Age related macular degeneration from Optometrist Point of View

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  • So what is age related macular degeneration?
    Macular degeneration is thought to be due to destruction of the fatty acids in the rods and cones of the eyes. Thus, antioxidant nutrients have long been thought to be protective
  • We believe that Bruch’s membrane, which separates the choroid from the RPE/retina becomes less permeable, which blocks the nutrition of the RPE and prevents waste products of the retina from escaping. The quality of the retina deteriorates (dry AMD) and new blood vessels are stimulated to grow into the retina in an effort to clear away the waste products (wet AMD). These new blood vessels leak fluid and bleed, further impairing the function of the retina.
  • Formation of drusen at macula----However, when drusen expands in size and number, they can distort vision. When present for a log time, drusen may cause the macula to thin and stop functioning
    The druse is an aggregation of hyaline material located between Bruch’s membrane and  the  RPE.  It is associated with atrophy and depigmentation of the overlying RPE. Certain types of drusen are  associated  with sight threatening pathology. Small,  hard drusen are referred to simply as drusen, soft drusen over 63 microns in diameter are statistically associated with visual pathology and are termed early ARM.
    • Hyper or hypopigmentation of the RPE also constitutes part of the description of ARM.
    Patients with early and intermediate AMD may have normal Snellen visual acuity as measured by the opticians chart, but suffer from difficulties with activities performed at night such as driving and recognising dimly lit road signs. This is due to loss of rod photoreceptor-mediated dark adaptation  in the early phases of the disease. Rods appear to be lost earlier than cones in early AMD. At the same time, drusen appear beneath the RPE. These are small deposits containing amyloid beta or activated complement but do not appear to affect vision in any specific way.
  • A new study linking poor vision under dim light conditions to progression of AMD has been published by the Complications of Age-related Macular Degeneration Prevention Trial (CAPT) study group. This study supports similar research findings published several months ago that night vision symptoms are an independent risk factor for progression of AMD. Two types of photoreceptors exist within the retina: cones and rods. Cones are responsible for daylight vision, and rods are used for night vision. Patients with early and intermediate AMD can have unimpaired visual acuity (VA) but may report difficulty with activities performed at night and under low illumination (eg, driving, reading at night) due to degeneration of rod photoreceptors.
    Studies of human donor retinas with early AMD have found that rod loss preceded and was more severe than cone loss in most patients. Photoreceptor studies have found a significant interdependence between rod and cone photoreceptors. Death of rod photoreceptors may contribute to the later degeneration of cones, possibly induced by either excitotoxicity or changes in the structural and biochemical microenvironment of the retina. Thus, dysfunction of rod photoreceptors may serve as an indicator for impending cone dysfunction.
  • If the light-sensitive cells and supportive tissues of the macula break down over time, central vision gradually deteriorates. We call this dry AMD (Dry Age-Related Macular Degeneration).
    In dry AMD, no bleeding or fluid leakage occurs. The occurrence of AMD in one eye dramatically increases your risk of developing it in the other eye.
    People with advanced dry AMD see a blur or a blank spot in the center of the visual field where the tissue has thinned and lost pigment. This round, well-defined, nearly transparent spot in the center of the macula is called an area of geographic atrophy.
    In one of every seven people with dry AMD, the disease evolves into wet AMD.
    Dry or non exudative ARM is due to a slow and progressive degeneration of the photoreceptors  and the RPE with  gradual failure of central vision. It is also known as atrophic ARM. RPE changes, as manifested  by hypo or hyperpigmentation may be present. There may be thinning of the overlying retina.
    No bleeding or leakage fluid occur
  • Dry or non exudative ARM is due to a slow and progressive degeneration of the photoreceptors  and the RPE with  gradual failure of central vision. It is also known as atrophic ARM. RPE changes, as manifested  by hypo or hyperpigmentation may be present. There may be thinning of the overlying retina.
    •Geographic atrophy consists of one or more areas of RPE hypopigmentation with clearly visible choroidal vessels.  It  is the  severest  form of  the non exudative ARM representing a zone of  RPE atrophy 175 microns or greater in diameter with exposure of the underlying choroidal vessels.
    •As yet, there is still no proven effective therapy for the non-neovascular form of AMD.
  • Cause macula to thin and stop functioning
  • The proliferation of these new blood vessels is called choroidal neovascularization, or CNV.
    with external blood vessels breaking through Bruch’s Membrane and bleeding beneath the internal retina
    It is believed that the diseased retina stimulates the production of these new blood vessels in response to a decreased supply of nutrients and slow transport of wastes. Unfortunately, new blood vessels do not improve the health of the retina. Instead, they often leak blood or fluid into the retina.
  • body‘s misguided way of attempting to create a new network of blood vessels to supply more nutrients and oxygen to the eye's retina.
