Trouble with vision as      we get older...• Is not always due to Age-  related macular  degeneration !• Your doctor needs...
Eye Examination -      DiagnosisVisual Acuity, Color Vision, Amsler Grid,Fundus Camera, Fluorescein Angiography,    Optica...
Amsler Grid Testing
Drusen, the yellow spots so characteristic  of Age-related Macular Degeneration
Drusen are sometimes more easily detectedOn Color Fundus photos than doctor’s exam
FluoresceinAngiography
Colour photography isroutinely undertaken withangiography. It helps todetermine the nature ofchanges seen on theangiogram…...
Side by side    comparisonof the color photo        and  the fluorescein      pictureoften complement        each       ot...
-
Optical Coherence  Tomography
• Diagnostic imaging technique that examines  living tissue non-invasively. It is based on a  complex analysis of the refl...
•       Macular Degeneration    Leading cause of    blindness in people    over 55    •   1:10 people over        55    • ...
How Does the Eye    Work?
•      What is Macular  Idiopathic• Central vision          Degeneration?  loss •   Peripheral vision     preserved• Two f...
What does my Doctor•  •    Drusen          see?        Metabolic waste        products        accumulating under        th...
My Doctor told me I have Macular   Degeneration. Will I go blind?• Not necessarily•   Only 10% develop    the wet form whi...
Risk factors for Vision• Non-modifiable:  things we cannot loss  change •   Age     •   (If you figure out how         to ...
Risk factors for Vision• Modifiable • Smoking   Loss    • Hypertension    • High      Cholesterol    • Obesity    • Sedent...
What about thoseAREDS study•    Vitamins? II    Followed 3640 patients    for average 6.3 years          • AREDS•   High d...
•                     Vitamins    Not found helpful for    everyone•   No benefit    •   No AMD                   •   Bene...
Which is the best         Multivitamin?•   They are all basically the    same as long as they have    the AREDS formula•  ...
•   Stop Smoking      Summary•   Exercise•   Heart Healthy Diet•   Eat leafy green    vegetables•   Control blood    press...
•       Macular Degeneration    Leading cause of    blindness in people    over 55    •   1:10 people over        55    • ...
How Does the Eye    Work?
•      What is Macular  Idiopathic• Central vision          Degeneration?  loss •   Peripheral vision     preserved• Two f...
What does my Doctor•  •    Drusen          see?        Metabolic waste        products        accumulating under        th...
My Doctor told me I have Macular   Degeneration. Will I go blind?• Not necessarily•   Only 10% develop    the wet form whi...
Risk factors for Vision• Non-modifiable:  things we cannot loss  change •   Age     •   (If you figure out how         to ...
Risk factors for Vision• Modifiable • Smoking   Loss    • Hypertension    • High      Cholesterol    • Obesity    • Sedent...
What about thoseAREDS study•    Vitamins? II    Followed 3640 patients    for average 6.3 years          • AREDS•   High d...
•                     Vitamins    Not found helpful for    everyone•   No benefit    •   No AMD                   •   Bene...
Which is the best         Multivitamin?•   They are all basically the    same as long as they have    the AREDS formula•  ...
•   Stop Smoking      Summary•   Exercise•   Heart Healthy Diet•   Eat leafy green    vegetables•   Control blood    press...
Age-related Macular  Degeneration
What is Age-Related Macular            Degeneration?• Age-related macular degeneration (AMD) is a  deterioration or breakd...
What is going on in the         eye?
Where exactly?
Where exactly?
Genetics• DNA• All information of life encoded in DNA and  expressed by proteins.• James Dewey Watson (US) & Francis Crick...
Before…
…After…Age-related     changes
Genetic Basics…get          small…• The human body is made up of trillions of Cells,• and with a few exceptions, each cell...
From DNA…to You    and Me…
…and smaller…From Cells to     Nucleus to Chromosomes• Every human cell contains 23 pairs of  chromosomes, for a total of ...
Human Chromosomes
…and smaller…• A CHROMOSOME contains hundreds to  thousands of genes.• A GENE is a segment of DNA containing  the code use...
From Chromosomes to       Genes
WhatStudies we know?…• Genetic do• 1988-2010 so far    • DNA and Gene-Environment Data      Collection    • Twin Study – W...
What do we know?…        so far• From the US Twin Study, we’ve learned• Substantial Genetic Component – • 46 to 71% of the...
OK…what “Genetic    Factors”?...• It’s not so much as a “bad” gene, but rather• Variations of “normal genes” that influenc...
From Chromosomes to       Genes
Genes associated…so• CFH – Y402H far•   CFH – rs1410996                              •   Hepatic Lipase C (LIPC)•   CFB   ...
Gene location… leads     to therapy• For example, the VEGFA locus and the  development of• Avastin• Lucentis and recently•...
Antigen/Antibody cell     membrane      Bayer Healthcare – Bayer Schering Pharma
Surfaceantigens/antibodies        Eylea.com
Relative risk of Genetic           loci        Nature Genetics 38: 1057, 2006
Epidemiology•   Epidemiology is the study of•   the distribution and patterns of health-events,•   health-characteristics ...
Epidemiology• It is our principal method of public health  research, and• helps us make policy decisions as well as  evide...
Epidemiologic studies looking at• Meta-analysis of 15 genome-wide       the genetics of AMD  association studies• Began in...
Epidemiology and             CausationRisk factors for cardiovascular disease (CVD)   are associated with age-related AMD;...
Epidemiology and            Causation• For the homozygous (pure trait) risk  genotype• Risk of AMD was • Increased for BMI...
So what can we say?• Genetic mutations make us susceptible to  the development of AMD• Multiple genetic factors are at wor...
The big question (at least for the          retina specialists)• What information from• TV,• Radio,• Internet,• YouTube,• ...
Types of Optical Devices         Near Devices
Stand Magnifier
Dome Magnifier
Illuminated Stand     Magnifier
Hand Held Pocket   Magnifier
Hand HeldIlluminated
Microscopes or Reading Glasses
Types of Optical Devices     Distance Devices
Binoculars
Monocular
Full-Field Telescopic       Systems
Bioptic Systems
Sunfilters
Night Vision Scopes
Getting the Right               Device(s)devices• Because there is such a variety of    available, it can be somewhat over...
What’s New inLow Vision Technology
Handheld Magnifying Cameras•   Miracle Mouse    Electronic TV    Magnifier•   MonoMouse-RM B&W    Electronic Magnifier•   ...
Traditional CCTV Video           Magnifiers reading                 • Increased                              speed        ...
Magnifiers      Integrated LCD• Available from all major vendors               Displays• Sizes: 17” to 24” + with WS•   Ad...
