age related macular degeneration

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age related macular degeneration

  1. 1. CASE PRESENTATIONDepartment of Ophthalmology October 13, 2010
  2. 2. GENERAL DATA•ZN, 69/F•Bauang, LU•Filipino•Catholic•Date of consult-November 2008
  3. 3. OCULAR PAST MEDICAL FAMILY PERSONAL HISTORY HISTORY HISTORY AND SOCIAL HISTORY2007-Cataract (+) HPN x 5 yrs (+) HPN Previousextraction, OU metoprolol (-) DM smokerNo other (-) DM (-) Ca Non alcoholicocular disease beverage drinker housewife
  4. 4. • REVIEW OF SYSTEMS• PHYSICAL EXAMINATION
  5. 5. OCULAR EXAMINATION OD OSVisual acuity 20/70-20/30 20/200- NIIOP 10 10Ocular adnexae E/N E/NAC Deep and quiet Deep and quietLens IOL in place IOL in placeEOM intact intactpupils 3-2 mm 3-2 mm (-) RAPD (-) RAPDColor perception (+) RGB (-) blue
  6. 6. AMSLER GRID
  7. 7. Dilated Fundus Exam
  8. 8. • Fasting blood sugar• Fluorescein Angiography
  9. 9. SALIENT FEATURES• 69 y/o• Blurred vision with metamorphopsia• History of smoking• hypertensive• Decreased color perception• (+) drusen, RPE atrophy
  10. 10. AGE- RELATED MACULAR DEGENERATION, NON- NEOVASCULAR
  11. 11. AGE- RELATED MACULAR DEGENERATION• Leading cause of IRREVERSIBLE vision loss in the developed countries• 4th common cause of vision loss in Phil• Autosomal dominant disease affected by nutritional and environmental factors• bilateral
  12. 12. • I. Dry/ Non- exudative/Non- neovascular AMD- 90%• II. WET/Exudative/Neovascular- 10 %
  13. 13. CHANGES DURING AGINGREDUCED DENSITY AND DISTRIBUTION OF PHOTORECEPTORS INVOLUTIONAL CHANGES IN THE CHORIOCAPILLARIES
  14. 14. RISKFACTORS
  15. 15. FAMILY HISTORY• Relatives w/ AMD- 50%• (-) relatives w/ AMD- 12 %GENETIC MUTATIONS:• CFH gene ( Ch.1)• BF and C2 ( Ch. 6)• LOC ( Ch. 10 )
  16. 16. Framimgham Eye Study:• 65- 74 y/o- 6.4%• >75 y/o- 19.7 %• >80 y/o- 6x
  17. 17. DRUSEN• Most important risk factor• Small, round, yellow lesions• Composed of vitronectin, lipids, immune and inflammatory related proteins
  18. 18. CLINICAL PRESENTATION
  19. 19. SCREENING• Amsler grid• Macular Photostress Test• Color perception test• Kollner Rule- – Optic nerve- RED, GREEN – Retina – BLUE, YELLOW
  20. 20. DIAGNOSTIC OPTICAL COHERENCEFLUORESCEIN ANGIOGRAPHY TOMOGRAPHY
  21. 21. CHOROIDAL NEOVASCULARIZATIONMost common cause of visual loss
  22. 22. MANAGEMENT• NO definitive treatment• DETERMINE PERSONS WHO WILL DEVELOP ADVANCED ARMD• Goal: prevent development of neovascularization
  23. 23. Age- Related Eye Disease Study• Vitamin A ( Beta Carotene)- 15 mg• Vitamin C- 500 mg• Vitamin E- 400 IU• Zinc- 80 mg• Copper- 2 mg
  24. 24. AREDS Antioxidants plus Zinc alone Antioxidants alone zinc Reduced risk ofdeveloping AMD by 25% 21% 17% Reduced risk of vision loss by 19% 11% 10%
  25. 25. Who will benefit from high- dose antioxidants?• Extensive intermediate drusen• At least 1 large druse• geographic atrophy• Advanced AMD in one eye
  26. 26. LUTEIN“Dietary lutein/zeaxanthin intake was inversely associated with neovascular AMD” -The Relationship of Dietary Carotenoid and Vitamin A, E, and C Intake With Age-Related Macular Degeneration in a Case-Control StudyAREDS Report No. 22• Age-Related Eye Disease Study Research Group*• Arch Ophthalmol. 2007;125(9):1225-1232
  27. 27. “visual function is improved with lutein alone or lutein together with other nutrients”• Double-masked, placebo-controlled, randomized trial of lutein and antioxidant supplementation in the intervention of atrophic age-related macular degeneration: the Veterans LAST study (Lutein Antioxidant Supplementation Trial).• Richer S, Stiles W, Statkute L, Pulido J, Frankowski J, Rudy D, Pei K, Tsipursky M, Nyland J.• Department of VeteransAffairs, Medical Center Eye Clinic, North Chicago, Illinois 60064-3095, USA. stuart.richer1@med.va.gov
  28. 28. PROPHYLACTIC LASERPROPHYLACTIC TREATMENT OF AMD TRIAL (PTAMD):̋ Patients treated wih prophylactic laser were more likely to have a CNV event ( 21%) than were the observed patients at 18 months ( 14%) ̋COMPLICATIONS OF AGE- RELATED MACULAR DEGENERATION PREVENTION TRIAL ( CAPT)Incidence of late AMD was 19.7% in treated eyes and 20.4 % in untreated eyes, incidence of CNV was 13.3% for both groups
  29. 29. RHEOPHERESIS• - An extracorporeal blood filtration procedure that removes circulating macromolecules from the bloodMULTICENTER INVESTIGATION OF RHEOPHERESIS OF AMD( MIRA-1)‘No statistically significant benefit of rheopheresis over sham treatment’
  30. 30. TREATMENT OF NEOVASCULAR ARMD
  31. 31. Laser Photocoagulation MACULAR PHOTOCOAGULATION STUDY • Treatment did not decrease the chance of maintaining good VA or vision within 1.5 lines of VA before the treatment
  32. 32. Photodynamic therapy TREATMENT OF AMD WITH PHOTODYNAMIC THERAPY -‘59 % of PDT treated eyes versus 31% (placebo) avoided moderate vision loss’ • Visudyne in Minimally Classic Trial • Vertoporfin in Photodynamic Therapy study
  33. 33. Anti- VEGF • MARINA Study ANCHOR STUDY • 95% of Ranibizumab -95% vs 64% of PDT treated patients treated patients experienced visual maintained/ improved vision- 12 mos vs 62% of improvement -90% vstreated patients sham 65.7 % after 24 mos -41% of patients improved 3 lines after 24 mos
  34. 34. • After a year…• VA- 20/100, OD HM, OS
  35. 35. “Age is an issue of mind over matter.   If you dont mind, it doesnt matter. ~Mark Twain

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