    With wet macular degeneration, new blood vessels grow beneath the retina and leak blood and fluid. This leakage causes permanent damage to light-sensitive retinal cells, which die off and create blind spots in central vision.
  • PVD can create minor damage to the retina, stimulating exudate, inflammation, and leucocyte response. These cells can form a transparent layer gradually and, like all scar tissue, tighten to create tension on the retina which may bulge and pucker (e.g. macular pucker), or even cause swelling or Macular edema.
    The underlying photoreceptor cells,rod cells and cone cells, are usually not damaged unless the membrane becomes quite thick and hard; so usually there is no macular degeneration.
  • Problems in driving at night
    A common complaint: one that I have often experienced is that when driving at night, a car on the road ahead may appear to have only one headlamp or one headlamp may seem to be higher than the other.
  • ften this results in distortions of vision that are clearly visible as bowing and blurring when looking at lines on chart paper (or an Amsler grid) within the macular area, or central 1.0 degree of visual arc. Usually it occurs in one eye first, and may cause binocular diplopia or double vision if the image from eye is too different from the image of the other eye. The distortions can make objects look different in size (usually larger = macropsia), especially in the central portion of the visual field, creating a localized or field dependent aniseikonia that cannot be fully corrected optically with glasses. Partial correction often improves the binocular vision considerably though. In the young (under 50 years of age), these cells occasionally pull free and disintegrate on their own; but in the majority of sufferers (over 60 years of age) the condition is permanent. The underlying photoreceptor cells,rod cells and cone cells, are usually not damaged unless the membrane becomes quite thick and hard; so usually there is no macular degeneration.
  • Macular degeneration symptoms develop when there is eye degeneration to the macula lutea - a tiny spot in the back of the retina.The macula lutea is responsible for our central vision. As macular degeneration progresses the photoreceptor cells, especially the cone cells, often die because of problems with getting oxygen and nutrients to the cells and waste products building up.
    Symptoms of macular degeneration also develop when abnormal,leaky blood vessels start to grow and leak fluid causing damage and degeneration to the cone cells.
  • There are two types of macular degeneration:
    Dry AMD is the most common form, affecting about 85% to 90% of people with macular degeneration. Small deposits form in the macula, blurring central vision.
    Wet AMD is less common, but progresses much more quickly and causes more severe damage to vision. Abnormal blood vessels form behind the macula, leak fluid and form scar tissue.
    Early detection is the key to saving vision. Wet macular degeneration progresses very quickly, but progression can be stopped with laser treatment. The only known treatment for dry AMD is nutritional support. If you experience any symptoms of AMD you must see your eye doctor immediately. 
  • Focal and diffuse drusen taking the form of abnormal material deposits in Bruch’s membrane predispose to the development of late-stage atrophic or neovascular lesion of ARMD associated with severe vision loss.
    Normal changes of aging untill high number of drusen (more than eight)
    Enlargement of hard drusen (drusen-softening)-soft drusen means proggression of ARMD-regular check up for Amsler chart-detachment of RPE-
    Detachment of the retinal pigment epithelium due to confluence of soft drusen
    Calcification
    Spontaneous regression
    Disappearance with subsequent corresponding atrophy
    End-stage of ARMD: disciform scar
  • 1. It useful in detecting small changes in retinal thickness, subretinal and sub-RPE fluid and choroidal neovascularization in ARMD.
    2. It also useful to monitor response to therapeutic intervention.
    3. Visual acuity is more likely to be affected by macular disease than by diseases of the optic nerve ( Table 187-2 ). Three tests—the measurement of the pupillary response,[6] color vision,[7] and sense of brightness testing[8] —are particularly sensitive to impairments of the optic nerve
  • Loss of color vision in AMDMeasurement of Red-Green and Yellow-Blue color vision can provide a measure of functional change in diseases of the retina, including age-related macular degeneration (AMD).Abnormalities in rod and cone photoreceptor morphology have been reported in normal aging retinas in the absence of known pathology and have been taken as an indicator of susceptibility to retinal disease. Some loss of visual performance may therefore precede retinal structural changes that can be detected reliably using conventional fundus imaging techniques. Red/green (RG) and yellow/blue (YB) colour discrimination thresholds are sensitive measures of normal retinal function and poor YB discrimination is often taken as an indicator of retinal disease, though it is generally acknowledged that RG loss is also present in most cases of acquired deficiency. Although structural changes in age-related macular degeneration (AMD) and diabetes share some similarities, significant differences remain and this may result in different patterns of RG and YB loss.In this study, patients with varying severity of AMD and diabetes and normal subjects of similar age were recruited for the study. RG and YB colour detection thresholds were measured in the two groups of patients and the control group, using the Colour Assessment and Diagnosis (CAD) test.Each AMD subject investigated showed significant, but unequal loss of YB and RG chromatic sensitivity, with YB discrimination showing the greatest loss. Diabetic subjects also exhibited reduced chromatic sensitivity, but with almost equal and highly correlated RG and YB thresholds (R2 = 0.99). The severity of colour vision loss measured with the CAD test also correlates well with a clinical classification index of disease progression in AMD, and with the level of hyperglycaemic control in diabetes.The investigators conclude that accurate measurements of RG and YB colour thresholds can provide a sensitive measure of functional change in diseases of the retina with patterns of loss that differ significantly in AMD and diabetes.