Integrated LCD Systems
Video             Magnification• Variable     Systems  Magnification• Adjustable brightness• Selectable contrast  setting•...
Magnification
Brightness
Contrast
Windowing and Underlining
Portable Video• More Compact, 7-inch screens         Magnifiers• Extensive reading tasks• Two handed use• Optelec Traveler...
Compact Video           Magnifiers:• Variable Magnification•   Replaceable Batteries•   Longer battery life•   Image Freez...
Compact/PocketVideo Magnifiers        • Advantages          •     Wide field of view            •   Image at display level...
Compact Systems with Distance Capabilities• Near and distance capabilities• Read mail, products on a shelf and get a  bett...
GW Micro           Sense View Duo•   Two cameras•   Stores up to 20 images•   3X to 13X magnification•   Lights off mode• ...
Ash TechnologyQuicklook Focus
Desktop Video Magnifiers• Full Size screen                 Features• Full Features• Remote Controllable• Near and Distance...
Vision Technology: VIEW
Enhanced Vision Acrobat LCD
Onyx Deskset
Laptop Compatible Video       Magnifiers•   Most students    use laptop    computers•   Video    magnification    could be...
Clarity PCMate•   Powered by USB•   Requires 2 USB 2    ports    •   Sequence, setup•   Remote control    camera•   Keyboa...
OptelecClearNote      • Ease of camera        aiming         •   Built in Light source         •   Camera control         ...
Freedom Scientific Onyx      PC Edition arm and flex            • Swing                   arm models               •   Rem...
Specialty Video        Magnifiers• Flipper• Shoppa
Headborne Low Vision      System          •   Eyetonomy SightMate LV920          •   www.vuzix.com/medical/lv920.h        ...
Scan and Read Devices• Kurzweil 1000 (software)• ABiSee Zoom-Ex, EyePal Vision (portable,  Solo)• FS Pearl (laptop compati...
Assessment functioning• Evaluation of visual Factors•   Response to low vision approaches•   Analysis of tasks, task speci...
Types of Optical Devices         Near Devices
Stand Magnifier
Dome Magnifier
Illuminated Stand     Magnifier
Hand Held Pocket   Magnifier
Hand HeldIlluminated
Microscopes or Reading Glasses
Types of Optical Devices     Distance Devices
Binoculars
Monocular
Full-Field Telescopic       Systems
Bioptic Systems
Sunfilters
Night Vision Scopes
Getting the Right               Device(s)devices• Because there is such a variety of    available, it can be somewhat over...
What’s New inLow Vision Technology
Handheld Magnifying Cameras•   Miracle Mouse    Electronic TV    Magnifier•   MonoMouse-RM B&W    Electronic Magnifier•   ...
Traditional CCTV Video           Magnifiers reading                 • Increased                              speed        ...
Magnifiers      Integrated LCD• Available from all major vendors               Displays• Sizes: 17” to 24” + with WS•   Ad...
Integrated LCD Systems
Video             Magnification• Variable     Systems  Magnification• Adjustable brightness• Selectable contrast  setting•...
Magnification
Brightness
Contrast
Windowing and Underlining
Portable Video• More Compact, 7-inch screens         Magnifiers• Extensive reading tasks• Two handed use• Optelec Traveler...
Compact Video           Magnifiers:• Variable Magnification•   Replaceable Batteries•   Longer battery life•   Image Freez...
Compact/PocketVideo Magnifiers        • Advantages          •     Wide field of view            •   Image at display level...
Compact Systems with Distance Capabilities• Near and distance capabilities• Read mail, products on a shelf and get a  bett...
GW Micro           Sense View Duo•   Two cameras•   Stores up to 20 images•   3X to 13X magnification•   Lights off mode• ...
Ash TechnologyQuicklook Focus
Desktop Video Magnifiers• Full Size screen                 Features• Full Features• Remote Controllable• Near and Distance...
Vision Technology: VIEW
Enhanced Vision Acrobat LCD
Onyx Deskset
Laptop Compatible Video       Magnifiers•   Most students    use laptop    computers•   Video    magnification    could be...
Clarity PCMate•   Powered by USB•   Requires 2 USB 2    ports    •   Sequence, setup•   Remote control    camera•   Keyboa...
OptelecClearNote      • Ease of camera        aiming         •   Built in Light source         •   Camera control         ...
Freedom Scientific Onyx      PC Edition arm and flex            • Swing                   arm models               •   Rem...
Specialty Video        Magnifiers• Flipper• Shoppa
Headborne Low Vision      System          •   Eyetonomy SightMate LV920          •   www.vuzix.com/medical/lv920.h        ...
Scan and Read Devices• Kurzweil 1000 (software)• ABiSee Zoom-Ex, EyePal Vision (portable,  Solo)• FS Pearl (laptop compati...
Assessment functioning• Evaluation of visual Factors•   Response to low vision approaches•   Analysis of tasks, task speci...
Pharmacogenomics• Treatment based on    genetic profile•   “Personalized    medicine”•   AREDS – 70% with    certain gene ...
Gene Therapy for retinal diseases
•                       Trials    Phase I Dose Escalation Safety Study    of RetinoStat in Advanced Age-    Related Macula...
WetDry AMD          Atrophi             c
So What Have We    Learned? Lory C. Snady-McCoy, MD
Answers to Common      QuestionsWhat defines macular degeneration?
What tests are used?Why are they necessary in the diagnosis and management?  Not everything that looks like      macular d...
What Should I Eat?
• Foods rich in antioxidants may delay the  progression of AMD• Green leafy vegetables, berries, nuts, seaweed  (?) Beta-c...
Which vitamins should I use?
• AREDS vitamins shown to be beneficial in  patients with high risk AMD• Vitamins slow the progression; they do not  stop ...
Will the high dose of vitamins in the AREDS formula have side effects?•   Vitamin A in smokers - lung cancer•   Vitamins A...
Is AMD hereditary?Are my children at risk?
•   Genetics of AMD is complex with many    associated genes•   Hereditary forms exist and can express    themselves at di...
Known risk factors:• Smoking, diet, exercise, obesity (BMI)• Hypertension, Hypercholesterolemia• Does this sound familiar??
Will I go totally blind?•   AMD causes central vision loss with    preservation of peripheral vision•   90% of severe visi...
Are there anynew treatments in the making?
•   Millions of dollars have been appropriated to    AMD research•   Medications based on a person’s individual    genetic...
Which treatment is best for me                     and why?•   Thermal “Hot” Laser (1970’s)•   PDT “Cold” Laser (Visudyne)...
Argon/Krypton/Dye/Diode Laser                                PDT Laser/Visudyne
MacugenLucentis/Avas     tin    Eylea
How many injections will I need? Is there a limit to the  number of treatments I can get? What is the side  effect of long...
