriorates. With wet macular degeneration, leaky blood vessels grow under the retina. Blurred vision is a key symptom. A special combination of vitamins and minerals (AREDS formula) may reduce disease progression. Surgery may also be an option

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AGE-RELATED MACULAR DEGENRATION POSTER –COURTSESY (OPTHO REMEDIES)

Types of Macular Degeneration

There are two basic types of Macular Degeneration: “dry” and “wet.” Approximately 85% to 90% of the cases of Macular Degeneration are the “dry” (atrophic) type, while 10-15% is the “wet” (exudative) type. Stargardt disease is a form of macular degeneration found in young people, caused by a recessive gene.

There are three stages of AMD defined in part by the size and number of drusen under the retina. It is possible to have AMD in one eye only, or to have one eye with a later stage of AMD than the other.

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Stages of ARMD
Early AMD: Early AMD is diagnosed by the presence of medium-sized drusen, which are about the width of an average human hair. People with early AMD typically do not have vision loss.
Intermediate AMD: People with intermediate AMD typically have large drusen, pigment changes in the retina, or both. Again, these changes can only be detected during an eye exam. Intermediate AMD may cause some vision loss, but most people will not experience any symptoms.
Late AMD: In addition to drusen, people with late AMD have vision loss from damage to the macula.

There are two types of late AMD:
In geographic atrophy (also called dry AMD), there is a gradual breakdown of the light-sensitive cells in the macula that convey visual information to the brain, and of the supporting tissue beneath the macula. These changes cause vision loss.

In neovascular AMD: (also called wet AMD), abnormal blood vessels grow underneath the retina. (“Neovascular” literally means “new vessels.”) These vessels can leak fluid and blood, which may lead to swelling and damage of the macula. The damage may be rapid and severe, unlike the more gradual course of geographic atrophy. It is possible to have both geographic atrophy and neovascular AMD in the same eye, and either condition can appear first.

AMD has few symptoms in the early stages, so it is important to have your eyes examined regularly. If you are at risk for AMD because of age, family history, lifestyle, or some combination of these factors, you should not wait to experience changes in vision before getting checked for AMD.

If you have late AMD in one eye only, you may not notice any changes in your overall vision. With the other eye seeing clearly, you may still be able to drive, read, and see fine details. However, having late AMD in one eye means you are at increased risk for late AMD in your other eye. If you notice distortion or blurred vision, even if it doesn’t have much effect on your daily life, consult an eye care professional.

Use an Amsler grid for checking for symptoms of Macular Degeneration Seek immediate attention from an eye care professional if there are any sudden changes in vision.

Risk factors/Diagnosis Age: The rate of Macular Degeneration increases dramatically with age, Macular Degeneration is not an inevitable consequence of ageing Family history 50% risk of developing MACULAR DEGENERATION if a family history is present.

Up to 70% of cases have a genetic link, Smoking 3 to 4 times the risk of Macular Degeneration, if you smoke Smokers get Macular Degeneration 5 to 10 years earlier, on average1,11,12 20 years after quitting, an ex-smoker’s risk is the same as someone who has never smoked.

How is AMD detected?

The early and intermediate stages of AMD usually start without symptoms. Only a comprehensive dilated eye exam can detect AMD. The eye exam may include the following:

Visual acuity test- This eye chart measures how well you see at distances.

Dilated eye exam- Your eye care professional places drops in your eyes to widen or dilate the pupils. This provides a better view of the back of your eye. Using a special magnifying lens, he or she then looks at your retina and optic nerve for signs of AMD and other eye problems.

Amsler grid- Your eye care professional also may ask you to look at an Amsler grid. Changes in your central vision may cause the lines in the grid to disappear or appear wavy, a sign of AMD.

Fluorescein angiogram- In this test, which is performed by an ophthalmologist, a fluorescent dye is injected into your arm. Pictures are taken as the dye passes through the blood vessels in your eye. This makes it possible to see leaking blood vessels, which occur in a severe, rapidly progressive type of AMD (see below). In rare cases, complications to the injection can arise, from nausea to more severe allergic reactions.

Optical coherence tomography- You have probably heard of ultrasound, which uses sound waves to capture images of living tissues. OCT is similar except that it uses light waves, and can achieve very high-resolution images of any tissues that can be penetrated by light—such as the eyes. After your eyes are dilated, you’ll be asked to place your head on a chin rest and hold still for several seconds while the images are obtained. The light beam is painless.

During the exam, your eye care professional will look for drusen, which are yellow deposits beneath the retina. Most people develop some very small drusen as a normal part of aging. The presence of medium-to-large drusen may indicate that you have AMD.

Another sign of AMD is the appearance of pigmentary changes under the retina. In addition to the pigmented cells in the iris (the colored part of the eye), there are pigmented cells beneath the retina. As these cells break down and release their pigment, your eye care professional may see dark clumps of released pigment and later, areas that are less pigmented. These changes will not affect your eye color.

How it is treated?

Early AMD:

Currently, no treatment exists for early AMD, which in many people shows no symptoms or loss of vision. Your eye care professional may recommend that you get a comprehensive dilated eye exam at least once a year. The exam will help determine if your condition is advancing.

