Macular degeneration is a leading cause of vision loss in older adults. There are two main types: dry and wet. Dry macular degeneration involves drusen deposits under the retina and gradual vision loss. Wet macular degeneration occurs when abnormal blood vessels grow behind the retina, leak blood and fluid, and cause sudden vision changes or loss. Risk factors include age, family history, smoking, and diet. Treatments for wet macular degeneration focus on blocking VEGF to prevent new blood vessel growth via injections or laser therapy. Antioxidant and mineral supplements can help reduce risks of progression for some patients.

1. Macular Degeneration
Dileep Raj Gupta
OA
Department of Ophthalmology

2. Retinal Anatomy
• Key Anatomical Features:
• Macula – oval area at posterior pole measuring
5 mm in diameter
• Fovea – is a depression in the inner retinal
surface at the center of the macula
• Foveola – central area of the fovea containing
only cones and thinnest part of the retina
• Retinal pigment epithelium (RPE) – single
layer supporting photoreceptors
• Bruchs membrane – separates RPE from
choriocapillaris

3. Retinal Anatomy

4. Retinal Anatomy

5. Age Related Macular
Degeneration (ARMD)
• Prevalence
• Leading cause of irreversible severe vision loss
in Western world over 60 yrs old
• In USA 10% between 65-75 have lost some central
vision
• In USA 30% older than 75 have lost some central
vision
• Two Types of ARMD:
• Atrophic (dry) – 90% of cases, slow progression
• Exudative (wet) – 10% but frequently devastating
vision loss

6. Age Related Macular
Degeneration (ARMD)
• Risk Factors for of ARMD
• Smoking – research shows two-fold increase in
risk for ARMD
• Race – caucasians more likely than African
American descent
• Family history – increased risk with family
history
• Diet – poor, fatty diet associated with increase
risk

7. Age Related Macular
Degeneration (ARMD)
• Signs of ARMD
• Drusen – earliest clinically detectable feature
• Asymptomatic yellow excrescence beneath the RPE
• Rarely clinically visible before 45 yrs
• Not uncommon between 45-60 yrs
• Universally present >60 yrs
• With age drusen increase in size and number

8. Age Related Macular
Degeneration (ARMD)
• Types of Drusen
• Hard drusen – small, round, yellow-white spots
• Associated with focal dysfunction of RPE
• Soft drusen – larger with indistinct edges
• Can coalesce, become confluent
• Diffuse dysfunction of the RPE
• Increases the risk of wet ARMD

10. Age Related Macular
Degeneration (ARMD)

11. Age Related Macular
Degeneration (ARMD)
• Pathogenesis:
• Drusen are discrete deposits of abnormal
material in the RPE. Failure to clear this
material which moves to inner portion of Bruch
membrane. This relationship has been
postulated as a determinant to progressing of
ARMD
• The exact pathogenesis of drusen in ARMD is
unclear

12. Age Related Macular
Degeneration (ARMD)

13. Age Related Macular
Degeneration (ARMD)
• Atrophic (dry) ARMD
• Slow progressive atrophy of RPE and
photoreceptors
• Three stages
• Early - small to few medium size drusen with no
symptoms or vision loss
• Intermediate – many medium size drusen with one
or more larger drusen symptoms of decreased
central vision noted
• Advanced dry – in addition to drusen, a breakdown
of photoreceptors in macular causes reduced central
vision

17. Age Related Macular
Degeneration (ARMD)
• All people who have wet form had
intermediate stage of dry form first
• No way to tell if dry form will turn into the
more severe wet form
• Dry ARMD can turn into wet ARMD at any
time

18. Age Related Macular
Degeneration (ARMD)
• Exudative (Wet) ARMD
• Fibrovascular tissue growing from
choriocapillaris, through defects in Bruch
membrane, into sub-RPE and subretinal space.
• Means abnormal new blood vessels grow
behind the retina/macula. Fragile and leak
blood and fluid.
• Sudden meta-morphopsia or changes to present
defects early sign of progression to Wet form

19. Age Related Macular
Degeneration (ARMD)
• Exudative (Wet) ARMD
• Course:
• Hemorrhagic RPE detachment
• Hemorrhagic sensory retina
• Vitreous hemorrhage
• Disciform scarring
• Massive exudation
• Exudative retinal detachment

21. Age Related Macular
Degeneration (ARMD)

23. Age Related Macular
Degeneration (ARMD)
• Exudative (Wet) ARMD
• Treatment:
• Injections – anti-VEGF
• Blocks vascular endothelial growth factor (VEGF) which
promotes new abnormal vessel growth
• Usually multiple injections monthly
• Photodynamic therapy
• IV with active laser destroying new blood vessel growth
• Laser surgery
• Focal laser to stop leaking of new blood vessel growth

24. Age Related Macular
Degeneration (ARMD)

25. Age Related Macular
Degeneration (ARMD)
• Amsler Grid
• Still best way to screen for macular disease
• Tests central 10 degrees/central fixation
• Patient complains of obstructing central vision
scotoma (positive scotoma)
• Wavy/distorted lines
• Optic nerve disease presents as a hole in central
vision (negative scotoma)
• Missing lines

26. Age Related Macular
Degeneration (ARMD)

27. Age Related Macular
Degeneration (ARMD)
• Age-Related Eye Disease Study (AREDS)
• Studied population for 10 years
• High levels of antioxidants and zinc
significantly reduce the risk of advanced
ARMD and its associated vision loss
• High risk of developing advanced ARMD
lowered their risk by about 25%
• First demonstrated treatment for people at high
risk developing advanced ARMD
• Not a cure, will not restore vision already lost just
delay onset of advanced ARMD

28. Age Related Macular
Degeneration (ARMD)
• Age-Related Eye Disease Study (AREDS)
• No reduction in progression of no ARMD to
early or early to intermediate ARMD
• Diet alone will not provide same high levels of
minerals
• Multivitamins do not contain same high levels
of minerals

29. Age Related Macular
Degeneration (ARMD)
• Age-Related Eye Disease Study (AREDS)
• Multivitamins can be taken with AREDS
formulation with physicians approval
• Eating a diet rich in green, leafy vegetables and
fish showing lower risk of developing ARMD
• AREDS II – release date 2013
• Added lutein, zeaxanthin and omega -3 fatty
acids DHA and EPA