Macular Degeneration

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Macular Degeneration - Dr James Beatty

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  • This is the most important risk factor after age and family history. Since we can’t change our age or our family, smoking is the most important modifiable risk factor for AMD.
  • Different sizes and types of drusen that have different risks
  • Vision severly impaired if the fovea involved FA: early hyperfluoresence due to unmasking of the choroidal vessels OCT: atrophy
  • Less common but devastatingCharacterized by neovascularization and eventually scaring
  • Haemmorrhage exudation and eventual scaring
  • Uses laser to make a cross sectional picture of the retina
  • Almost like a hitiological cross section
  • Up until recently very little and mostly to try and stop usually no improvement
  • Cold laser
  • Retinectomy Poor results and high recurrence rate
  • Early detection and treatment Amsler Education reduced chance by 20% of getting severe visual loss in pts with one eye ARMD
  • Mostly magnification
  • Computer have large print Kindel books Audio books
  • Compares pts with ARMD to normal pts and how they cope with simple activities of daily living
  • Macular Degeneration

    1. 1. Macular Degeneration Dr James Beatty
    2. 2. Introduction • Disease of the macular – The macula is responsible for the fine central vision in the eye that is needed for driving a car, reading fine print, recognising faces, etc. – Loss of central vision • Most common cause of irreversible visual loss in the western world in individuals over the age of 50yrs
    3. 3. Introduction
    4. 4. Introduction
    5. 5. Introduction
    6. 6. Introduction
    7. 7. Introduction
    8. 8. Prevalence • Most common cause of irreversible visual loss in the western world in individuals over 50 years • 65-75yrs - 11% some central vision loss • >75yrs - 30% • Two types – Dry (atrophic) most common 85-90% – Wet (exudative or neovascular) 10-15%
    9. 9. Prevalence
    10. 10. Prevalence
    11. 11. Risk Factors
    12. 12. Risk factors ■ Age ■ Family history. ARMD is, at least in part, an inherited disease. Relative with ARMD then life time risk increases from 12% to 50% ■ Smoking. Current smokers have a 2–3-fold increased risk of AMD with vision loss, compared with people that have never smoked. ■ Hypertension. There is an association between hypertension and wet ARMD. ■ Race. ARMD is more common in Caucasians. ■ Female gender. Wet ARMD is more common in women.
    13. 13. Risk factors ■ Light exposure. Excessive light exposure can damage the retina, but it is difficult to quantify. ■ Diet poor in antioxidants. A high intake of fats may increase the risk of advanced ARMD. On the other hand a diet rich in fish and antioxidant nutrients has been shown to lower the risk of ARMD. In the Beaver Dam Eye Study, high dietary intake of carotenoids, vitamin E and zinc was associated with a lower risk of ARMD. • Carotenoids are red and yellow pigments found in plants, and include zeaxanthin,lutein and beta-carotene.
    14. 14. Pathophysiology
    15. 15. Drusen • Deposition of waste material under the retina • Often but not always a precursor to ARMD
    16. 16. Drusen
    17. 17. Two patterns • Dry or Atrophic • Wet or Exudative
    18. 18. Dry ARMD • Presentation – Most common, slowly progressive – Gradual decrease in vision – Often asymmetrical
    19. 19. Dry ARMD • Signs – Drusen – Hyperpigmentation(RPE) or atrophy(photoreceptors) – Enlagement of these areas with visualization of the choroidal vessels
    20. 20. Dry ARMD
    21. 21. Dry ARMD • Slow progressive atrophy of the photoreceptors, retinal pigment epithelium and choriocapillaris
    22. 22. Wet ARMD • Less common but devestating • Caused by choroidal neovascularization from the choriocapillaris, which break through defects in Bruch’s membrane. • May form a membrane under the RPE or retina. • Eventually leads to scaring
    23. 23. Wet ARMD • Presentation – Metamorphopsia – Decreased vision (often sudden)