What will happen if I do nothing?• Natural history of AMD is to cause significant  and permanent loss of central vision le...
Will changing my glasses help?Multiple aids to help people with decreased vision with AMD:•   Spectacle-mounted magnifiers...
Congratulations!           You have now            earned your              diploma!
So What Have We    Learned? Lory C. Snady-McCoy, MD
Answers to Common      QuestionsWhat defines macular degeneration?
What tests are used?Why are they necessary in the diagnosis and management?  Not everything that looks like      macular d...
What Should I Eat?
• Foods rich in antioxidants may delay the  progression of AMD• Green leafy vegetables, berries, nuts, seaweed  (?) Beta-c...
Which vitamins should I use?
• AREDS vitamins shown to be beneficial in  patients with high risk AMD• Vitamins slow the progression; they do not  stop ...
Will the high dose of vitamins in the AREDS formula have side effects?•   Vitamin A in smokers - lung cancer•   Vitamins A...
Is AMD hereditary?Are my children at risk?
•   Genetics of AMD is complex with many    associated genes•   Hereditary forms exist and can express    themselves at di...
Known risk factors:• Smoking, diet, exercise, obesity (BMI)• Hypertension, Hypercholesterolemia• Does this sound familiar??
Will I go totally blind?•   AMD causes central vision loss with    preservation of peripheral vision•   90% of severe visi...
Are there anynew treatments in the making?
•   Millions of dollars have been appropriated to    AMD research•   Medications based on a person’s individual    genetic...
Which treatment is best for me                     and why?•   Thermal “Hot” Laser (1970’s)•   PDT “Cold” Laser (Visudyne)...
Argon/Krypton/Dye/Diode Laser                                PDT Laser/Visudyne
MacugenLucentis/Avas     tin    Eylea
How many injections will I need? Is there a limit to the  number of treatments I can get? What is the side  effect of long...
What will happen if I do nothing?• Natural history of AMD is to cause significant  and permanent loss of central vision le...
Will changing my glasses help?Multiple aids to help people with decreased vision with AMD:•   Spectacle-mounted magnifiers...
Congratulations!           You have now            earned your              diploma!
• Can only be used in patients with functioning inner         retinal cells – for example AMD and RP    • Uses an artifici...
Retinal Implant
ARGUS II Implant 60 electrodes (16 in      ARGUS I)250 electrode array in    development
Subretinal implant
Microprocessor power
Emerging treatments for        Dry AMDAtrophic AMD   AL-8309B (Alcon Laboratories)                •   2 year study evaluat...
ACU-4429 - Acucela    Phase II granted fast track statusFenretinide    Phase III began 2011
Emerging treatments for dry     AMD• Encapsulated human cells genetically modifiedto secrete ciliary neurotrophic factor (...
Emerging treatments• OT- 551 Antioxidant Eye drops       for Dry AMD • Othera Pharmaceuticals/ National Eye Institute• A M...
Human embryonic   stem • Can differentiate into any of        cells                    the 220 cell type in the           ...
Stem Cell Research
• hES Cells modified to become RPE cells whichnourish damaged photorecptors•First study of   human transplantation reporte...
Stem Cells – Current• Rejection Problems• Tumor formation• Expense – producing and cultivating cell  lines is costly• Inte...
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
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Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
Age related macula degen
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Age related macula degen

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May 2012 discussion of age related macular degeneration to a lay audience by 5 different doctors

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  • Amsler grids are everywhere. Check the vision in each eye daily.
  • Throughout the history of medicine, doctors have observed treatment variability among patients which we know now to be due to genetic differences. Why some people respond well to one drug and others don’t or why some people develop certain side effects and others don’t is due to small differences in genetic make up between us. Some preliminary pharmacogenetic relationships have been reported to exist between genetic risk factors associated with AMD and the response to treatment. These pharmacogenetic associations could be used in the future to create a personalized therapeutic plan whereby patients with different genotypes are offered different treatments.
  • So how can we use our knowledge of genetics to actually treat patients. Many diseases come about b/c of an abnormal protein produced by a faulty gene. Gene therapy aims to alter or stop the formation of proteins that lead to disease. This approach is still a long way off in treating AMD but is being used to treat other eye diseases. On the other hand creating a so called “biofactory” by injecting genes that produce proteins such as anti-VEGF compounds drugs would obviously be very helpful for patients with wet AMD. An injection every year or two rather than monthly is not an unrealistic possibility.
  • The wet form of AMD with bleeding and scarring (shown in the top picture) and the Atrophic form (bottom picture) with thinning and and loss of retinal tissue are the primary causes of severe loss of vision in pts with macular degeneration. The treatments I’ll discuss here pertain primarily to this subset of patients. Both of these forms of AMD will become less prevalent as we become better at indentifying those patients who are at greatest risk and as preventative treatments become available.
  • Three models are now in development or testing. Model 1, with 16 electrodes, has been implanted in six patients. As of mid-July 2009, a second model integrating a 60-electrode array has been implanted in 30 human subjects domestically and internationally. A third model, an array with a higher electrode count, is under development.
  • May 2012 – details released of a wireless, subretinal 256 channel implant being developed in Boston. Disadvantages: more complex surgical procedure. All the implant designs in development have advantages and disadvantages not the least of which is the complexity of the surgical procedure, the lack of long term follow-up and cost ($100K)
  • Moore’s law loosely defined says that the power of a computer chip doubles approximately every 2 years. Timeline for progress of the artificial retina. Progress started with the installation of the first 16-electrode device in 2002, which restored light perception and the ability to perform simple visual spatial and motion tasks (hand motion level). Theoretically, there is improvement with 60 and 200+ electrode implants (finger count level) with the possibility of face recognition and reading ability with a 1000+ electrode device. (Left scale) Progression in vision from bare hand motion to face recognition. At 20/200 visual acuity, large letters can be recognized. At 20/20, small letters can be seen with good reading ability. (Right scale) Number of patients potentially helped with the different generations of prosthetic devices.
  • Pixels (short for picture element) are the smallest controllable element of a digital image. It is a single point in a graphic image. The more pixels on the display the higher the resolution. Examples of pixilated vision. Lower resolution may allow crude shape recognition, but increasing resolution can lead to reading letters on an eye chart and face recognition.
  • AL-8309 protects the photoreceptors and RPE cells from photo-oxidative stress and may be a useful pharmacotherapy for AMD
  • Reducing the speed of the visual cycle has been shown to protect the retina from light damage, improve retinal vasculature (the arrangement of blood vessels) and reduce the accumulation of retinal-related toxic by-products, including A2E, which is implicated in AMD. RPE cells continually consume the tips of Photoreceptors as they grow (at a constant rate of speed), accumulating toxic by-products of the visual cycle. ACU 4429 slows Visual cycle modulation resulting in a decrease of toxic by-product accumulation, and a slowing of AMD.