  •  The central visual field can then be tested by asking the patient to report any defects in your facial features while they look toward your nose.  An alternative, and perhaps more sensitive, way to test the visual field is to have the patient compare the color of two red objects, each held in different visual quadrants (Figure 3).1
     
    Figure 3:  Visual fields loss can be detected by asking the patient to compare the appearance two red objects presented simultaneously in different visual quadrants.
    Showing targets simultaneously in different quadrants is useful in detecting visual extinction.  With visual extinction, the patient, despite having no visual field loss, will be unaware of objects in areas of their visual field when a target is simultaneously presented in the opposite hemifield. 
  • An area of central visual distortion affecting one AGS (viewed at thirty centimeters distance) could potentially lead to complete inability to recognize a human face at six meters distance. Likewise, a face at three meters distance may be unrecognizable with a distortion area affecting two AGS, and a face at one meter may not be recognized with a distortion area affecting seventeen AGS.
    Patients with one or more AGS of distortion are at risk for impaired facial recognition at distances of usual interpersonal interaction, thereby negatively affecting their social functioning.
    Abstract
    Purpose: The objective of this study was to calculate the geometric relationship between an area of distortion on the Amsler Grid Test to the corresponding area of an average human face at various viewing distances. The overall objective was to develop an alternate use for the Amsler Grid Test in predicting the social functioning abilities of patients with central visual distortions, as determined by their abilities for facial recognition.
    Methods:A simple geometric relationship was used to calculate the area of retinal distortion affected by one Amsler Grid Square (AGS), measuring twenty five square–millimeters, viewed from thirty centimeters distance, with the corresponding area of a human face viewed from a one, three or six meters distance. The geometric calculations were then applied to previously reported facial recognition data to determine whether or not the face would be recognizable given the area covered by the distortion.
    Results:An area of central visual distortion affecting one AGS (viewed at thirty centimeters distance) could potentially lead to complete inability to recognize a human face at six meters distance. Likewise, a face at three meters distance may be unrecognizable with a distortion area affecting two AGS, and a face at one meter may not be recognized with a distortion area affecting seventeen AGS.
    Conclusions: Patients with one or more AGS of distortion are at risk for impaired facial recognition at distances of usual interpersonal interaction, thereby negatively affecting their social functioning.
    Keywords: face perception • aging: visual performance • vision and action
  • An alternative, and perhaps more sensitive, way to test the visual field is to have the patient compare the color of two red objects, each held in different visual quadrants (Figure 3).1
    Figure 3:  Visual fields loss can be detected by asking the patient to compare the appearance two red objects presented simultaneously in different visual quadrants.
     
    Showing targets simultaneously in different quadrants is useful in detecting visual extinction.  With visual extinction, the patient, despite having no visual field loss, will be unaware of objects in areas of their visual field when a target is simultaneously presented in the opposite hemifield. 
  • It can give useful information regarding central scotoma, areas of missing, blurred, or distorted lines according to patient reported.
    Areas of missing, blurred, or distorted lines on the Amsler grid can give useful information regarding central scotomas seen with optic neuropathies.
    It is sensitive to small scotomas. 
    The test is also useful for differentiating neuro-ophthalmic and macular disease.   
  • Advantages of Goldmann perimetry (Figure 4) include the ability to directly monitor patient attention, present custom test points, and test the complete visual field.  This type of visual field testing requires more training to do properly and can be more time consuming. 
     
    This may be due to fatigue, slower cognitive skills, low reliability, poor fixation, or decreased
    vision.
    Secondly, the GVF is helpful when the visual defect is located or extends beyond
    the central 30 degrees (peripheral visual field defect).
    Lastly, the GVF is extremely useful in patients with functional visual loss.
  • Automated visual field machines allows standardized testing and statistical analysis (Figure 5).  However, it requires increased patient cognitive skills and is more likely to produce fatigue.  Perhaps the biggest disadvantage of automated perimetry is the lack of flexibility in evaluating difficult patients.  Despite this, a central 30˚ threshold test will pick up the majority of neuro-ophthalmic lesions.       
     
    Figure 5:  An advantage of automated perimetry is the standardized testing and the ability to statistically analyze the data.
  • It is very useful to see occult CNV especially in vascularized PED.
  • -Macular degeneration cannot be prevented, but it may be controlled. The best way to prevent vision loss is to get prompt examination and diagnosis by optometrist. The earlier you treat macular degeneration, the better the chance that macular degeneration treatment will help.
