Age-Related Macular Degeneration By: Elizabeth Grigg
Look straight ahead
Cover one eye with one hand
Make a fist with your other hand
Put your fist approximately five inches away from your open eye
Move your fist closer to your eye and then farther away
Age-related macular degeneration
Degenerative disease of the macula, which is the area on the retina responsible for fine central vision as well as color vision .
The leading cause of blindness in Americans over the age of 65 (Kaufman, 2009)
Two different forms: wet exudative and dry non-exudative, but one person can have both (Perski, n.d.)
Often abbreviated as AMD or ARMD
What happens in the eye?
Dry non-exudative form
This form is much more common, occurring in approximately 90% of the cases of AMD (Macular, 2009).
Characterized by small yellow spots (fatty deposits) under the retina, called drusen (Kaufman, 2009).
Dry non-exudative form continued
Over time, the fatty deposits multiply and combine, causing cell death. This is known as geographic atrophy and can cause permanent loss of central vision (Kaufman, 2009).
Can progress to the wet form of age-related macular degeneration (Kaufman, 2009).
Wet exudative form:
Rarer, occurring in approximately 10% of the cases of AMD (Macular, 2009).
Characterized by the abnormal growth of blood vessels under the retina, which may leak or hemorrhage (Prasad, Schwartz, & Hubschman, 2010).
Wet exudative form continued
If a sub-retinal hemorrhage occurs and is not treated immediately, a disciform scar will result, which may cause permanent loss of central vision (Prasad, Schwartz, & Hubschman, 2010).
What does age-related macular degeneration look like? Healthy, normal retina Early AMD - drusen appearing on retina Macula Optic disc Yellow spots are drusen Images from http://www.agingeye.net/maculardegen/maculardegeninformation.php
As the disease progresses… Late or end-stage dry AMD (geographic atrophy) Geographic atrophy (may lead to) Wet or exudative AMD Sub-retinal hemorrhage Images from http://www.agingeye.net/maculardegen/maculardegeninformation.php
How do these forms affect vision?
For all types of AMD, peripheral vision is rarely affected (Kaufman, 2009).
Central vision and visual acuity may be unaffected (Yin et al., 2006).
Color vision may be decreased (Bremridge, 2008).
Vision may appear wavy or blurry (Pelletier, 2009).
May have difficulty adapting from indoor lighting to sunlight (Kaufman, 2009).
More effects on vision…
Late-stage dry AMD (geographic atrophy)
Depending on the location and size of the atrophy, central vision will be affected by scotomas , or blind spots (Kaufman, 2009).
Reduced visual acuity; may be 20/200 or worse (Perski, n.d.)
Reduced color vision and wavy lines.
Effects on vision continued…
Wet exudative AMD
Central vision will appear wavy (Pelletier, 2009).
Reduced visual acuity; may be 20/200 or worse (Perski, n.d.)
Central vision can be destroyed permanently by hemorrhaging and subsequent disciform scar (Kaufman, 2009).
What are the risk factors?
Risk factors are both genetic and environmental (Prasad, Schwartz, & Hubschman, 2010)
Age and smoking are two of the biggest risk factors (Coleman et al., 2010)
Family history (Kaufman, 2009)
Female gender (Bremridge, 2008)
More common among Caucasians (Perski, n.d.)
More risk factors…
Risk factors continued
Excessive sunlight exposure (Bremridge, 2008)
High blood pressure (Yin et al., 2006)
High body mass index (Singh & Tewari, 2009)
Diet high in saturated fats (Singh & Tewari, 2009)
Diet low in omega-3 fatty acids and fish (Singh & Tewari, 2009)
How does AMD affect daily living?
Individuals with AMD often have difficulty with any activity that depends on fine central vision or color vision:
Driving, especially at night
Reading fine print
Increased difficulty with glare
Increased risk of falls
(Kaufman, 2009; Bremridge, 2008)
What are the treatments or cures?
