This document discusses macular degeneration (AMD), including its causes, types (dry and wet), investigations like OCT and fluorescein angiography, symptoms, signs, and treatments. It notes that dry AMD accounts for 80-90% of cases and involves drusen and retinal pigment epithelium changes, while wet AMD involves choroidal neovascularization, leakage, and vision loss. Treatments discussed include nutritional supplementation based on AREDS trials, regular anti-VEGF injections for wet AMD, and monitoring for dry AMD.

1. Raj Chalasani FRANZCO
Cataract Surgeon and Retinal Specialist
Hills Eye Surgery Pennant Hills
Staff Specialist Westmead Hospital

3. Macular Degeneration
 Disease of:
 Retinal pigment
epithelium
 Bruch’s membrane
 Choroid
 These structures
support photoreceptors
 Accumulation of waste
products
 Drusen
 Common starting point
for different types of
AMD

4. Dry AMD
 80-90% cases
 Drusen
 Disruption of RPE
function
 Atrophy of
photoreceptors
 End stage is
geographic atrophy
Loss of central vision

5. Wet AMD
 Drusen
 Disruption of RPE function
 Disruption to Bruch’s membrane
 Increased VEGF expression
 New vessel formation from choroid into retina
Choroidal neovascularisation (CNV)
Leak
Bleeding
Scarring
Disruption of normal architecture and photoreceptors
Loss of vision

6. Wet AMD

7. AMD – Key Investigations
 Optical coherence tomography (OCT)
 Cross sectional image of the macula

8. AMD – Key Investigations
 Fluorescein
angiography
 Identify CNV
and obtain PBS
funding for
treatment

9. Presentation
 Age > 60
 Symptoms
Reduced central vision
Distortion
Central scotomata
Reduced contrast
sensitivity

10. Presentation
 Age > 60
 Symptoms
Reduced central vision
Distortion
Central scotomata
Reduced contrast
sensitivity
 Signs
 Drusen
 Haemorrhage
 Exudate
 Sub/intraretinal fluid
 Fibrosis

11. Treatment – Dry AMD
 Delay Progression
Stop smoking
Nutritional advice
○ Low risk
Balanced diet
○ High risk
Supplementation
- Vit C,E
- Zn, Cu
 Early detection
Amsler grid
 Support
Vision Australia
Visual aids
Access to
benefits/support

12. Treatment – Wet AMD
 Anti-VEGF agents
Lucentis®
Eylea®
 Regular intra-vitreal
injections
Maintains vision in
90%
Improves vision in 30-
40%

14. Case
 Mr LS
 89 yo male
 4 day history of blurred vision LE and
‘edges looking crooked’
 PMhx
HT
Hypercholesterolaemia
 POHx
Bilateral cataract surgery 10 years ago

15. Examination
 Vision
RE 6/9
LE 6/18
 Normal IOP
 Anterior segment unremarkable

16. Examination
 Amsler

20. “I read in the
newspaper that aspirin
can cause AMD”
“Should I stop taking
my aspirin?”

21. Aspirin and AMD
 JAMA Intern Med. 2013; 173(4): 258-264
 2389 participants BMES
 Followed prospectively for 15 years
 257 ‘regular’ aspirin users
 One or more per week in the past year
 Wet AMD in 63 patients
 OR (Age/Sex/Smoking/CVD/BMI/SBP adjusted) 2.46 (CI
1.24-4.83)

22. Aspirin and AMD
 Literature – conflicting results
 Well designed study with limitations
Not randomised
Association not causation
Only 56% patients available for f/up at 15
years
Limited number of wet AMD cases (63)
 Not enough evidence to change clinical
practice

23. “My friend is on
macuvision”
“Should I be taking
a supplement?”

24. Nutritional Supplementation
 AREDS 1
Vit C 500mg
Vit E 400 IU
Zinc 80mg
Copper 2mg
(Beta-carotene
15mg)
 25% reduction in
risk of progressing
to advanced AMD
over 5 years
Only for those at
‘high risk’
No benefit for those
at “low risk”

25. AREDS 2
 Designed to assess
Antioxidants
○ Lutein (10mg)
○ Zeaxanthin (2mg)
Omega 3 fatty acids
○ Docosahexaenoic acid (DHA 350mg)
○ Eicosapentaenoic acid (EPA 650mg)

26. AREDS 2
 4203 participants aged 50-85
 At high risk for progression
 Followed for 5 years
 All got AREDS 1 plus either antioxidants
or omega 3 or both
 Outcome measure
Development of “Advanced AMD”
○ GA
○ Wet AMD

27. Results
 No difference between placebo vs
antioxidants vs omega 3 vs antioxidants
+ omega 3
 Modest effect for lutein/zeaxanthin in
reducing advanced AMD in the 20%
most undernourished patients

28. Take Home Point
 Think of AMD in an older patient with
macular symptoms
Early treatment in wet AMD improves outcome
Early referral in dry AMD allows counseling