    See eye doctor if found any symptoms of age-related macular degeneration and make sure keeping regularly scheduled eye exams.
    Using the Amsler grid may help detect subtle changes in our vision. We can monitor our vision daily by posting an Amsler grid on refrigerator.
    Vision exams for those older than 65 should include age-related macular degeneration screening.
  • Smoking impairs the body’s circulation, decreasing the efficiency of the retinal blood vessels.
    Cardiovascular exercise improves the body’s overall health and increases the efficiency of the circulatory system.
  • Prevent the factor contribute to ARMD (eg. Smoking, diet,blood pressure,alcohol)
    This is important for the younger relations of age related macular degeneration sufferers:
    Smoking increases the risk of macular degeneration about 3 times. Macular degeneration occurs 10 years earlier in smokers. Passive smoking is also harmful
    30 minutes a day at least, walking, or more active exercise for younger people,  reduces risk by 70%  : a 2006 study. Exercise may help by preventing hardening of the arteries. 30 minutes walking a day for example, three times a week will result in less than a third of the amount of neovascular ARMD compared to people who don't walk or exercise and who drive everywhere.- A low salt diet is important /needed
    This should include a variety of vegetables and fruit(at least 5-9 x 100gm portions/day)
    Oily fish twice a week reduces ARMD by 40%, especially oily fish such as tuna, mackerel, sardines, herring, and salmon.
    The Age-Related Eye Disease Study found that supplementation with antioxidants plus zinc decreased the likelihood of developing advanced age-related macular degeneration in some people.
    but a healthy diet may be better still.
    Add on: protect our eyes from sun exposure with sunglasses that block ultraviolet (UV) sunrays.
  • A number of treatments are available for wet AMD. These mainly work by stopping the growth of new blood vessels. This means that treatments usually need to be given fairly quickly once the blood vessels start to grow in your eye. If the blood vessels are allowed to grow for too long the blood vessels may scar the retina and this scarring cannot be treated.
    .
  • At the moment there is no treatment for dry AMD. This is because dry AMD doesn't involve new blood vessels growing. Although research is continuing to find a treatment for dry AMD, nothing is available yet
  • T(x) of wet ARMD
    Anti-vascular endothelial growth factor (anti-VEGF) drug, called Lucentis interferes with VEGF (a chemical subtance that stimulates further new blood vessels growth) and stop the vessels from growing by intravitreal injection. Thus, it prevents further damage of vision.
    - The main complications of this treatment are the chance of a rise in pressure in your eye, retinal detachment and eye infections. These only happen to a very small minority of people (less than one per cent of people having the treatment) and there are treatments available if any of these complications happen to you.
     
  • - Normally, a course of three monthly injections is given to start with and then you should be monitored every four weeks to check that the treatment is working.
    - Usually anti-VEGF treatments have a high success rate and in most people they stop sight getting worse. About 40 per cent of people also see an improvement in their vision.
  • A type of laser treatment which uses a combination of a light sensitive drug and a low energy (cold) laser to stop new blood vessels growing. Usually the patient will be given an injection in their arm,Drug injects into the vein and then circulates in the bloodstream to be absorbed by the abnormal blood vessels in the eye. The laser beam can be localised on the required blood vessels only. ADV: reducing the damage to surrounding tissue. Esp for armd tat have CNV in the fovea area.called as classic CNV- subfoveal type
  • New drugs are being used to slow down or prevent the growth of the abnormal blood vessels within the eye. (prophylaxis tx)
    Submacular surgery involves vitrectomy. posterior
    retinotomy and removal of the subfoveal CNV (Fig. 17.1 G).
    The procedure carries a high rate of recurrence and
    causes a large central scotoma because it is impossible to
    remove a type 1 CNV without also removing the overlying
    RPE. Therefore. CNV removal is not normally carried out
    for patients with AMD.
  • Dry ARMD
    Nutrition and macular degeneration
    A recent study has shown that for some groups of patients with dry ARMD, specific vitamin supplements can reduce further significant visual loss by about 25%. Consult your eye doctor for further information. At present no other treatment is available for dry ARMD, other than visual aids and lifestyle advice.
     
  • Quit smoking
    Exercise regularly. Cardiovascular exercise improves the body’s overall health and increases the efficiency of the circulatory system.
    Learning to adapt LV can make life easier n safer. making changes to lighting, using contrast in objects that you use often and in structures such as door frames and light switches, labeling and marking medicines and food, and getting rid of potential hazards.
    Counseling, rehabilitation, and training can help you with managing your household, cooking, shopping, personal grooming, and other aspects of daily home and work life that can be challenging to a person who has low vision.
    Developing a personal support network can help you maintain your quality of life and deal with the fear and anxiety that can result from having an ongoing (chronic) illness.
    Advice for AMD patients
    If you’ve been diagnosed with ARMD, making a few simple lifestyle changes could have a positive impact on the health of your retina.
