diagnosis of ARMD how to detect ARMD different types of ARMD

1. ARMD
…
How to detect?
Mohamed ELShafie
Assistant lecturer of ophthalmology
Kafr ELShiekh university

3. Clinical Picture
Symptoms
Signs
Loss of central vision, visual distortion,
visual field defects, loss of contrast
sensitivity.
Hemorrhage, macular edema, subretinal
fluid, PED.

4. Evaluation
4. Fundus Camera
5. Fluorescein Angiography: pattern, location & size
6. Optical Coherence Tomography
7. Indocyanine angiography: detect polyp
8. OCT-A: QUIESENT or ACTIVE?!! Mild fluid with stable VA.
1. Visual Acuity : Difficulties reading/recognising faces
• Gradual change = non-exudative
• Sudden change = exudative
2. Color Vision: Most of the ARMD patient suffered yellow-blue defect.
3. Amsler Grid: Distortion = exudative change!

5. ARMD
1- Early: several small or medium-sized
drusen. Patients have no symptoms.
2- Intermediate: many medium-sized or one
or more large drusen. They can see a blurred
spot in the center of their vision.
3- Advanced = Geographic Atrophy: causing
blurred spot in the center and getting bigger
over time.
Dry (Non-exudative) Wet (Exudative)
• Choroidal neo-vascularisation (CNV)
• Exudative detachment of RPE and/or retina
• Disciform scar

6. Drusen
Classification:
1. Hard drusen (nodular):
Small (<63 μm), round, discrete, yellow-white lesions,
usually located at macula.
may be asymptomatic
2. Soft drusen (Exudative):
Larger (>63 μ m), ill-defined edges
associated with exudative ARMD.
3. basal laminar or cuticular drusen:
diffuse, small, regular, and nodular deposits in
macula.
4. calcific drusen: sharply demarcated, glistening, refractile
associated with RPE atrophy.

7. Drusen

8. Hard drusen Soft drusen

9. Geographic Atrophy

10. OCT Risk Factors for Atrophy development
1. hyporeflective foci within drusen
(hardening of drusen)
2. hyperreflective foci overlying drusen
(pigment migration)
3. subretinal drusenoid deposits
(reticular pseudodrusen)
4. drusen volume (DV) of 0.03 mm3
or more

11. ARMD
1- Early: several small or medium-sized
drusen. Patients have no symptoms.
2- Intermediate: many medium-sized or one
or more large drusen. They can see a blurred
spot in the center of their vision.
3- Advanced = Geographic Atrophy: causing
blurred spot in the center and getting bigger
over time.
Dry (Non-exudative) Wet (Exudative)
• Choroidal neo-vascularisation (CNV)
• Exudative detachment of RPE and/or retina
• Disciform scar

12. Choroidal neo-vascularisation
Clinically: small, focal, pale pink yellow or grey-green elevation at macula.
associate with: Exudation of serous fluid or blood in subretinal or sub-RPE space.
RPE detachment and tear

13. Type I: Occult CNV (beneath RPE)
Early: poorly delineated with fluorescein
Disrupted reflections from
(RPE/choriocapillaris) with
poorly defined boundaries.
mid : Stippled hyperflourescence
Late: stained with irregular margins.

14. Classic CNV Type II: above RPE
.
Early: well delineated vascular pattern
Late: stained with indistinct margins
disrupted reflections from
(RPE/choriocapillaris) with well-defined
boundaries

15. RPE DETACHMENT (PED)
Types:
Serous
Drusenoid
Fibro vascular
Hemorrhagic

16. “Burnt out” Wet AMD (Disciform Scar)

17. Type-III CNVM (RAP)
► abnormal blood vessels growing downwards from Retina into Choroid
► Multiple intraretinal haemorrhages at macula
• Can look like macular BRVO ??
but does not stop at horizontal midline

20. POLYPOIDAL VASCULOPATHY (PCV)
Characteristics feature:
branching network of inner choroidal vessels.
Nodular polypoidal aneurysm at edge of abnormal vessels
network.

21. POLYPOIDAL VASCULOPATHY (PCV)
Lesions considered as active on the evidence of
clinical, OCT, FFA any one of the following:
1. Vision loss of 5 or more letters (ETDRS chart)
2. Subretinal fluid with or without intraretinal fluid.
3. PED
4. Subretinal hemorrhage or fluorescence leakage.

22. Double-layer sign:
shallow and irregular elevation of RPE from
underlying intact Bruch's membrane

23. Pachychoroid
subfoveal choroidal thickness measurement from outer portion of hyperreflective line (RPE) to
inner portion of hyperreflective zone (choroidoscleral junction).
pachychoroid pigment epitheliopathy (PPE),
central serous chorioretinopathy (CCSCR),
pachychoroid neovasculopathy (PCN),
polypoidal choroidal vasculopathy (PCV)

25. polypoidal choroidal vasculopathy
(PCV)
central serous chorioretinopathy
(CCSCR)
broad-based
significantly greater height
hyporeflectivity between RPE
and Bruch's membrane

28. Outer Retinal Tubulation
► indicates disorganized outer retinal layers, irreversible photoreceptor damage → worse visual
prognosis.
► well-defined circular or ovoid areas of hyporeflectivity, surrounded by a hyperreflective band.
► confuse them with cysts or subretinal fluid ???

29. Myopic CNV
SPCA- derived CNV

32. Macular Telangiectasia Type 2

33. • Purposes of EARLY DETECTION OF ARMD:
– To monitor the progression of small drusen in the macula.
– give appropriate management to the patient according to their stage.
– To prevent the dry ARMD progression from develop into the wet ARMD.
–Wet ARMD is progresses much more quickly and can cause severe damage of vision.
► Once advanced AMD develops in one eye, there is an increased likelihood of having
geographic atrophy or neovascularization in the fellow eye.
► A simplified severity scale based on fundus appearance was established to assess the risk of
converting to advanced AMD:
♠ Large drusen
♠ any pigment changes
♠ disease state of the fellow eye