  • Dry or atrophic AMD has become an orphan disease – we know a lot about it but we have no effective treatments. My point is not to overwhelm you with technical information but to highlight the exciting and extensive ongoing research in dry AMD.
  • This model consists of rats with a genetic disorder where they do not have one of the enzymes needed for the RPE cell layer to function. As a result, the rats become blind due to deterioration of their photoreceptors. Following transplantation of human ES cells, injected into the sub-retinal area of the eye, rats displayed recovery of their photoreceptors and improved visual ability compared to the control rats, which were injected with a mock treatment and showed no significant improvement.  
  • RPE dysfunction is the most common cause of blindness in people over 60 in the United States, and it affects over 30 million people worldwide.
  • Age related macula degen

    1. 1. Trouble with vision as we get older...• Is not always due to Age- related macular degeneration !• Your doctor needs to perform a complete eye exam before reaching a diagnosis
    2. 2. Eye Examination - DiagnosisVisual Acuity, Color Vision, Amsler Grid,Fundus Camera, Fluorescein Angiography, Optical Coherence Tomography
    3. 3. Amsler Grid Testing
    4. 4. Drusen, the yellow spots so characteristic of Age-related Macular Degeneration
    5. 5. Drusen are sometimes more easily detectedOn Color Fundus photos than doctor’s exam
    6. 6. FluoresceinAngiography
    7. 7. Colour photography isroutinely undertaken withangiography. It helps todetermine the nature ofchanges seen on theangiogram… particularlythe cause of blockedfluorescence due tohaemorrhage, pigment orother cause.
    8. 8. Side by side comparisonof the color photo and the fluorescein pictureoften complement each other !
    9. 9. -
    10. 10. Optical Coherence Tomography
    11. 11. • Diagnostic imaging technique that examines living tissue non-invasively. It is based on a complex analysis of the reflection of low coherence radiation from the tissue under examination.• Real time cross sectional analysis
    12. 12. • Macular Degeneration Leading cause of blindness in people over 55 • 1:10 people over 55 • Increases by a factor of 6 in people over 80 • 1.75 million Americans over age 40 have severe AMD • Estimated that 2.95 million people affected by 2020
    13. 13. How Does the Eye Work?
    14. 14. • What is Macular Idiopathic• Central vision Degeneration? loss • Peripheral vision preserved• Two forms • Dry (Nonexudative) • 90% of people • Wet (Exudative) • Affects 10% of people
    15. 15. What does my Doctor• • Drusen see? Metabolic waste products accumulating under the retina• Pigment clumping and atrophy • Death of support cells under retina• Geographic atrophy • Large areas of cell death• Hemorrhage (blood) • Hallmark of wet AMD
    16. 16. My Doctor told me I have Macular Degeneration. Will I go blind?• Not necessarily• Only 10% develop the wet form which is responsible for 90% of blindness from AMD • Newer treatments may reduce risk of blindness• Only 10% of the dry patients will develop severe vision loss
    17. 17. Risk factors for Vision• Non-modifiable: things we cannot loss change • Age • (If you figure out how to stop aging, please let me know) • Caucasian race • Female gender • Family history • 2.5x increased risk of first degree family relative
    18. 18. Risk factors for Vision• Modifiable • Smoking Loss • Hypertension • High Cholesterol • Obesity • Sedentary Lifestyle• Heart Health= Eye
    19. 19. What about thoseAREDS study• Vitamins? II Followed 3640 patients for average 6.3 years • AREDS• High doses of antioxidant vitamins • Started in 2006 – ongoing• Hope they will reduce oxidative stress in • Added macula • Lutein: forms macular • Vitamin A pigment • Vitamin C • Zeaxanthin • Vitamin E • Subtracted • Zinc: antioxidant in • Vitamin A: Potential conjunction with C and increased risk of lung E cancer in smokers • Copper
    20. 20. • Vitamins Not found helpful for everyone• No benefit • No AMD • Benefit: • Mild AMD • If everyone took AREDS,• Beneficial 300,000 people could be prevented from developing • Moderate AMD advanced AMD over 5 year • Severe AMD • Persons with wet AMD • Unfortunately will not stop progression of AMD in all• Benefit patients • Reduced risk of progression of AMD by 25% • Reduced risk of vision
    21. 21. Which is the best Multivitamin?• They are all basically the same as long as they have the AREDS formula• Differences in brands • AREDS I vs AREDS II formula • Dosing • Price • Packaging • Advertising
    22. 22. • Stop Smoking Summary• Exercise• Heart Healthy Diet• Eat leafy green vegetables• Control blood pressure and cholesterol• AREDS Multivitamin if indicated by your eye doctor• Monitor vision and regular eye checks
    23. 23. • Macular Degeneration Leading cause of blindness in people over 55 • 1:10 people over 55 • Increases by a factor of 6 in people over 80 • 1.75 million Americans over age 40 have severe AMD • Estimated that 2.95 million people affected by 2020
    24. 24. How Does the Eye Work?
    25. 25. • What is Macular Idiopathic• Central vision Degeneration? loss • Peripheral vision preserved• Two forms • Dry (Nonexudative) • 90% of people • Wet (Exudative) • Affects 10% of people
    26. 26. What does my Doctor• • Drusen see? Metabolic waste products accumulating under the retina• Pigment clumping and atrophy • Death of support cells under retina• Geographic atrophy • Large areas of cell death• Hemorrhage (blood) • Hallmark of wet AMD
    27. 27. My Doctor told me I have Macular Degeneration. Will I go blind?• Not necessarily• Only 10% develop the wet form which is responsible for 90% of blindness from AMD • Newer treatments may reduce risk of blindness• Only 10% of the dry patients will develop severe vision loss
    28. 28. Risk factors for Vision• Non-modifiable: things we cannot loss change • Age • (If you figure out how to stop aging, please let me know) • Caucasian race • Female gender • Family history • 2.5x increased risk of first degree family relative
    29. 29. Risk factors for Vision• Modifiable • Smoking Loss • Hypertension • High Cholesterol • Obesity • Sedentary Lifestyle• Heart Health= Eye
    30. 30. What about thoseAREDS study• Vitamins? II Followed 3640 patients for average 6.3 years • AREDS• High doses of antioxidant vitamins • Started in 2006 – ongoing• Hope they will reduce oxidative stress in • Added macula • Lutein: forms macular • Vitamin A pigment • Vitamin C • Zeaxanthin • Vitamin E • Subtracted • Zinc: antioxidant in • Vitamin A: Potential conjunction with C and increased risk of lung E cancer in smokers • Copper
    31. 31. • Vitamins Not found helpful for everyone• No benefit • No AMD • Benefit: • Mild AMD • If everyone took AREDS,• Beneficial 300,000 people could be prevented from developing • Moderate AMD advanced AMD over 5 year • Severe AMD • Persons with wet AMD • Unfortunately will not stop progression of AMD in all• Benefit patients • Reduced risk of progression of AMD by 25% • Reduced risk of vision
    32. 32. Which is the best Multivitamin?• They are all basically the same as long as they have the AREDS formula• Differences in brands • AREDS I vs AREDS II formula • Dosing • Price • Packaging • Advertising
    33. 33. • Stop Smoking Summary• Exercise• Heart Healthy Diet• Eat leafy green vegetables• Control blood pressure and cholesterol• AREDS Multivitamin if indicated by your eye doctor• Monitor vision and regular eye checks
    34. 34. Age-related Macular Degeneration
    35. 35. What is Age-Related Macular Degeneration?• Age-related macular degeneration (AMD) is a deterioration or breakdown of the eyes 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. • American Academy of Ophthalmology
    36. 36. What is going on in the eye?