     
    Monitor your vision daily with an Amsler chart (Request this from your doctor). By checking your vision regularly, changes that may require treatment can be detected early.
    Take a multi-vitamin with zinc. (check with your eye physician for a recommendation). Antioxidants, along with zinc and lutein are essential nutrients, all found in the retina. It is believed that people with ARMD may be deficient in these nutrients.
    Consult a low vision specialist. These professionals are specially trained to help visually impaired patients improve their quality of life. After a personalized consultation, they can recommend appropriate magnifiers, reading aids, practical tips, and many resources.
    Always protect your eyes with sunglasses that have UV protection. Ultraviolet rays are believed to cause damage to the pigment cells in the retina.
    Quit smoking. Smoking impairs the body’s circulation, decreasing the efficiency of the retinal blood vessels.
    Exercise regularly. Cardiovascular exercise improves the body’s overall health and increases the efficiency of the circulatory system.
     
  • Unfortunately, even after macular degeneration treatment, the condition can recur. Because of this, individuals with macular degeneration must test their own vision regularly and follow up, as recommended by their ophthalmologist. The various procedures, however, can slow the rate of vision loss and hopefully preserve some sight.
  • The earlier you treat macular degeneration, the better the chance that macular degeneration treatment will help.
    Vision exams for those older than 65 should include age-related macular degeneration screening.
    Armd is not painful,rarely lose all of the vision,they may have poor central vision but they are still able to perform many normal activities
  • Age related macular degeneration from Optometrist Point of View

    1. 1. PRESENTED BY: ANIS SUZANNA BINTI MOHAMAD Optometrist and Contact Lens Consultant B.Sc (Hons) Optometry UKM
    2. 2. Healthy retina
    3. 3. ANATOMY OF RETINA
    4. 4. AGE RELATED MACULAR DEGENARATION • Definition: – A DEGENERATIVE eye disease that AFFECT MACULA – which responsible to the central vision • Types of ARMD – Early stage – Late stage • Dry ARMD • Wet ARMD
    5. 5. • Bruch membrane become less permeable – Blocks nutrition from RPE, prevent waste product from retina escaping • The quality of retina deteriorate (dry armd) • New blood vessel are stimulated into retina to clear away the waste products (wet armd)
    6. 6. Early stage ARMD SIGN • Drusen – Discrete yellow spot at macula – The accumulation occurs as bruch's membrane becomes thicker • prevents the free flow of materials to and from photoreceptors layer. – Also, the retinal pigment cells accumulate lipofuscin. • This pigment will also slow down the passage of chemicals to and from the retina.
    7. 7. SYMPTOM • Usually has normal vision • Difficult driving, recognizing dimly road sign – Loss of rod photoreceptors (earlier than cones)
    8. 8. Late stage: DRY ARMD • Slowly progressive atrophy of photoreceptor, RPE, and choriocappilaries • Tissue has thinned and lost pigment • Also known as atrophic AMD, nonexudatives AMD, nonvascular AMD • Progress over month, years • Bilateral – Severity and progress may different between BE
    9. 9. • SIGN – Usually assoc with hard drusen • Small, round, discrete, yellow white spot asocc with focal disfunction of RPE – Atrophy of RPE – Enlargement of atrophic area, pre-existing drusen appear, choroidal vessel visible  geographic atrophy Geographic atrophy Dry ARMD
    10. 10. • SYMPTOM – Slow and progressive loss central vision • Called central scotoma – Vision distorted • Called metamhorphopsia • Drusen has expand and increase in no.
    11. 11. Late stage: Wet ARMD • New blood vessel growth underneath the retina • body's misguided way of attempting to create a new network of blood vessels – to supply more nutrients and oxygen to the retina. • Called choroidal neovascularization (CNV) – leak fluid under the macula – then form scar tissue leading to central vision loss. • Also known as exudatives AMD, neovascular AMD
    12. 12. Sign • Soft drusen appear – Larger and have indistinct margin – May slowly enlarged and coalesce to form solid drusenoid detachment of RPE • area of the macula is elevated by subretinal fluid or blood, often associated clumps of exudates Soft drusen in wet ARMD Wet ARMD or neovascular ARMD
    13. 13. • Symptom – Profound central vision impairment • Sudden decrease (weeks) – Vision distorted
    14. 14. Risk factors 1. Aging 2. Smoking 3. Obesity and inactivity 4. High blood pressure 5. hereditary
    15. 15. Complications of ARMD 1. Decreased contrast sensitivity 2. Decreased visual acuity 3. Metamorphopsia 4. Central scotoma
    16. 16. Decreased contrast sensitivity – It occurs at early phase of onset. – The macular at this stage has discrete yellow spots or drusen. – The hyperpigmentation of RPE can decreased contrast sensitivity of the eye.
