1. Age Related Macular Degeneration (AMD)
in the Asia Pacific Region:
Where do we stand ?
Rumita S. Kadarisman MD1, Gitalisa Adriono MD2,
Mario Hutapea MD2
1R.S MataAINI Prof DR Isak Salim, Jakarta, Indonesia
2Dept of Ophthalmology, Dr Cipto Mangunkusumo Hospital,
University of Indonesia, Jakarta,Indonesia
Asia Pacific AMD 1st Meeting , Singapore, 2012

2. AMD
 Many definitions in epidemiology studies
making comparison difficult
 Classification and Grading, complicated by
large variation in location,size,number and
types of lesions

3. AMD Definition
 AMD is a degenerative retinal disease that can cause
central vision loss and lead to legal blindness in
Western and Asian countries
 AMD is the leading cause of permanent visual
impairment among the elderly (severe vision loss in
people >50 years of age) in theWestern and Asian
countries
3
Friedman et al,Vision Problems in the US: Prevalence of AdultVision Impairment and Age-Related Eye Disease in America. 4th ed. Prevent
Blindness America; 2002
Vingerling et al, Epidemiol Rev 1995; 17: 347
Ferris et al, Arch Ophthalmol 1984; 102: 1640

4. AMD classifications and grading
 TheWisconsin Age Related Maculopathy
Grading with 5 gradings (grade 0-4).
- Grade 0-3 Early AMD
- Grade 4Late AMD
 The International Classification and Grading
of Age Related Maculopathy
 The Age Related Eye Disease Study (AREDS)
with 4 categories

5. Risk factors for AMD
5
 Age (Vingerling et al, 1995)
 Genetic factors
 AMD is, at least in part, an inherited disease (AREDS, 2000)
 certain phenotypes have heritability (Hammond et al, 2002)
 the complement Factor H Gene (Klein, 2003)
 Smoking
 cigarette smoking has been shown to increase the risk of
AMD in a dose-dependent fashion
(AREDS Study Research Group, 2000)
 Hypertension and cardiovascular disease (AREDS, 2000)
 Gender
 Race
 High cholesterol (Vingerling et al, 1995)
 Low intake of antioxidants / lutein (AREDS, 2001)

6. AMD diagnosis
 History (duration and characteristics, visual
symptoms, metamorphopsia, scotoma)
family history, risk factors
 VA (logMAR preferrable to Snellen)
 Stereoscopic biomicroscopic fundus
examination (78D or similar lens)
 Fundus Photography
 Fundus Fluoresence Angiography (FFA) w/wo
IndoCyanine Green Angiography (ICGA)
 Optical CoherenceTomography

7. Studies to investigate Prevalence
and risk factors of AMD
InWestern population
 The Framingham Eye Study
 The Beaver Dam Eye Study
 The Blue Mountain Eye Study
 The Rotterdam Eye Study
 The EUREYE
 The Reykjavic Eye Study
 The Eye Disease Study

8. Prevalence of AMD
8
Beaver Dam
Eye Study
1988–2005
(3.1%–14.3%)
Framingham
Eye Study
1973–1975
(1.6%–28%)
Rotterdam
Eye Study
1990–1993
(0.2%–11%)
Blue Mountains
Eye Study
1992–1993
(2.8%–10.8%)
3-year incidence of AMD 9.4–11.4 per 1000
Klein et al,Ophthalmology 2007;114:253
Kahn et al, Am J Epidemiol 1977;106:17
Vingerling et al, Ophthalmology 1995; 102:205
Wang et al, Ophthalmology 2007;114:92
Javitt et al,Ophthalmology 2003;110:1534

9. Studies to investigate Prevalence
and Risk factors of AMD
Multiracial
 USA multiracial population study
 Arizona Hispanic people study
 The Los Angeles Latino eye study
Multiethnic
 The Singapore Multiethnic Asian study
Ethnic
 The Hasayama study (Japan)
 The Singapore Malay Study
 The Central India eyes and medical study
 Risk Factors for AMD in eldery Cinese population of Shenyang
in China

10. A S I A
 The largest continent with a population of
almost half of the world population
 Almost 2.000.000 blind population
 Prevalence of bilateral blindness in
developing countries 0.3-4.4%
 Mongoloid race, 4% ofWorld population
400.000.000 are in South East Asia

11. AMD in Asia
 AMD is also a major cause of blindness in Asian
countries, and the number is growing
 With more information on recent studies AMD
has its own prespectives in terms of:
epidemiology,genetics,phenotype presentation,
clinical subtype and management
 Asia has mixed populations of different races
and ethnics
 Different dietary intake, enviromental and
maybe other factors might account for the
disparity in prevalence among Asians

