PRESENTED BY:

ANIS SUZANNA BINTI MOHAMADOptometrist and Contact Lens Consultant

B.Sc (Hons) Optometry UKM

Healthy retina

ANATOMY OF RETINA

AGE RELATED MACULAR DEGENARATION

• Definition:– A DEGENERATIVE eye disease that AFFECT

MACULA– which responsible to the central vision

• Types of ARMD– Early stage– Late stage

• Dry ARMD• Wet ARMD

• Bruch membrane become less permeable– Blocks nutrition from RPE, prevent waste product from

retina escaping• The quality of retina deteriorate (dry armd)• New blood vessel are stimulated into retina to clear away

the waste products (wet armd)

Early stage ARMDSIGN• Drusen

– Discrete yellow spot at macula– The accumulation occurs as bruch's membrane

becomes thicker• prevents the free flow of materials to and from

photoreceptors layer. – Also, the retinal pigment cells accumulate

lipofuscin. • This pigment will also slow down the passage of

chemicals to and from the retina.

SYMPTOM• Usually has normal vision• Difficult driving, recognizing dimly road sign– Loss of rod photoreceptors (earlier than cones)

Late stage: DRY ARMD• Slowly progressive atrophy of

photoreceptor, RPE, and choriocappilaries• Tissue has thinned and lost pigment

• Also known as atrophic AMD, nonexudatives AMD, nonvascular AMD

• Progress over month, years

• Bilateral– Severity and progress may

different between BE

• SIGN– Usually assoc with hard

drusen• Small, round, discrete, yellow

white spot asocc with focal disfunction of RPE

– Atrophy of RPE

– Enlargement of atrophic area, pre-existing drusen appear, choroidal vessel visible geographic atrophy

Geographic atrophy

Dry ARMD

• SYMPTOM– Slow and progressive loss central vision• Called central scotoma

– Vision distorted• Called metamhorphopsia• Drusen has expand and increase in no.

Late stage: Wet ARMD• New blood vessel growth

underneath the retina

• body's misguided way of attempting to create a new network of blood vessels – to supply more nutrients

and oxygen to the retina.

• Called choroidal neovascularization (CNV)– leak fluid under the macula– then form scar tissue

leading to central vision loss.

• Also known as exudatives AMD, neovascular AMD

Sign • Soft drusen appear

– Larger and have indistinct margin– May slowly enlarged and coalesce to form solid

drusenoid detachment of RPE

• area of the macula is elevated by subretinal fluid or blood, often associated clumps of exudates

Soft drusen in wet ARMD Wet ARMD or neovascular ARMD

• Symptom

– Profound central vision impairment• Sudden decrease (weeks)

– Vision distorted

Risk factors

1. Aging2. Smoking3. Obesity and inactivity4. High blood pressure5. hereditary

Complications of ARMD1. Decreased contrast sensitivity2. Decreased visual acuity3. Metamorphopsia4. Central scotoma

Decreased contrast sensitivity

– It occurs at early phase of onset.

– The macular at this stage has discrete yellow spots or drusen.

– The hyperpigmentation of RPE can decreased contrast sensitivity of the eye.

Decreased visual acuity – Common in late

stage.– It is due to slowly

progressive atrophy of photoreceptors, RPE and choriocapillaries.

– RPE detachment can occur.

– The gradual vision impairment occurs gradually over months or years.

– Normally both eye is affected but asymmetry.

Metamorphopsia

• It occurs due to thickened Bruch membrane of the eye.

• It may cause unilateral metamorphosia and lead to impairment of central vision.

Patient complains of all the object seen smaller than actual size. (micropsia)

Central scotoma– It occurs when the

foveal area is affected.

– The scotoma, or central blind spot, can be due to geographic atrophy or to the damage of photoreceptor cells from choroidal neovascularization (leaking blood vessels).

Patient complaints of difficult to recognize the face

Clinical manifestations of age-related macular Clinical manifestations of age-related macular degeneration degeneration

Phase Clinical manifestation Associated visual defect

Early stage

Focal drusenIrregular pigmentations of the retinal pigment epithelium

Good visual functionAbnormal dark adaptationReading problem in dark roomBlue-yellow defectDriving car at night is impaired

Late stage

Detachment of the retinal pigment epitheliumRip in the retinal pigment epitheliumChoroidal neovascularizationDisciform scarGeographic atrophy of the RPE

Decreased visual acuity

MetamorphopsiaCentral scotoma

EARLY DETECTION OF ARMD

• Purposes: – To monitor the progression of the sign of

small drusen form in the macula.– Can give appropriate management to the

patient according to their stage. – To prevent the dry ARMD progression from

develop into the wet ARMD.–Wet ARMD is progresses much more quickly

and can cause severe damage of vision.