    17. 17. Decreased visual acuity – Common in late stage. – It is due to slowly progressive atrophy of photoreceptors, RPE and choriocapillaries. – RPE detachment can occur. – The gradual vision impairment occurs gradually over months or years. – Normally both eye is affected but asymmetry.
    18. 18. Metamorphopsia • It occurs due to thickened Bruch membrane of the eye. • It may cause unilateral metamorphosia and lead to impairment of central vision. Patient complains of all the object seen smaller than actual size. (micropsia)
    19. 19. Central scotoma – It occurs when the foveal area is affected. – The scotoma, or central blind spot, can be due to geographic atrophy or to the damage of photoreceptor cells from choroidal neovascularization (leaking blood vessels). Patient complaints of difficult to recognize the
    20. 20. Clinical manifestations of age-related macular degenerationClinical manifestations of age-related macular degeneration Phase Clinical manifestation Associated visual defect Early stage Focal drusen Irregular pigmentations of the retinal pigment epithelium Good visual function Abnormal dark adaptation Reading problem in dark room Blue-yellow defect Driving car at night is impaired Late stage Detachment of the retinal pigment epithelium Rip in the retinal pigment epithelium Choroidal neovascularization Disciform scar Geographic atrophy of the RPE Decreased visual acuity Metamorphopsia Central scotoma
    21. 21. EARLY DETECTION OF ARMD • Purposes: – To monitor the progression of the sign of small drusen form in the macula. – Can 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.
    22. 22. Spontaneous modifications of drusen DrusenDrusen Choroidal neovascularization Choroidal neovascularization RPE detachmentRPE detachment Geographic atrophy Geographic atrophy Disciform scarDisciform scar
    23. 23. ASSESSMENT OF AGE-RELATED MACULAR DEGENERATION
    24. 24. Patient’s History • Purpose: – A careful review of the patient’s family history can help differentiate the ARMD or the other macula associated disease. • Questions: – Chief complaint • Ask patient about chief complaint carefully.- onset and course of symptom. – Symptoms • Ask patient whether they have see object blurred or distorted. • Ask patient if they notice any missing part or wavy of a straight line. • Ask about glaring problems especially when driving at night, early morning or early-evening hours – Ocular history – Medications and allergies – Family History • Any family members have the ARMD disease?
    25. 25. Ocular Examination • Visual acuity – Pinhole visual acuity test • Contrast sensitivity – loss of contrast sensitivity at high spatial frequencies – loss of peak contrast sensitivity with increasing drusen severity • Pupillary responses – To differentiate the central scotoma due to optic nerve disease or macular disease • Biomicroscopy – to examine other factor that contribute to disability glare • Color Vision - For screening and diagnosis of color vision defect on the ARMD patient.
    26. 26. Visual acuity • At early onset of the disease, visual acuity will be slightly decreased. (VA=<6/9) • Pinhole visual acuity must be done at distance with habitual correction. The expected findings: • If the patient decreased visual acuity due to pathological disease such as ARMD, pinhole visual acuity is no improvement and possibly a further decrease will occur. • A refraction should improve acuity level of the patient at least to the level obtained through the pinhole.
    27. 27. Contrast sensitivity • Patient with ARMD is often complaint of blurring at distance, difficulties to see face and road signboard due to decreased in contrast sensitivity. • Contrast sensitivity reduced when there are changes happened on RPE. • Test for contrast sensitivity must be done in order to see the severity of the morphological changes at the macular. • Expected findings: – Patient with ARMD usually demonstrates profound loss of acuity on contrast sensitivity test.
    28. 28. Contrast sensitivity can be measured with the use of a contrast sensitivity chart (A) or neutral density filters (B). (A) (B)
    29. 29. Color Vision • Color vision test: – Clinical screening: Ishihara plate. – Diagnosis: D-15 Color Test or FM 100 Hue Test • Purpose: – To detect the color vision defect that occur in ARMD patient either red –green or blue-yellow defect. – To classified as congenital or acquired color defect. • Expected findings: – Most of the ARMD patient suffered yellow-blue defect. – But patient must be differentiate with other macular disease such as diabetic retinopathy.
    30. 30. Supplemental testing • Visual Field – Facial Amsler – Amsler grid – Goldmann perimetry – Automated Perimetry • All Fundus Related Procedures • Fundus Biomicroscopy • Fundus photography • Opthalmoscopy • Fundus Fluorescein angiography • Optical coherence tomography (OCT)
    31. 31. Visual Field There are number of different ways to evaluate the visual field of age-related macula degeneration patient. These include: 1. Facial Amsler 2. Amsler grid 3. Goldmann perimetry 4. Automated Perimetry No one type of visual field is good for all situations.
    32. 32. Facial Amsler • Purpose: – It is very useful for patient with cognitive impairment. – Detect gross monocular visual field of the patient. • The central visual field can then be tested by asking the patient to report any defects in your facial features while they look toward your nose.