    24. 24. Wet ARMD • Signs – Retinal thickening or elevation – Haemorrage – Exudate – Often a grey/green colour
    25. 25. Wet ARMD
    26. 26. Wet ARMD
    27. 27. Wet ARMD
    28. 28. Wet ARMD • Course – Relentless with very poor prognosis • Haemorrhagic PED • Vitreous haemorrhage • Subretinal scaring • Massive exudation
    29. 29. Symptoms • Visual acuity
    30. 30. Symptoms • Scotoma
    31. 31. Symptoms • Metamorphopsia
    32. 32. Examination • Fundoscopy
    33. 33. Examination • Amsler Grid
    34. 34. Examination • Metamorphopsia and scotoma
    35. 35. Special investigations • Fluorescein angiogram • OCT
    36. 36. Normal FA
    37. 37. Dry ARMD
    38. 38. Wet ARMD
    39. 39. Wet ARMD
    40. 40. OCT
    41. 41. OCT
    42. 42. OCT
    43. 43. OCT
    44. 44. OCT
    45. 45. Treatment • Argon laser – MPS study – Extrafoveal or juxtafoveal – Reduces the chance of sever visual loss – 50% recurrence
    46. 46. Argon laser
    47. 47. PDT • PDT (photodynamic therapy) – Verteporfin – Light activated compound that targets the neovascularization – But does not damage the retina – Some stability and some improvement of vision
    48. 48. Surgery • Surgery – Submacular surgery – Macular translocation – Pneumatic displacement of submacular haemorrhage
    49. 49. Submacular surgery
    50. 50. Macular translocation
    51. 51. Macular translocation
    52. 52. Macular translocation
    53. 53. Pneumatic displacement of Hx
    54. 54. VEGF inhibitors VEGF: Vascular endothelial growth factor • Main regulator that promotes angiogenesis • Excessive amounts of VEGF are found in excised specimens of neovascular ARMD • VEGF promotes increased vessel permeability, endothelial cell proliferation and inflammation. • VEGF inhibitors target VEGF receptors
    55. 55. VEGF inhibitors – Macugen – Lucentis – Avastin
    56. 56. VEGF inhibitors
    57. 57. VEGF inhibitors
    58. 58. VEGF inhibitors
    59. 59. VEGF inhibitors • Unfortunatly most patients require these infections on an ongoing basis • Future – Implants – VEGF trap – Gene therapy
    60. 60. Prevention • AREDS study – Patients at high risk benefited from taking supplements with a specific formulation of vitamins and antioxidants – Vit C, E and Zinc – Beta carotene, Lutine, Zeaxanthine – Ocuvite and ocuvite with lutine
    61. 61. Supportive therapy
    62. 62. Supportive therapy
    63. 63. Supportive therapy
    64. 64. Supportive therapy
    65. 65. Burden of illness • Vision loss can devastate lives. ■ Visual impairment is associated with declining physical function and depression ■ Vision loss increases the risk of co-morbid conditions and increases mortality ■ Clinicians may underestimate the impact of vision loss on patient’s functioning and well-being.
    66. 66. Burden of illness
    67. 67. Burden of illness
    68. 68. Conclusion • ARMD is the leading cause of blindness in the over 50s in the developed world • There are essentially two main types of ARMD – dry and wet • Drusen, pigment and atrophy are features of early and dry ARMD • Neovascularization is a feature of wet ARMD
    69. 69. Conclusion • Vision loss progresses slowly in dry ARMD, but more aggressively in wet ARMD, which accounts for 90% of severe vision loss in ARMD • VEGF is the main factor promoting angiogenesis • VEGF promotes increased vessel permeability, endothelial cell proliferation and inflammation • VEGF is found in high consentrations in eyes with wet ARMD
    70. 70. Conclusion • Symptoms of ARMD include metamorphopsia, scotoma, loss of contrast sensitivity, and loss of visual acuity. • The amsler grid is a useful screening tool for macular function. • Fundus examination is key to diagnosis.
    71. 71. Conclusion • OCT provides cross sectional images of the retina, very valuable in monitoring treatment. • Loss of vision translates into loss of function, loss of independence, depression and susceptibility to falls and accidents. • New treatments with VEGF inhibitors can stabalize the retina and improve vision.
    72. 72. Thank you Questions?

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