As for prevention, AMD occurs less often in people who exercise, avoid smoking, and eat nutritious foods including green leafy vegetables and fish. If you already have AMD, adopting some of these habits may help you keep your vision longer.

Intermediate and late AMD:

Researchers at the National Eye Institute tested whether taking nutritional supplements could protect against AMD in the Age-Related Eye Disease Studies (AREDS and AREDS2). They found that daily intake of certain high-dose vitamins and minerals can slow progression of the disease in people who have intermediate AMD, and those who have late AMD in one eye.

The first AREDS trial showed that a combination of vitamin C, vitamin E, beta-carotene, zinc, and copper can reduce the risk of late AMD by 25 percent. The AREDS2 trial tested whether this formulation could be improved by adding lutein, zeaxanthin or omega-3 fatty acids. Omega-3 fatty acids are nutrients enriched in fish oils. Lutein, zeaxanthin and beta-carotene all belong to the same family of vitamins, and are abundant in green leafy vegetables.

The AREDS2 trial found that adding lutein and zeaxanthin or omega-three fatty acids to the original AREDS formulation (with beta-carotene) had no overall effect on the risk of late AMD. However, the trial also found that replacing beta-carotene with a 5-to-1 mixture of lutein and zeaxanthin may help further reduce the risk of late AMD. Moreover, while beta-carotene has been linked to an increased risk of lung cancer in current and former smokers, lutein and zeaxanthin appear to be safe regardless of smoking status.

Here are the clinically effective doses tested in AREDS and AREDS2:

500 milligrams (mg) of vitamin C

400 international units of vitamin E

80 mg zinc as zinc oxide (25 mg in AREDS2)

2 mg copper as cupric oxide

15 mg beta-carotene, OR 10 mg lutein and 2 mg zeaxanthin

A number of manufacturers offer nutritional supplements that were formulated based on these studies. The label may refer to “AREDS” or “AREDS2.”

If you have intermediate or late AMD, you might benefit from taking such supplements. But first, be sure to review and compare the labels. Many of the supplements have different ingredients, or different doses, from those tested in the AREDS trials. Also, consult your doctor or eye care professional about which supplement, if any, is right for you. For example, if you smoke regularly, or used to, your doctor may recommend that you avoid supplements containing beta-carotene.

Even if you take a daily multivitamin, you should consider taking an AREDS supplement if you are at risk for late AMD. The formulations tested in the AREDS trials contain much higher doses of vitamins and minerals than what is found in multivitamins. Tell your doctor or eye care professional about any multivitamins you are taking when you are discussing possible AREDS formulations.

You may see claims that your specific genetic makeup (genotype) can influence how you will respond to AREDS supplements. Some recent studies have claimed that, depending on genotype, some patients will benefit from AREDS supplements and others could be harmed. These claims are based on a portion of data from the AREDS research. NEI investigators have done comprehensive analyses of the complete AREDS data. Their findings to date indicate that AREDS supplements are beneficial for patients of all tested genotypes. Finally, remember that the AREDS formulation is not a cure. It does not help people with early AMD, and will not restore vision already lost from AMD. But it may delay the onset of late AMD. It also may help slow vision loss in people who already have late AMD.

I-GEM 6 is based on AREDS 2 formulation (Optho Remedies)

Neovascular AMD typically results in severe vision loss. However, eye care professionals can try different therapies to stop further vision loss. You should remember that the therapies described below are not a cure. The condition may progress even with treatment.

Injections: One option to slow the progression of neovascular AMD is to inject drugs into the eye. With neovascular AMD, abnormally high levels of vascular endothelial growth factor (VEGF) are secreted in your eyes. VEGF is a protein that promotes the growth of new abnormal blood vessels. Anti-VEGF injection therapy blocks this growth. If you get this treatment, you may need multiple monthly injections. Before each injection, your eye will be numbed and cleaned with antiseptics. To further reduce the risk of infection, you may be prescribed antibiotic drops. A few different anti-VEGF drugs are available. They vary in cost and in how often they need to be injected, so you may wish to discuss these issues with your eye care professional.

Photodynamic therapy: This technique involves laser treatment of select areas of the retina. First, a drug called verteporfin will be injected into a vein in your arm. The drug travels through the blood vessels in your body, and is absorbed by new, growing blood vessels. Your eye care professional then shines a laser beam into your eye to activate the drug in the new abnormal blood vessels, while sparing normal ones. Once activated, the drug closes off the new blood vessels, slows their growth, and slows the rate of vision loss. This procedure is less common than anti-VEGF injections, and is often used in combination with them for specific types of neovascular AMD.

Laser surgery: Eye care professionals treat certain cases of neovascular AMD with laser surgery, though this is less common than other treatments. It involves aiming an intense “hot” laser at the abnormal blood vessels in your eyes to destroy them. This laser is not the same one used in photodynamic therapy which may be referred to as a “cold” laser. This treatment is more likely to be used when blood vessel growth is limited to a compact area in your eye, away from the centre of the macula that can be easily targeted with the laser. Even so, laser treatment also may destroy some surrounding healthy tissue. This often results in a small blind spot where the laser has scarred the retina. In some cases, vision immediately after the surgery may be worse than it was before. But the surgery may also help prevent more severe vision loss from occurring years later.