Dry non-exudative AMD
No cure available (Singh & Tewari, 2009)
Current focus is on prevention through lifestyle changes
Smoking cessation (Kaufman, 2009)
Diet high in omega-3 fatty acids, fish, and dark green leafy vegetables (Singh & Tewari, 2009)
Exercise regularly (Macular, 2009)
Wear sunglasses outside (Macular, 2009)
Treatments or cures
AREDS study – nutritional supplements found to slow progression of AMD
vitamin C, 500 mg; vitamin E; 400 IU; beta carotene, 15mg) with or without zinc (80 mg) and copper (2 mg) (Singh & Tewari, 2009)
However, beta carotene increased risk of lung cancer in smokers and zinc increased number of urologic problems (Singh & Tewari, 2009; Pelletier, 2009).
Dry AMD continued
AREDS 2 (follow-up study)
Determine if removal of beta-carotene and reduction in zinc is as effective as original formulation (Singh & Tewari, 2009).
New formulation includes addition of omega-3 fatty acids, lutein, and zeaxanthin (these are pigments that exist in the macula) (Slotnick, 2010).
Treatments or cures
Wet exudative AMD
Neither of these show significant improvements in vision nor do they prevent reoccurrences (Prasad, Schwartz, & Hubschman, 2010).
Wet exudative AMD
Intravitreal injections of anti-VEGF drugs (Macugen,Lucentis, and Avastin)
Surgery is used to remove sub-retinal hemorrhages (Prasad, Schwartz, & Hubschman, 2010).
What about cataracts?
Studies have shown that there is no increased risk of advanced age-related macular degeneration after cataract surgery (Hasson, 2009).
Charles Bonnet Syndrome
Realistic visual hallucinations associated with vision loss (Bremridge, 2008)
May be caused by brain attempting to interpret incomplete images (Bremridge, 2008)
What research is being done?
Reduce vitamin A in retina in order to slow the deterioration of rods, which is thought to contribute to AMD (Webb & Kubota, 2009).
Some studies focusing on the role of mutations in the Complement H factor, which is part of the immune system (Kaufman, 2009).
Slowing the progression of AMD
Implantable device that contains genetically engineered cells that help slow death of cells in retina (Prasad, Schwartz, & Hubschman, 2010).
Potential cures in the future
Stem cell transplants
Gene therapy (Prasad, Schartz, & Hubschman, 2010)
This simple tool helps detect changes in vision, such as possible progression from dry to wet AMD (Pelletier, 2009).
The Amsler grid is made of evenly spaced horizontal and vertical lines. A small dot is located in the center of the grid for fixation.
Detecting AMD or changes in vision: the Amsler grid
The Amsler grid Taken from: http://www.stlukeseye.com/eyeq/amslerprint.html
Instructions on using the Amsler grid
Use a bright reading light
Hold the chart approximately 14-16 inches from your eye
Cover one eye
Look at center dot
Note irregularities (wavy, size, gray, fuzzy)
Repeat the test with your other eye
Contact an ophthalmologist if you see any irregularities or notice any changes d
How might the Amsler grid look to a person who has AMD? First image from http:// www.nei.nih.gov/photo/keyword.asp?conditions =Age-Related+Macular+Degeneration+%28AMD%29 Second image from http://www.cnib.ca/en/your-eyes/eye-conditions/amd/diagnosing/diagnostic-tests/Default.aspx
What might the world look like to someone who has AMD?
Normal vision The same scene as viewed by a person with age-related macular degeneration Images from: http://www.nei.nih.gov/health/maculardegen/armd_facts.asp#1a
More examples… Clockwise from top: First image from http://www.dukehealth.org/eye_center/specialties/macular_degeneration/care_guides/macular _degeneration_frequently_asked_questions Second image from http://www.stlukeseye.com/conditions/MacularDegeneration.html Third image from http://www.nei.nih.gov/photo/sims/images/ESD11.jpg
What are some things individuals can use to adapt to their vision loss?
contrast throughout the home to keep objects visible
tactile objects or add raised bumps
Individuals with AMD should schedule a visit with a low vision specialist and a rehabilitation therapist to learn about which devices to use and how to use them (Kaufman, 2009).