    37. 37. Where exactly?
    38. 38. Where exactly?
    39. 39. Genetics• DNA• All information of life encoded in DNA and expressed by proteins.• James Dewey Watson (US) & Francis Crick (UK) – Co-discoverers Structure of DNA 1953• Awarded Nobel Prize in Physiology or Medicine 1962
    40. 40. Before…
    41. 41. …After…Age-related changes
    42. 42. Genetic Basics…get small…• The human body is made up of trillions of Cells,• and with a few exceptions, each cell contains a Nucleus• and with a few exceptions, each nucleus contains a COMPLETE set of Chromosomes• And the chromosomes are made of DNA
    43. 43. From DNA…to You and Me…
    44. 44. …and smaller…From Cells to Nucleus to Chromosomes• Every human cell contains 23 pairs of chromosomes, for a total of 46 chromosomes.• Each Chromosome is made up of• a double- stranded,• Tightly-coiled,• helix of DNA
    45. 45. Human Chromosomes
    46. 46. …and smaller…• A CHROMOSOME contains hundreds to thousands of genes.• A GENE is a segment of DNA containing the code used to synthesize a protein.• A TRAIT is any gene-determined characteristic and is usually determined by more than one gene.• Some traits are caused by abnormal genes that are inherited or that are the result of a mutation.
    47. 47. From Chromosomes to Genes
    48. 48. WhatStudies we know?…• Genetic do• 1988-2010 so far • DNA and Gene-Environment Data Collection • Twin Study – WWII Registry• 1997 Familial Aggregation Study – Relatives of Cases with Wet AMD. Relatives of controls.• 1997 Phenotypic Heterogeneity in Families with AMD • Johanna M. Seddon, M.D., Sc.M.
    49. 49. What do we know?… so far• From the US Twin Study, we’ve learned• Substantial Genetic Component – • 46 to 71% of the variation in phenotype • Important Environmental Influence: 19 to 37%
    50. 50. OK…what “Genetic Factors”?...• It’s not so much as a “bad” gene, but rather• Variations of “normal genes” that influence the risk of developing AMD.• Specific DNA chromosomes associated with the defective genes are located on chromosomes• 1q and 10q
    51. 51. From Chromosomes to Genes
    52. 52. Genes associated…so• CFH – Y402H far• CFH – rs1410996 • Hepatic Lipase C (LIPC)• CFB • CETP• C2 • ABCA1• Complement Component • TIMP 3 / SYN3 3 (C3) • VEGFA• Complement Factor I CFI • COL10A1• ARMS2/HTRA1 gene • COL8A1 region • TNFRSF10A
    53. 53. Gene location… leads to therapy• For example, the VEGFA locus and the development of• Avastin• Lucentis and recently• Eylea
    54. 54. Antigen/Antibody cell membrane Bayer Healthcare – Bayer Schering Pharma
    55. 55. Surfaceantigens/antibodies Eylea.com
    56. 56. Relative risk of Genetic loci Nature Genetics 38: 1057, 2006
    57. 57. Epidemiology• Epidemiology is the study of• the distribution and patterns of health-events,• health-characteristics and• their causes or influences in well-defined populations.
    58. 58. Epidemiology• It is our principal method of public health research, and• helps us make policy decisions as well as evidence-based medicine• by identifying risk factors for disease and helps us with recommendations for appropriate preventive medicine.
    59. 59. Epidemiologic studies looking at• Meta-analysis of 15 genome-wide the genetics of AMD association studies• Began in 2009• 8,000 cases and 50,000 controls• 19 groups from 13 countries• 19 genomic loci associated with AMD• Six novel loci not previously associated with disease• Pathways similar to other known genes. • ASHG Oct 2011
    60. 60. Epidemiology and CausationRisk factors for cardiovascular disease (CVD) are associated with age-related AMD; • Smoking • Dietary antioxidants, fats, omega-3 fatty acids • Physical activity • Obesity, abdominal adiposity • Hypertension • Cholesterol • CRP (C-reactive protein)
    61. 61. Epidemiology and Causation• For the homozygous (pure trait) risk genotype• Risk of AMD was • Increased for BMI (Body Mass Index) and • Increased with smoking
    62. 62. So what can we say?• Genetic mutations make us susceptible to the development of AMD• Multiple genetic factors are at work• Risk profiles help us to change life style to decrease the chance of AMD development• Which leads us to…
    63. 63. The big question (at least for the retina specialists)• What information from• TV,• Radio,• Internet,• YouTube,• Email,• Fax, Photocopy, Text, Blog, Wikipedia….etc• Should You believe?
    64. 64. Types of Optical Devices Near Devices
    65. 65. Stand Magnifier
    66. 66. Dome Magnifier
    67. 67. Illuminated Stand Magnifier
    68. 68. Hand Held Pocket Magnifier
    69. 69. Hand HeldIlluminated
    70. 70. Microscopes or Reading Glasses
    71. 71. Types of Optical Devices Distance Devices
    72. 72. Binoculars
    73. 73. Monocular
    74. 74. Full-Field Telescopic Systems
    75. 75. Bioptic Systems
    76. 76. Sunfilters
    77. 77. Night Vision Scopes
    78. 78. Getting the Right Device(s)devices• Because there is such a variety of available, it can be somewhat overwhelming to locate the correct device.• Individuals should receive an evaluation from an Optometrist who specializes in treating individuals with low vision.• This assures that the individual receives the correct device with consideration of all goals and needs.