    33. 33. Simultaneously present targets • Purpose: – Alternative method to get grossly detection of patient’s visual field – Patient have to report the existence of the object that shown. – Each of the object held in different visual quadrant.
    34. 34. Amsler Grid • Purpose: – It can give useful information regarding central scotoma, areas of missing, blurred, or distorted lines. – It is sensitive to small scotoma within central 10° of visual field. – The test is also useful for differentiating neuro- ophthalmic and macular disease. Patient experienced deep dark spot at the center of the Amsler Grid
    35. 35. • Instruction: 1. Hold the chart at a reading distance of 30 cm; adequate and even lighting is important. 2. You should wear your fully prescribed spectacles and for elderly, their reading glasses, during the test. 3. Cover the left eye, and use your right eye to focus on the center dot. 4. If patient difficult to see the white dot at the center, ask them to imagine the intersect of the two line at the center. 5. Ask patient: Do you notice any wavy, broken or distorted lines or blurred or missing areas of vision within the chart? 6. Repeated the above examining on your left eye. It is a 10 x 10 cm square grid formed by multiple white lines on a black background and with a white dot at the center.
    36. 36. Goldmann perimetry • Advantages: – Ability to directly monitor patient attention – Present custom test points – Test the complete visual field. Large central scotoma seen with Goldmann perimetry test.
    37. 37. Automated perimetry • It is difficult to do with patient ARMD because they reduced in contrast sensitivity. • The test can be done on short-wavelength automated perimetry. • If possible to be done, the result is very useful especially in detecting presence of the central scotoma in advanced cases of ARMD. Automated visual field machines allows standardized testing and statistical analysis .
    38. 38. All Fundus Related Procedures I. Opthalmoscopy – Direct – Indirect I. Fundus photography II. Fundus Biomicroscopy III. Fundus Fluorescein angiography IV. Optical coherence tomography (OCT)
    39. 39. Fundus Related Examinations • Purpose: – To see fundus and macula for both eyes. • Clinical findings: Clinical features Signs Hard drusen (nodular) Small, round, discrete, yellow-white lesions, and usually located at the macula. Soft drusen (Exudative) Larger lesions with ill-defined edges associated with exudative ARMD. Non-exudative ARMD Hyperplastic changes of RPE associated with slowly progressive degeneration of the overlying neuroretina and underlying choriocapillaries. Exudative ARMD Present with elevated macular area with subretinal fluid or blood associated with clumps of exudates. If the lesion recover, it will leave with subretinal ‘disciform’ scarring.
    40. 40. Fundus Fluorescein Angiography • Purposes: – To see the leakage of the blood vessels around the macula. – The test is done to help the doctor confirm a diagnosis, to provide guidelines for treatment, and to keep a permanent record of the vessels at the back of the eye. – This test carry out mostly in cases of advanced cases of ARMD for further treatment.
    41. 41. Procedure: • Pupil dilated with the mydriatics drop before the florescein injected into the body. • Fluorescein dye injected into bloodstream via hand or arm. • Following the injection, the fundus photo are taken quickly within 60 seconds during dye enters blood vessels at the back of the eyes. Fluorescein Angiogram of ARMD
    42. 42. Optical coherence tomography (OCT) – It useful in detecting small changes in retinal thickness, subretinal and sub- RPE fluid and choroidal neovascularization in ARMD. – It also useful to monitor response to therapeutic intervention.
    43. 43. PREVENTION
    44. 44. • Using the Amsler grid may help detect subtle changes in vision • A healthy lifestyle helps to prevent ARMD - Stop smoking - Regular exercise - Reduce risk by 70% - Keep your blood pressure low - Salt and more than 2 units of alcohol a day may cause BP to rise
    45. 45. - Avoid obesity - Take a balanced diet - Fruit and vegetables- prevent 36-50% of ARMD - Oily fish twice a week reduces ARMD by 40% - Vitamin supplements Eg. Antioxidants plus zinc • Protect eyes from sun exposure with sunglasses
    46. 46. Management 1. Basic Treatment 2. Available Treatment Options 3. Patient Education 4. Prognosis and Follow up
    47. 47. Basic Treatment • There is NO CURE • T(x) : - slow the progression of disease - prevent the vision loss • Wet AMD : - a lot of treatments are available - mainly for stopping the growth of new blood vessels - if delayed t(x), scar formation
    48. 48. • Dry AMD: - no treatment available - does not involve new blood vessels growing - Low vision aids may be helpful
    49. 49. Treatment of Wet ARMD 1. Anti-VEGF treatment - The most recent treatment - Use anti-vascular endothelial growth factor (anti-VEGF) drug such as Lucentis, Macugen, Avastin - Injects into the eyeball (IV) under local anaesthetic - Cause constriction and closure of the leaking blood vessels - Prevent further damage of vision
    50. 50. Cont.. - Begins with a course of three monthly injections - Monitor every months - High success rate - Most effective when treating blood vessels that are ‘active’ or ‘leaking’ - Stop sight getting worse - Improvement of vision- 40% - Complication: ↑ IOP, RD, eye infections
    51. 51. 2. Photodynamic Therapy (PDT) • A type of laser t(x) • Use a combination of a light sensitive drug (Verteporfin) and a low energy (non -thermal) laser • To stop new blood vessels growing • Adv: the ability to selectively damage tissue • Indication: classic CNV-subfoveal type • SE: transient decrease in vision, sensitivity to bright light for 24-48 hours.