12. AMD in Asian populations
 Genetics of AMD in Asian populations are
different compared toWestern population
 TheY402H is present in 34.9% of Caucasian
population but low in Chinese and Japanese
population
 The CFH polymorphismTyr402His is strongly
linked to AMD in Indian population

13. Prevalence and Risk factors of AMD in
Asian populations
Study Early AMD (%) Late AMD (%)
The Hisayama Study (Japan) 12.7 0.9
The Beijing Eye Study (China) 1.4 0.2
The Shihpai Eye Study (Taiwan) 9.2 1.9
The Singapore Malay Study (Singapore) 4.9 0.7
Andra Pradesh Eye Study (India) 1.9
Jakarta Urban Eye Health Study (FKUI)
Indonesia
4.2 0.1

14. Prevalence and Risk factors of AMD in Asian
populations
Study Early AMD
(%)
Late AMD
(%)
Handan Eye Study (China) 3.0 0.1
Funagata (Japan) 3.5 0.5
Pakistan
2.1-8.7
Bangladesh
Nepal
Indian subcontinent 1.8-4.7
INDEYE feasibility Study 1.4
Yogjakarta (Indonesia) 1.11
Korea 3.08
Thailand 7.4

15. AMD studies in Asia

16. AMD in Asian populations
Diagnosis
Fundus Fluorescein Angiography
 Exudative AMD: - Classic
- Occult
Recently clinical subtypes of AMD are found
Indocyanine Green Angiography
 Polypoidal ChoroidalVasculopathy (PCV)
 Retinal Angiomatosis Proliferation (RAP)

17. AMD in Asian populations
Treatment
Preferred treatment for Excudative AMD and
subtypes of AMD:
 Ranibizumab
 Bevacizumab
 Combined with otherTreatment modalities
Depending on:
 Accessibility in the medical system
 Affordability
 Physician preference

18. Indonesia
 An Archipelago of 17.000 islands
 Population 237.424.363 ( census 2010 )
248.216.193 ( 2012 )
 Age structure
0-14 years 27.3%
15-64years 66.5%
65 years and over 6.1%
 Life expectancy
male 69.07 years
female 74.29 years
 Ophthalmologists 1.179 ( 2011)
 Population growth
254 milion by 2020
288 milion by 2050

19. AMD/AMD Studies in Indonesia
 Prevalence of AMD inYogjakarta Province
(2005)
 Jakarta Urban Eye Health Study (2008)
 Prevalence of AMD in Dept of Ophthalmology
Cipto Mangunkusumo Hospital,Jakarta(2012)

20. Indonesian National Guideline
for the management of AMD (2012)
 Definition
 Classification
 Risk factors
 Clinical findings
 Diagnosis
 Treatment

21. Perception of AMD
 The negative effect of AMD on quality-of-life can
be underestimated by1
 non-ophthalmic physicians
 by the public
 even by ophthalmologists who treat patients
with AMD
 The assessment of quality-of-life may be an
important factor in patients’ perception of overall
outcome of any therapy2
21
1Brown et al, Can J Ophthalmol 2005; 40(3): 277
2Mitchell and Bradley, Health Qual life Outcomes 2006; 4: 97

22. AMD impacts the patient
(physical burden)
 More likely to have difficulty with daily
activities such as meal preparation,
handling money, and using the telephone
 Increased risk of recurrent falls
 Experience more depression and emotional
distress than those without AMD
 Potentially as debilitating as other chronic
disabling diseases, such as arthritis, chronic
obstructive pulmonary disease, and AIDS
 Health-related quality-of-life
questionnaires may detect problem areas
in function
22
Williams et al, Arch Ophthalmol 1998; 116: 514
Ivers et al,J Am Geriatr Soc 1998; 46: 58
Brody et al, Ophthalmology 2001; 108: 1893

23. Conclusions
 The magnitude and awareness of AMD is
growing.
 some studies in Asia shows the
prevalence of AMD in Asian studies
compared to European studies is quite
similar,but Risk Factors vary, some
conflicting
 Accurate diagnosis of AMD subtypes are
important for appropiate management

24. Conclusions
 PCV constitues a high precentage of
patients with ExcudativeAMD in Asian
Population
 Life expectancy is increasing . Besides the
physical burden, cost of the longlife
treatment will be a social and financial
burden which
 increasing awareness towards AMD
should be a prority

25. Thank you