    79. 79. What’s New inLow Vision Technology
    80. 80. Handheld Magnifying Cameras• Miracle Mouse Electronic TV Magnifier• MonoMouse-RM B&W Electronic Magnifier• Max Digital Color Magnifier• Primer 2 Color Electronic Magnifier
    81. 81. Traditional CCTV Video Magnifiers reading • Increased speed • Increased duration • Reduced visual effort • Comfortable• Desktop systems working position• Variable Magnification• Color, W/B, B/W• Large Field of View
    82. 82. Magnifiers Integrated LCD• Available from all major vendors Displays• Sizes: 17” to 24” + with WS• Adjustable height screens• High contrast• Flicker free• Improved response rates• Well received by consumers
    83. 83. Integrated LCD Systems
    84. 84. Video Magnification• Variable Systems Magnification• Adjustable brightness• Selectable contrast setting• Wide field of view for better viewing abilities
    85. 85. Magnification
    86. 86. Brightness
    87. 87. Contrast
    88. 88. Windowing and Underlining
    89. 89. Portable Video• More Compact, 7-inch screens Magnifiers• Extensive reading tasks• Two handed use• Optelec Traveler• FS Sapphire• EV Amigo• Fusion 7” LCD Portable Video Magnifier
    90. 90. Compact Video Magnifiers:• Variable Magnification• Replaceable Batteries• Longer battery life• Image Freeze• Color Select• Light off mode: for reading cell phones, other displays• Writing Cameras• Distance Viewing• Smaller Designs
    91. 91. Compact/PocketVideo Magnifiers • Advantages • Wide field of view • Image at display level • Use at arms-length • Reverse contrast available • Cell phone, PDA displays! • Short-term writing tasks • Kids reading comic books under the blanket
    92. 92. Compact Systems with Distance Capabilities• Near and distance capabilities• Read mail, products on a shelf and get a better view of distance object.• Allows users to see an object that is at distance close up on the screen• Limited clarity and magnification at a distance
    93. 93. GW Micro Sense View Duo• Two cameras• Stores up to 20 images• 3X to 13X magnification• Lights off mode• Image panning• 7 Viewing modes, 4 Brightness levels• 4.5 hour battery life, integrated, rechargeable• Cost: $1299.00
    94. 94. Ash TechnologyQuicklook Focus
    95. 95. Desktop Video Magnifiers• Full Size screen Features• Full Features• Remote Controllable• Near and Distance Viewing• For Classroom, Conference or In- Service Training Activities• Transportable “Luggable”• AC or optional battery
    96. 96. Vision Technology: VIEW
    97. 97. Enhanced Vision Acrobat LCD
    98. 98. Onyx Deskset
    99. 99. Laptop Compatible Video Magnifiers• Most students use laptop computers• Video magnification could be helpful• Portable camera using notebook display
    100. 100. Clarity PCMate• Powered by USB• Requires 2 USB 2 ports • Sequence, setup• Remote control camera• Keyboard controlled software
    101. 101. OptelecClearNote • Ease of camera aiming • Built in Light source • Camera control positioning • Keyboard controlled software • Keyboard controlled camera • Dolphin, Zoom Text compatible
    102. 102. Freedom Scientific Onyx PC Edition arm and flex • Swing arm models • Remote control • MAGic with EyeMerge software included • Camera can be powered by USB port • Distance, desktop, self view modes • Cost: $2895.00
    103. 103. Specialty Video Magnifiers• Flipper• Shoppa
    104. 104. Headborne Low Vision System • Eyetonomy SightMate LV920 • www.vuzix.com/medical/lv920.h tml • Zoom at near: 3X optical, 4X digital • Zoom at distance: 0.5X to 6X • Edge contrasting, Inverse mode • Sleek design, 8 ounces • $3499.00 • Not yet available for purchase or review
    105. 105. Scan and Read Devices• Kurzweil 1000 (software)• ABiSee Zoom-Ex, EyePal Vision (portable, Solo)• FS Pearl (laptop compatible)• KNFB Reader (smartphone)• AI Squared ZoomReader (app)
    106. 106. Assessment functioning• Evaluation of visual Factors• Response to low vision approaches• Analysis of tasks, task specific• Required performance level• Integration of systems• Training• Trial of system; speed, duration, productivity• Modifications• Provision
    107. 107. Types of Optical Devices Near Devices
    108. 108. Stand Magnifier
    109. 109. Dome Magnifier
    110. 110. Illuminated Stand Magnifier
    111. 111. Hand Held Pocket Magnifier
    112. 112. Hand HeldIlluminated
    113. 113. Microscopes or Reading Glasses
    114. 114. Types of Optical Devices Distance Devices
    115. 115. Binoculars
    116. 116. Monocular
    117. 117. Full-Field Telescopic Systems
    118. 118. Bioptic Systems
    119. 119. Sunfilters
    120. 120. Night Vision Scopes
    121. 121. Getting the Right Device(s)devices• Because there is such a variety of available, it can be somewhat overwhelming to locate the correct device.• Individuals should receive an evaluation from an Optometrist who specializes in treating individuals with low vision.• This assures that the individual receives the correct device with consideration of all goals and needs.