    52. 52. Classic sub-foveal CNV -Most people with neovascular ARMD have CNV in the centre of the retina - Regular laser cannot be used as it would destroy the central vision -Thus, photodynamic laser (PDT) is used. -But still causing some vision loss Yellow spot: fovea Red area: CNV
    53. 53. Classic extra-foveal CNV -CNV are not in the centre of fovea -Can be treated by regular laser therapy -Argon Laser Photocoagulation. High-energy laser light - used to destroy actively growing abnormal blood vessels
    54. 54. Photodynamic Therapy (PDT) a) Small dirty grey lesion at the fovea surrounded by blood b) Fundus Angiography venous phase shows hyperfluorescence from classic subfoveal CNV surrounded by a hypofluorescent ring
    55. 55. Photodynamic Therapy (PDT) c) measurement of greatest linear dimension of the lesion; d) FA 3 months following successful treatment shows hypofluorescence of the lesion (Courtesy of S Milewski)
    56. 56. 3. Anti-angiogenic drug - Used to slow down or prevent the growth of the abnormal blood vessels within the eye - Eg. Intravitreal steroid (triamcinolone acetonide) - SE: ocular hypertension, cataract - Submacular: removal of the subfoveal CNV - Macular translocation: is aimed at surgically moving the fovea away from the CNV 4. Surgery
    57. 57. 5. Vitamin Supplements • Age-Related Eye Disease Study (AREDS) showed that for certain individuals, antioxidants such as – 500 g of vitamin C – 400 IU of Vitamin E – 15 mg of beta-carotene – 80 mg of Zinc oxide – 2 mg of Copper • can decrease the risk of vision loss in patients with intermediate to advanced dry age-related macular degeneration.
    58. 58. 6. Refractive correction or low vision aids • Prescribe and increasing near addition for reduced acuity in patient with macular degeneration • Other options: - Telescope - Hand magnifiers - Enlarged size print - Enlarged screen size for television or computer screen - Closed-circuit television (CCTV) or computer magnification system
    59. 59. Advice for ARMD patient • Consume fruit on daily basis and quit smoking • Exercise regularly • Monitor vision- regular eye examination • Adapt to low vision- eg.making changes to lighting, using contrast in objects that often used such as door frames and light switches, do labeling and marking medicines and food, and getting rid of potential hazards. • Counseling, rehabilitation, and training can help with managing household, cooking, shopping, personal grooming and others. • Develop a personal support network-deal with fear and anxiety-maintain quality of life
    60. 60. Prognosis and Follow up • Dry ARMD: - slow progression- keep most of the vision - may develop the wet form- pt should monitor vision daily-KIV annually - attend to clinic immediately if signs of reduced vision or distortion are noted. • Wet ARMD and have had laser treatment: - can be recur-should test vision to see if any blind spots grow bigger or if any new blind spots appear. - New blood vessels can emerge months or years after have had successful laser treatment. • If only one eye is affected: - A regular eye examination on the other eye is needed to discover any sign of new problems.
    61. 61. Summary • ARMD is the most common cause of irreversible vision loss in people over 50 years of age in Western countries. • 2 types of ARMD: a) Dry and b) Wet • Currently no other t(x) is available for dry ARMD except of visual aids and lifestyle advice. • Early detection is critical for successful t(x) of wet ARMD. • Consultation is very important – to cope with low vision • Rehabilitation and training can make their living with low vision more easier and safer.
    62. 62. References • Jack J Kanski. 2007. Kanski Clinical Ophthalmology 6th edition: Butterworth- Heinemann • Adrian S Bruce. 2008. Posterior Eye Disease and Glaucoma A-Z : Butterworth- Heinemann • Theodore Grosvenor. 2007. Primary Care Optometry. Fifth Edition. St. Louis, Missouri: Butterworth-Heinemann. • http://www.goodhope.org.uk/departments/eyedept/armdwet.htm (9.00a.m,20/2/2011) • http://www.webrn-maculardegeneration.com/central-scotoma.html(10.00 a.m, 22/2/2011) • http://www.mdsupport.org/library/angio.html (11.00 a.m,21/2/11). • http://www.myvisiontest.com/newsarchive.php?id=1219 (10.00 a.m, 22/2/2011) • http://bjo.bmj.com/content/85/12/1432.abstract(10.00 a.m, 22/2/2011

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