Low vision management of age-Related macular degeneration.

1. Low Vision
Management in Age
Related Macular
Degeneration
Mr. Mahendra Singh
PhD (Scholar) M.Optom, FLVPEI (Hyd)
Assistant Professor and consultant Optometrist.
CL Gupta Eye Institute. UP India

2. DEFINITION
 ARMD is defined as the Presence of
some degree of visual loss in
association with Drusen and
geographical atrophy of RPE or
changes associated with sub retinal
neo vascularisation in individual over
50 yrs of age

3. DEMOGRAPHICS
AMD
•1998 approximately 8.3
on people over the age
of 65 in England
and Wales
–4.3 million have impaired
vision
–AMD is the leading
cause in over 65s
By 2020
–A 25% increase in the
over 65 population is
expected
–Incidence of ARMD
expected to rise by 31%

4. Types of ARMD
 Atrophic(Dry,Non-exudative): It is the most
common slowly Progressive disease
characterised by Drusen and geographic
atrophy of RPE
 Exudative(Wet,Neovascular):Less common
but devastating is characterised by
choroidal neovascularization and subretinal
scarring

5. Drusen
 It is an asymtomatic yellow
excrescences beneath the RPE
 Dusen are rarely clinically visible
before the age of 45 yrs

6. Types of Drusens
 Hard Drusen : They are small,round
discrete yellow white spots which are
associated with focal dysfunction of
RPE
 Soft Drusen : They are larger and have
indistinct margins

7. Drusen

8.  Only 10 % of Patients have exudative
form whereas have 90% Patients have
Non-exudative form

9. Quality of Vision in
ARMD
 Central Scotoma as shown in the
Picture

11. Risk factors
 Most Prevalent in caucasian
 Genetic and environmental factor
modify the risk of Visual loss
 Cigaratte smoking is the only
modifiable risk factor

12. Functional implications
of Symptoms
 Effect of disease causing a central
field defect is a scotoma at or near
fixation
 Symptoms vary on the number
size.location and the density of the
scotoma

13.  Difficulty seeing in central visual field
details for Distance,Intermediate and
Near task
 Common complain deal with reading
print,recognising faces and reading
signs

14. Problems in Daily
Activities
 Increased morbidity / falls / fractures
 Increased road accidents
 Increased anxiety & depression
 Poorer self care & independence
 Greater need for community & institutional
resources
 Social isolation - quality of life
 Loss of income

15. Functional test
 Visual Acuity :
20/40 to 20/1000
 Amsler grid may
demonstrate
distortion or
scotoma or be
normal

16. Impaired Contrast
 High and mild frequency retention of
low frequency loss can predict
response to magnification
 Mid and low frequency loss extra
magnification needed

17.  Severe loss : Optical magnification of
little benefit,CCTV may be a only
useful reading aid
 Visual field testing is useful to
establish the extent and location of
Scotoma
Glare test : Not necessary unless
patient has cataract or corneal
pathology

18. Evaluation of ARMD
Patients
 Refraction : A careful refraction is
always important since even a modest
increase in best corrected acuity may
translate a large improvement in
reading performance

19.  In case of good acuity proper
spectacle Rx with an increased add
 Light and glare control : Increased
illumination usually improves contrast
and reduces the amount of
magnification needed for a given task
in the Presence of relative scotoma

20. Management
 Patient with macular degeneration
benefit from most rehabilitation
strategies
 Early disease require a proper
refraction,increased add and improved
lightening in order to read

21.  Disease progresses acuity and contrast
sensitivity worsens and patient may adopt a
eccentric viewing strategies
 Different amount of magnification may be
needed for different task but the goal should
be to prescribe the least magnification and
the widest field possible

22. Magnification
 Increase magnification and illumination
are the main strays of therapy
 All types of magnification devises may
be used for reading including
spectacles,hand and stand magnifiers
and CCTV

23.  Another possibility is moving the image
to the preffered retinal locus(PRL) by a
means of a prism position with its apex
in the direction of the viable retina
 Illuminated stand magnifiers are useful
with poor acuity

24. Telescope
 Telescope is useful in earlier stages for
Distance task wide field,low
power,spectacle mounted telescopes
may be helpful for watching
television,play or sporting events

25. Non Optical devices
 Reading Lamp(Long arm adjustable
with 60 watts incandescent or 11 watt
Fluorescein bulb)
 Reading stand
 Felt tipped markers

26.  Yellow filters indoors and outdoors
 Signature guide
 Writing guide
 Notex (currency identification)
 Needle threader

27. Summary
 Proper Counselling
 Approach Magnification for Visualizing
Distance objects
 Head Scanning
 Distance vision Glasses
 Environment modification to enhance
Contrast

28.  Magnifier (Stand, Spectacle or pocket)
 Reading Lamp
 Reading Stand
 Other Non Optical Device which are
useful according to need of patient
should be Prescribed

29.  It is crucial that patient be introduced
to optical devises earlier in the course
of their disease
 Most patients progress slowly gradual
adaptation is possible allowing more
complex and more powerful aid to be
used later

30. The ‘NEW’ AMD Pathway
PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY COMMUNITY
OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSIS
SELF
REFERRAL
REFERRED BY
ANOTHER CLINICIAN
OR CARER
OTHER SOURCE
NOT
ARMD APPROPRIATE
CARE AS
INDICATED
SYMPTOMS SUGGESTIVE OF ARMD
‘DRY’ (NON-NEOVASCULAR)
ARMD
‘WET’ (NEOVASCULAR) OR
SUSPECTED ‘WET’
ARMD
DIRECT REFERRAL TO HES FOR
FLUORESCEIN AGIOGRAPHY
AND
FURTHER INVESTIGATION
TREATABLE
UNTREATABLE
ACCESS TO TREATMENT
OPTICAL / OPHTHALMIC
LOW VISION SERVICES
COUNSELLING
SOCIAL SERVICE SUPPORT
REHABILITATION
BD8/LV1 AS REQUIRED