    122. 122. What’s New inLow Vision Technology
    123. 123. Handheld Magnifying Cameras• Miracle Mouse Electronic TV Magnifier• MonoMouse-RM B&W Electronic Magnifier• Max Digital Color Magnifier• Primer 2 Color Electronic Magnifier
    124. 124. Traditional CCTV Video Magnifiers reading • Increased speed • Increased duration • Reduced visual effort • Comfortable• Desktop systems working position• Variable Magnification• Color, W/B, B/W• Large Field of View
    125. 125. Magnifiers Integrated LCD• Available from all major vendors Displays• Sizes: 17” to 24” + with WS• Adjustable height screens• High contrast• Flicker free• Improved response rates• Well received by consumers
    126. 126. Integrated LCD Systems
    127. 127. Video Magnification• Variable Systems Magnification• Adjustable brightness• Selectable contrast setting• Wide field of view for better viewing abilities
    128. 128. Magnification
    129. 129. Brightness
    130. 130. Contrast
    131. 131. Windowing and Underlining
    132. 132. Portable Video• More Compact, 7-inch screens Magnifiers• Extensive reading tasks• Two handed use• Optelec Traveler• FS Sapphire• EV Amigo• Fusion 7” LCD Portable Video Magnifier
    133. 133. Compact Video Magnifiers:• Variable Magnification• Replaceable Batteries• Longer battery life• Image Freeze• Color Select• Light off mode: for reading cell phones, other displays• Writing Cameras• Distance Viewing• Smaller Designs
    134. 134. Compact/PocketVideo Magnifiers • Advantages • Wide field of view • Image at display level • Use at arms-length • Reverse contrast available • Cell phone, PDA displays! • Short-term writing tasks • Kids reading comic books under the blanket
    135. 135. Compact Systems with Distance Capabilities• Near and distance capabilities• Read mail, products on a shelf and get a better view of distance object.• Allows users to see an object that is at distance close up on the screen• Limited clarity and magnification at a distance
    136. 136. GW Micro Sense View Duo• Two cameras• Stores up to 20 images• 3X to 13X magnification• Lights off mode• Image panning• 7 Viewing modes, 4 Brightness levels• 4.5 hour battery life, integrated, rechargeable• Cost: $1299.00
    137. 137. Ash TechnologyQuicklook Focus
    138. 138. Desktop Video Magnifiers• Full Size screen Features• Full Features• Remote Controllable• Near and Distance Viewing• For Classroom, Conference or In- Service Training Activities• Transportable “Luggable”• AC or optional battery
    139. 139. Vision Technology: VIEW
    140. 140. Enhanced Vision Acrobat LCD
    141. 141. Onyx Deskset
    142. 142. Laptop Compatible Video Magnifiers• Most students use laptop computers• Video magnification could be helpful• Portable camera using notebook display
    143. 143. Clarity PCMate• Powered by USB• Requires 2 USB 2 ports • Sequence, setup• Remote control camera• Keyboard controlled software
    144. 144. OptelecClearNote • Ease of camera aiming • Built in Light source • Camera control positioning • Keyboard controlled software • Keyboard controlled camera • Dolphin, Zoom Text compatible
    145. 145. Freedom Scientific Onyx PC Edition arm and flex • Swing arm models • Remote control • MAGic with EyeMerge software included • Camera can be powered by USB port • Distance, desktop, self view modes • Cost: $2895.00
    146. 146. Specialty Video Magnifiers• Flipper• Shoppa
    147. 147. Headborne Low Vision System • Eyetonomy SightMate LV920 • www.vuzix.com/medical/lv920.h tml • Zoom at near: 3X optical, 4X digital • Zoom at distance: 0.5X to 6X • Edge contrasting, Inverse mode • Sleek design, 8 ounces • $3499.00 • Not yet available for purchase or review
    148. 148. Scan and Read Devices• Kurzweil 1000 (software)• ABiSee Zoom-Ex, EyePal Vision (portable, Solo)• FS Pearl (laptop compatible)• KNFB Reader (smartphone)• AI Squared ZoomReader (app)
    149. 149. Assessment functioning• Evaluation of visual Factors• Response to low vision approaches• Analysis of tasks, task specific• Required performance level• Integration of systems• Training• Trial of system; speed, duration, productivity• Modifications• Provision
    150. 150. Pharmacogenomics• Treatment based on genetic profile• “Personalized medicine”• AREDS – 70% with certain gene did not progress (vs. 11% without)• Relationship between certain genes and outcomes with Lucentis and Avastin
    151. 151. Gene Therapy for retinal diseases
    152. 152. • Trials Phase I Dose Escalation Safety Study of RetinoStat in Advanced Age- Related Macular Degeneration (AMD) Oxford BioMedica • Subretinal injection of virus vector that produces anti-VEGF proteins• Safety and Efficacy Study of rAAV.sFlt-1 in Patients With Exudative Age-Related Macular Degeneration • Intravitreal injection of a non-pathogenic virus to express a therapeutic protein within the eye
    153. 153. WetDry AMD Atrophi c
    154. 154. So What Have We Learned? Lory C. Snady-McCoy, MD
    155. 155. Answers to Common QuestionsWhat defines macular degeneration?
    156. 156. What tests are used?Why are they necessary in the diagnosis and management? Not everything that looks like macular degeneration is macular degeneration Importance of continued monitoring and care50% chance of developing wet AMD in fellow eye over 5 years
    157. 157. What Should I Eat?
    158. 158. • Foods rich in antioxidants may delay the progression of AMD• Green leafy vegetables, berries, nuts, seaweed (?) Beta-carotene, omega 3 fatty acids, lutein
    159. 159. Which vitamins should I use?
    160. 160. • AREDS vitamins shown to be beneficial in patients with high risk AMD• Vitamins slow the progression; they do not stop it• Benefits of AREDS II not proven yet
    161. 161. Will the high dose of vitamins in the AREDS formula have side effects?• Vitamin A in smokers - lung cancer• Vitamins A and E stored in the liver - potential liver toxicity• Zinc - anemia if not taken with copper• Vitamin E - cardiovascular issues not typical in dose prescribed, prostate cancer?• AREDS II - High dose Vitamin A removed; Lutein and Zeaxanthin added
    162. 162. Is AMD hereditary?Are my children at risk?
    163. 163. • Genetics of AMD is complex with many associated genes• Hereditary forms exist and can express themselves at different ages and in different degrees of severity• Environmental factors may trigger the disease in susceptible people
    164. 164. Known risk factors:• Smoking, diet, exercise, obesity (BMI)• Hypertension, Hypercholesterolemia• Does this sound familiar??
    165. 165. Will I go totally blind?• AMD causes central vision loss with preservation of peripheral vision• 90% of severe vision loss occurs in the wet (neovascular) type. 10% of patients have wet AMD• 90% of patients have dry (atrophic) AMD. 10% of these with develop severe vision loss
    166. 166. Are there anynew treatments in the making?
    167. 167. • Millions of dollars have been appropriated to AMD research• Medications based on a person’s individual genetic profile (pharmacogenomics)• Gene therapy to enhance a person’s own production of beneficial compounds• Retina implant / retinal prosthesis• Stem cells• Antioxidant eye drops for dry / atrophic AMD
    168. 168. Which treatment is best for me and why?• Thermal “Hot” Laser (1970’s)• PDT “Cold” Laser (Visudyne)• Macugen - First anti-VEGF intraocular treatment• Lucentis - First to show improved vision 95% stabilized 40% improved• Avastin - Cost• Eylea - Less frequent treatment
    169. 169. Argon/Krypton/Dye/Diode Laser PDT Laser/Visudyne
    170. 170. MacugenLucentis/Avas tin Eylea
    171. 171. How many injections will I need? Is there a limit to the number of treatments I can get? What is the side effect of long-term treatment?Lucentis Study - injection every 4 weeks. May still give best outcomeTreat and Extend protocolDouble-dosingCombined PDT with anti-VEGF therapyRisks: Infection, Retinal detachment, Cataract, Inflammation, GlaucomaTherapy for a chronic condition requires long term treatment. Underlying degenerative changes will continue with potential gradual vision loss even with treatment.