Eccentric viewing (the use of peripheral vision to read) can make reading easier for those with severe central vision loss (Symptoms, 2004).
How eccentric viewing can help Advanced vision Magnifier alone Eccentric viewing defect + magnifier Images from http://www.agingeye.net/maculardegen/maculardegensymptoms.php
Here! Lighthouse of Pinellas offers variety of services
Florida Division of Blind Services: http://www.myflorida.com/dbs/
Pinellas Talking Book Library: http://www.pplc.us/tbl/
WUSF Radio Reading Service: http://www.wusf.usf.edu/radio/radio_ reading_service_on_wusf
Brembridge, T. (2008). Caring for people with age-related macular degeneration. Nursing & Residential Care , 10 (9), 443. Retrieved from CINAHL database.
Coleman, A. L., Seitzman, R. L., Cummings, S. R., Yu, F., Cauley, J. A., Ensrud, K. E.,…Mangione, C.M. (2010). The association of smoking and alcohol use with age-related macular degeneration in the oldest old: The study of osteoporotic fractures. American Journal of Ophthalmology, 149 (1), 160-169. doi: 10.1016/j.ajo.2009.07.025
Hasson, M. (2009, October). Increased risk of advanced AMD after cataract surgery unfounded. Ocular Surgery News Europe , p. 6. Retrieved from Academic Search Complete database.
Jeganathan, V., & Verma, N. (2009). Safety and efficacy of intravitreal anti-VEGF injections for age-related macular degeneration. Current Opinion in Ophthalmology , 20 (3), 223-225. Retrieved from CINAHL with Full Text database.
Kaufman, S. (2009). Developments in age-related macular degeneration: diagnosis and treatment. Geriatrics , 64 (3), 16-19. Retrieved from CINAHL database.
Macular degeneration info. (2009, May 19). University of Illinois Eye & Ear Institute. Retrieved from The Eye Digest website: http://www.agingeye.net/maculardegen /maculardegeninformation.php
Pelletier, A.L. (2009). Vision loss in older persons. American Family Physician , 79(11), 963-70. MEDLINE® is the source for the citation and abstract of this record.
Perski, T. B. (n.d.). Age-related understanding macular degeneration. Retrieved from Macular Degeneration International website: http://www.maculardegeneration .org/agedex.html
Prasad, P.S., Schwartz, S.D., Hubschman, J.P. (2010). Age-related macular degeneration: Current and novel therapies. Maturitas . doi: 10.1016/j.maturitas.2010.02.006.
Redesigning your home. (n.d.). American Foundation for the Blind. Retrieved from the AFB Senior Site website: http://www.afb.org/seniorsite.asp ?SectionID=65&TopicID=299.
Singh, C., & Tewari, A. (2009). Supplements, lifestyle and AMD: What we know today. Review of Ophthalmology , 16 (10), 55-58. Retrieved from Academic Search Complete database.
Slotnick, S. (2010). Portable and at-home tech for AMD. Review of Optometry , 147 (2), 45-49. Retrieved from Academic Search Complete database.
Symptoms of macular degeneration. (2004). University of Illinois Eye & Ear Institute. Retrieved from The Eye Digest website: http://www.agingeye.net/maculardegen /maculardegensymptoms.php
Webb, J., & Kubota, R. (2009). Potential dry AMD treatment slows visual cycle to prolong eye health. Optometry Times , 1 (9), 20-22. Retrieved from Academic Search Complete database.
Yin, W., Klein, R., Cong, S., Mitchell, P., Couper, D., Hong, L., et al. (2006). Age-related macular degeneration and risk for stroke. Annals of Internal Medicine , 145 (2), 98-W22. Retrieved from Academic Search Complete database.