Macular Degeneration - Dr James Beatty

1. Macular Degeneration
Dr James Beatty

2. Introduction
• Disease of the macular
– The macula is responsible for the fine central
vision in the eye that is needed for driving a
car, reading fine print, recognising faces, etc.
– Loss of central vision
• Most common cause of irreversible
visual loss in the western world in
individuals over the age of 50yrs

3. Introduction

4. Introduction

5. Introduction

6. Introduction

7. Introduction

8. Prevalence
• Most common cause of irreversible visual
loss in the western world in individuals over
50 years
• 65-75yrs - 11% some central vision loss
• >75yrs - 30%
• Two types
– Dry (atrophic) most common 85-90%
– Wet (exudative or neovascular) 10-15%

9. Prevalence

10. Prevalence

11. Risk Factors

12. Risk factors
■ Age
■ Family history. ARMD is, at least in part, an inherited disease.
Relative with ARMD then life time risk increases from 12% to 50%
■ Smoking. Current smokers have a 2–3-fold increased risk of AMD
with vision loss, compared with people that have never smoked.
■ Hypertension. There is an association between hypertension and
wet ARMD.
■ Race. ARMD is more common in Caucasians.
■ Female gender. Wet ARMD is more common in women.

13. Risk factors
■ Light exposure.
Excessive light exposure can damage the retina, but it is difficult to
quantify.
■ Diet poor in antioxidants.
A high intake of fats may increase the risk of advanced ARMD.
On the other hand a diet rich in fish and antioxidant nutrients has
been shown to lower the risk of ARMD.
In the Beaver Dam Eye Study, high dietary intake of carotenoids,
vitamin E and zinc was associated with a lower risk of ARMD.
• Carotenoids are red and yellow pigments found in plants, and include
zeaxanthin,lutein and beta-carotene.

14. Pathophysiology

15. Drusen
• Deposition of waste
material under the
retina
• Often but not always a
precursor to ARMD

16. Drusen

17. Two patterns
• Dry or Atrophic
• Wet or Exudative

18. Dry ARMD
• Presentation
– Most common, slowly progressive
– Gradual decrease in vision
– Often asymmetrical

19. Dry ARMD
• Signs
– Drusen
– Hyperpigmentation(RPE) or
atrophy(photoreceptors)
– Enlagement of these areas with visualization of
the choroidal vessels

20. Dry ARMD

21. Dry ARMD
• Slow progressive
atrophy of the
photoreceptors, retinal
pigment epithelium
and choriocapillaris

22. Wet ARMD
• Less common but devestating
• Caused by choroidal neovascularization
from the choriocapillaris, which break
through defects in Bruch’s membrane.
• May form a membrane under the RPE or
retina.
• Eventually leads to scaring

23. Wet ARMD
• Presentation
– Metamorphopsia
– Decreased vision (often sudden)

24. Wet ARMD
• Signs
– Retinal thickening or
elevation
– Haemorrage
– Exudate
– Often a grey/green
colour

25. Wet ARMD

26. Wet ARMD

27. Wet ARMD

28. Wet ARMD
• Course
– Relentless with very poor prognosis
• Haemorrhagic PED
• Vitreous haemorrhage
• Subretinal scaring
• Massive exudation

29. Symptoms
• Visual acuity

30. Symptoms
• Scotoma

31. Symptoms
• Metamorphopsia

32. Examination
• Fundoscopy

33. Examination
• Amsler Grid

34. Examination
• Metamorphopsia and
scotoma

35. Special investigations
• Fluorescein angiogram
• OCT

36. Normal FA

37. Dry ARMD

38. Wet ARMD

39. Wet ARMD

40. OCT

41. OCT

42. OCT

43. OCT

44. OCT

45. Treatment
• Argon laser
– MPS study
– Extrafoveal or
juxtafoveal
– Reduces the chance of
sever visual loss
– 50% recurrence

46. Argon laser

47. PDT
• PDT (photodynamic
therapy)
– Verteporfin
– Light activated
compound that targets
the neovascularization
– But does not damage
the retina
– Some stability and
some improvement of
vision

48. Surgery
• Surgery
– Submacular surgery
– Macular translocation
– Pneumatic displacement of submacular
haemorrhage

49. Submacular surgery

50. Macular translocation

51. Macular translocation

52. Macular translocation

53. Pneumatic displacement of Hx

54. VEGF inhibitors
VEGF: Vascular endothelial growth factor
• Main regulator that promotes angiogenesis
• Excessive amounts of VEGF are found in excised
specimens of neovascular ARMD
• VEGF promotes increased vessel permeability, endothelial
cell proliferation and inflammation.
• VEGF inhibitors target VEGF receptors

55. VEGF inhibitors
– Macugen
– Lucentis
– Avastin

56. VEGF inhibitors

57. VEGF inhibitors

58. VEGF inhibitors

59. VEGF inhibitors
• Unfortunatly most patients require these
infections on an ongoing basis
• Future
– Implants
– VEGF trap
– Gene therapy

60. Prevention
• AREDS study
– Patients at high risk benefited from taking
supplements with a specific formulation of
vitamins and antioxidants
– Vit C, E and Zinc
– Beta carotene, Lutine, Zeaxanthine
– Ocuvite and ocuvite with lutine

61. Supportive therapy

62. Supportive therapy

63. Supportive therapy

64. Supportive therapy

65. Burden of illness
• Vision loss can devastate lives.
■ Visual impairment is associated with declining physical function and
depression
■ Vision loss increases the risk of co-morbid conditions and increases
mortality
■ Clinicians may underestimate the impact of vision loss on patient’s
functioning and well-being.

66. Burden of illness

67. Burden of illness

68. Conclusion
• ARMD is the leading cause of blindness in the
over 50s in the developed world
• There are essentially two main types of ARMD –
dry and wet
• Drusen, pigment and atrophy are features of early
and dry ARMD
• Neovascularization is a feature of wet ARMD

69. Conclusion
• Vision loss progresses slowly in dry ARMD, but
more aggressively in wet ARMD, which accounts
for 90% of severe vision loss in ARMD
• VEGF is the main factor promoting angiogenesis
• VEGF promotes increased vessel permeability,
endothelial cell proliferation and inflammation
• VEGF is found in high consentrations in eyes with
wet ARMD

70. Conclusion
• Symptoms of ARMD include metamorphopsia,
scotoma, loss of contrast sensitivity, and loss of
visual acuity.
• The amsler grid is a useful screening tool for
macular function.
• Fundus examination is key to diagnosis.

71. Conclusion
• OCT provides cross sectional images of the retina,
very valuable in monitoring treatment.
• Loss of vision translates into loss of function, loss
of independence, depression and susceptibility to
falls and accidents.
• New treatments with VEGF inhibitors can
stabalize the retina and improve vision.

72. Thank you
Questions?