This case presentation summarizes the medical history and ocular examination findings of a 69-year-old Filipino woman. She has a history of hypertension, cataract surgery, and is a former smoker. Her ocular exam revealed decreased vision and color perception in both eyes consistent with age-related macular degeneration. Based on her clinical features and angiography results, she was diagnosed with non-neovascular age-related macular degeneration. Risk factors, screening, and management options for this common cause of vision loss were discussed.

1. CASE
PRESENTATION
Department of Ophthalmology
October 13, 2010

4. GENERAL DATA
•ZN, 69/F
•Bauang, LU
•Filipino
•Catholic
•Date of consult-November 2008

6. OCULAR PAST MEDICAL FAMILY PERSONAL
HISTORY HISTORY HISTORY AND
SOCIAL
HISTORY
2007-Cataract (+) HPN x 5 yrs (+) HPN Previous
extraction, OU metoprolol (-) DM smoker
No other (-) DM (-) Ca Non alcoholic
ocular disease beverage
drinker
housewife

7. • REVIEW OF SYSTEMS
• PHYSICAL EXAMINATION

8. OCULAR EXAMINATION
OD OS
Visual acuity 20/70-20/30 20/200- NI
IOP 10 10
Ocular adnexae E/N E/N
AC Deep and quiet Deep and quiet
Lens IOL in place IOL in place
EOM intact intact
pupils 3-2 mm 3-2 mm
(-) RAPD (-) RAPD
Color perception (+) RGB (-) blue

9. AMSLER GRID

10. Dilated Fundus Exam

11. • Fasting blood sugar
• Fluorescein Angiography

12. SALIENT FEATURES
• 69 y/o
• Blurred vision with metamorphopsia
• History of smoking
• hypertensive
• Decreased color perception
• (+) drusen, RPE atrophy

13. AGE- RELATED MACULAR
DEGENERATION, NON-
NEOVASCULAR

14. AGE- RELATED MACULAR
DEGENERATION
• Leading cause of IRREVERSIBLE vision loss in
the developed countries
• 4th common cause of vision loss in Phil
• Autosomal dominant disease affected by
nutritional and environmental factors
• bilateral

15. • I. Dry/ Non- exudative/Non-
neovascular AMD- 90%
• II. WET/Exudative/Neovascular-
10 %

16. CHANGES DURING AGING
REDUCED DENSITY AND DISTRIBUTION OF
PHOTORECEPTORS
INVOLUTIONAL CHANGES IN THE
CHORIOCAPILLARIES

18. RISK
FACTORS

19. FAMILY HISTORY
• Relatives w/ AMD- 50%
• (-) relatives w/ AMD- 12 %
GENETIC MUTATIONS:
• CFH gene ( Ch.1)
• BF and C2 ( Ch. 6)
• LOC ( Ch. 10 )

20. Framimgham Eye Study:
• 65- 74 y/o- 6.4%
• >75 y/o- 19.7 %
• >80 y/o- 6x

21. DRUSEN
• Most important risk
factor
• Small, round, yellow
lesions
• Composed of
vitronectin, lipids,
immune and
inflammatory related
proteins

22. CLINICAL PRESENTATION

25. SCREENING
• Amsler grid
• Macular Photostress Test
• Color perception test
• Kollner Rule-
– Optic nerve- RED, GREEN
– Retina – BLUE, YELLOW

26. DIAGNOSTIC
OPTICAL COHERENCE
FLUORESCEIN ANGIOGRAPHY TOMOGRAPHY

27. CHOROIDAL NEOVASCULARIZATION
Most common cause
of visual loss

28. MANAGEMENT
• NO definitive treatment
• DETERMINE PERSONS WHO WILL DEVELOP
ADVANCED ARMD
• Goal: prevent development of
neovascularization

29. Age- Related Eye Disease Study
• Vitamin A ( Beta Carotene)- 15 mg
• Vitamin C- 500 mg
• Vitamin E- 400 IU
• Zinc- 80 mg
• Copper- 2 mg

30. AREDS
Antioxidants plus Zinc alone Antioxidants alone
zinc
Reduced risk of
developing AMD by
25% 21% 17%
Reduced risk of
vision loss by
19% 11% 10%

31. Who will benefit from high- dose
antioxidants?
• Extensive intermediate drusen
• At least 1 large druse
• geographic atrophy
• Advanced AMD in one eye

32. LUTEIN
“Dietary lutein/zeaxanthin intake was inversely
associated with neovascular AMD”
-The Relationship of Dietary Carotenoid and Vitamin A, E, and C Intake With Age-Related Macular Degeneration
in a Case-Control StudyAREDS Report No. 22
• Age-Related Eye Disease Study Research Group*
• Arch Ophthalmol. 2007;125(9):1225-1232

33. “visual function is improved with lutein alone or
lutein together with other nutrients”
• Double-masked, placebo-controlled, randomized trial of lutein and antioxidant supplementation in the intervention of
atrophic age-related macular degeneration: the Veterans LAST study (Lutein Antioxidant Supplementation Trial).
• Richer S, Stiles W, Statkute L, Pulido J, Frankowski J, Rudy D, Pei K, Tsipursky M, Nyland J.
• Department of Veterans'Affairs, Medical Center Eye Clinic, North Chicago, Illinois 60064-3095, USA.
stuart.richer1@med.va.gov

34. PROPHYLACTIC LASER
PROPHYLACTIC TREATMENT OF AMD TRIAL (PTAMD):
̋ Patients treated wih prophylactic laser were more likely to have
a CNV event ( 21%) than were the observed patients at 18
months ( 14%) ̋
COMPLICATIONS OF AGE- RELATED MACULAR
DEGENERATION PREVENTION TRIAL ( CAPT)
Incidence of late AMD was 19.7% in treated eyes and 20.4 % in
untreated eyes, incidence of CNV was 13.3% for both groups

35. RHEOPHERESIS
• - An extracorporeal blood filtration procedure that
removes circulating macromolecules from the blood
MULTICENTER INVESTIGATION OF RHEOPHERESIS OF
AMD( MIRA-1)
‘No statistically significant benefit of rheopheresis over sham
treatment’

36. TREATMENT OF NEOVASCULAR
ARMD

37. Laser Photocoagulation
MACULAR
PHOTOCOAGULATION
STUDY
• Treatment did not decrease
the chance of maintaining
good VA or vision within 1.5
lines of VA before the
treatment

38. Photodynamic therapy
TREATMENT OF AMD
WITH PHOTODYNAMIC
THERAPY
-‘59 % of PDT treated eyes
versus 31% (placebo)
avoided moderate vision
loss’
• Visudyne in Minimally
Classic Trial
• Vertoporfin in
Photodynamic Therapy
study

39. Anti- VEGF
• MARINA Study
ANCHOR STUDY
• 95% of Ranibizumab
-95% vs 64% of PDT
treated patients
treated patients
experienced visual
maintained/ improved
vision- 12 mos vs 62% of
improvement
-90% vstreated patients
sham 65.7 % after 24
mos
-41% of patients improved
3 lines after 24 mos

40. • After a year…
• VA- 20/100, OD HM, OS

41. “Age is an issue of mind
over matter.
If you don't mind, it
doesn't matter.
~Mark Twain