    172. 172. What will happen if I do nothing?• Natural history of AMD is to cause significant and permanent loss of central vision leading to legal blindness
    173. 173. Will changing my glasses help?Multiple aids to help people with decreased vision with AMD:• Spectacle-mounted magnifiers• Hand-held and spectacle-mounted telescopes• Hand-held and stand magnifiers• Video magnification / Computer devices• Importance of illumination, brightness and increased contrast• Writings devices, voice command, “gadgets”• Importance of early evaluation when moderate vision loss by a low vision specialist• Devices require training; use of eccentric vision
    174. 174. Congratulations! You have now earned your diploma!
    175. 175. So What Have We Learned? Lory C. Snady-McCoy, MD
    176. 176. Answers to Common QuestionsWhat defines macular degeneration?
    177. 177. What tests are used?Why are they necessary in the diagnosis and management? Not everything that looks like macular degeneration is macular degeneration Importance of continued monitoring and care50% chance of developing wet AMD in fellow eye over 5 years
    178. 178. What Should I Eat?
    179. 179. • Foods rich in antioxidants may delay the progression of AMD• Green leafy vegetables, berries, nuts, seaweed (?) Beta-carotene, omega 3 fatty acids, lutein
    180. 180. Which vitamins should I use?
    181. 181. • AREDS vitamins shown to be beneficial in patients with high risk AMD• Vitamins slow the progression; they do not stop it• Benefits of AREDS II not proven yet
    182. 182. Will the high dose of vitamins in the AREDS formula have side effects?• Vitamin A in smokers - lung cancer• Vitamins A and E stored in the liver - potential liver toxicity• Zinc - anemia if not taken with copper• Vitamin E - cardiovascular issues not typical in dose prescribed, prostate cancer?• AREDS II - High dose Vitamin A removed; Lutein and Zeaxanthin added
    183. 183. Is AMD hereditary?Are my children at risk?
    184. 184. • Genetics of AMD is complex with many associated genes• Hereditary forms exist and can express themselves at different ages and in different degrees of severity• Environmental factors may trigger the disease in susceptible people
    185. 185. Known risk factors:• Smoking, diet, exercise, obesity (BMI)• Hypertension, Hypercholesterolemia• Does this sound familiar??
    186. 186. Will I go totally blind?• AMD causes central vision loss with preservation of peripheral vision• 90% of severe vision loss occurs in the wet (neovascular) type. 10% of patients have wet AMD• 90% of patients have dry (atrophic) AMD. 10% of these with develop severe vision loss
    187. 187. Are there anynew treatments in the making?
    188. 188. • Millions of dollars have been appropriated to AMD research• Medications based on a person’s individual genetic profile (pharmacogenomics)• Gene therapy to enhance a person’s own production of beneficial compounds• Retina implant / retinal prosthesis• Stem cells• Antioxidant eye drops for dry / atrophic AMD
    189. 189. Which treatment is best for me and why?• Thermal “Hot” Laser (1970’s)• PDT “Cold” Laser (Visudyne)• Macugen - First anti-VEGF intraocular treatment• Lucentis - First to show improved vision 95% stabilized 40% improved• Avastin - Cost• Eylea - Less frequent treatment
    190. 190. Argon/Krypton/Dye/Diode Laser PDT Laser/Visudyne
    191. 191. MacugenLucentis/Avas tin Eylea
    192. 192. How many injections will I need? Is there a limit to the number of treatments I can get? What is the side effect of long-term treatment?Lucentis Study - injection every 4 weeks. May still give best outcomeTreat and Extend protocolDouble-dosingCombined PDT with anti-VEGF therapyRisks: Infection, Retinal detachment, Cataract, Inflammation, GlaucomaTherapy for a chronic condition requires long term treatment. Underlying degenerative changes will continue with potential gradual vision loss even with treatment.
    193. 193. What will happen if I do nothing?• Natural history of AMD is to cause significant and permanent loss of central vision leading to legal blindness
    194. 194. Will changing my glasses help?Multiple aids to help people with decreased vision with AMD:• Spectacle-mounted magnifiers• Hand-held and spectacle-mounted telescopes• Hand-held and stand magnifiers• Video magnification / Computer devices• Importance of illumination, brightness and increased contrast• Writings devices, voice command, “gadgets”• Importance of early evaluation when moderate vision loss by a low vision specialist• Devices require training; use of eccentric vision
    195. 195. Congratulations! You have now earned your diploma!
    196. 196. • Can only be used in patients with functioning inner retinal cells – for example AMD and RP • Uses an artificial means to detect light (video camera) • Converts light energy into an electrical signal • Deliver the electrical signal to the retinal neurons other than photoreceptors to elicit activity that is interpreted as vision • Vision equivalent to 20/1260
    197. 197. Retinal Implant
    198. 198. ARGUS II Implant 60 electrodes (16 in ARGUS I)250 electrode array in development
    199. 199. Subretinal implant
    200. 200. Microprocessor power
    201. 201. Emerging treatments for Dry AMDAtrophic AMD AL-8309B (Alcon Laboratories) • 2 year study evaluating an Eye drop for dry AMD • Primary endpoint is size of the atrophic area • Randomized, double blind • 772 patients • Study completed July 2011
    202. 202. ACU-4429 - Acucela  Phase II granted fast track statusFenretinide  Phase III began 2011
    203. 203. Emerging treatments for dry AMD• Encapsulated human cells genetically modifiedto secrete ciliary neurotrophic factor (CNTF)• CNTF is a growth factor capable of rescuingdying photoreceptors and protecting them fromdegeneration
    204. 204. Emerging treatments• OT- 551 Antioxidant Eye drops for Dry AMD • Othera Pharmaceuticals/ National Eye Institute• A Multicenter, Proof-Of-Concept Study Of Intravitreal AL-78898A In Patients With Geographic Atrophy • Alcon
    205. 205. Human embryonic stem • Can differentiate into any of cells the 220 cell type in the human body • Cells acquired from unwanted or discarded embryo • Can propagate indefinitely • Proposed for regenerative medicine and tissue replacement after injury or disease
    206. 206. Stem Cell Research
    207. 207. • hES Cells modified to become RPE cells whichnourish damaged photorecptors•First study of human transplantation reported inJanuary 2012• Study of safety and tolerability of subretinaltransplantation• 2 patients studied, one with AMD and one withStargardt’s disease, vision did not worsen in either one• No tumor formation or signs of rejection
    208. 208. Stem Cells – Current• Rejection Problems• Tumor formation• Expense – producing and cultivating cell lines is costly• Intellectual property rights• Ethics• No good animal models of macular degeneration
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