Spontaneous modifications of drusen

Drusen Drusen

Choroidal neovascularizationChoroidal neovascularization

RPE detachmentRPE detachment

Geographic atrophyGeographic atrophy

Disciform scarDisciform scar

ASSESSMENT OF AGE-RELATED MACULAR DEGENERATION

Patient’s History• Purpose:

– A careful review of the patient’s family history can help differentiate the ARMD or the other macula associated disease.

• Questions:– Chief complaint

• Ask patient about chief complaint carefully.- onset and course of symptom.

– Symptoms • Ask patient whether they have see object blurred or distorted.• Ask patient if they notice any missing part or wavy of a straight

line.• Ask about glaring problems especially when driving at night,

early morning or early-evening hours

– Ocular history– Medications and allergies– Family History

• Any family members have the ARMD disease?

Ocular Examination• Visual acuity

– Pinhole visual acuity test• Contrast sensitivity

– loss of contrast sensitivity at high spatial frequencies

– loss of peak contrast sensitivity with increasing drusen severity

• Pupillary responses – To differentiate the central scotoma due to optic

nerve disease or macular disease• Biomicroscopy

– to examine other factor that contribute to disability glare

• Color Vision- For screening and diagnosis of color vision

defect on the ARMD patient.

Visual acuity• At early onset of the disease, visual acuity will be

slightly decreased. (VA=<6/9)• Pinhole visual acuity must be done at distance with

habitual correction.

The expected findings:• If the patient decreased visual

acuity due to pathological

disease such as ARMD, pinhole

visual acuity is no improvement

and possibly a further decrease

will occur.

• A refraction should improve

acuity level of the patient at

least to the level obtained

through the pinhole.

Contrast sensitivity• Patient with ARMD is often complaint of

blurring at distance, difficulties to see face and road signboard due to decreased in contrast sensitivity.

• Contrast sensitivity reduced when there are changes happened on RPE.

• Test for contrast sensitivity must be done in order to see the severity of the morphological changes at the macular.

• Expected findings:– Patient with ARMD usually demonstrates

profound loss of acuity on contrast sensitivity test.

Contrast sensitivity can be measured with the use of a contrast sensitivity chart (A) or neutral density

filters (B).

(A) (B)

Color Vision• Color vision test:

– Clinical screening: Ishihara plate.– Diagnosis: D-15 Color Test or FM 100 Hue Test

• Purpose: – To detect the color vision defect that occur in

ARMD patient either red –green or blue-yellow defect.

– To classified as congenital or acquired color defect.

• Expected findings:– Most of the ARMD patient suffered yellow-blue

defect.– But patient must be differentiate with other

macular disease such as diabetic retinopathy.

Supplemental testing• Visual Field – Facial Amsler – Amsler grid– Goldmann perimetry– Automated Perimetry

• All Fundus Related Procedures• Fundus Biomicroscopy• Fundus photography• Opthalmoscopy• Fundus Fluorescein angiography• Optical coherence tomography (OCT)

Visual FieldThere are number of different ways to evaluate the visual field of age-related macula degeneration patient. These include:

1.Facial Amsler2.Amsler grid3.Goldmann perimetry4.Automated Perimetry

No one type of visual field is good for all situations. 

Facial Amsler• Purpose:

– It is very useful for patient with cognitive impairment.

– Detect gross monocular visual field of the patient.

• The central visual field can then be tested by

asking the patient to report any defects in your

facial features while they look toward your nose.

Simultaneously present targets

• Purpose:– Alternative method to get grossly detection of patient’s

visual field– Patient have to report the existence of the object that

shown.– Each of the object held in different visual quadrant.

Amsler Grid• Purpose:

– It can give useful information regarding central scotoma, areas of missing, blurred, or distorted lines.

– It is sensitive to small scotoma within central 10° of visual field. 

– The test is also useful for differentiating neuro-ophthalmic and macular disease.   

Patient experienced deep dark spot at the center of the Amsler Grid

• Instruction:1. Hold the chart at a reading

distance of 30 cm; adequate and even lighting is important.

2. You should wear your fully prescribed spectacles and for elderly, their reading glasses, during the test.

3. Cover the left eye, and use your right eye to focus on the center dot.

4. If patient difficult to see the white dot at the center, ask them to imagine the intersect of the two line at the center.

5. Ask patient: Do you notice any wavy, broken or distorted lines or blurred or missing areas of vision within the chart?

6. Repeated the above examining on your left eye.

It is a 10 x 10 cm square grid formed by multiple white lines on a black background and with a white dot at the center.

Goldmann perimetry

• Advantages:– Ability to

directly monitor patient attention

– Present custom test points

– Test the complete visual field. 

Large central scotoma seen with Goldmann perimetry test.

Automated perimetry• It is difficult to do with

patient ARMD because they reduced in contrast sensitivity.

• The test can be done on short-wavelength automated perimetry.

• If possible to be done, the result is very useful especially in detecting presence of the central scotoma in advanced cases of ARMD. Automated visual field machines

allows standardized testing and statistical analysis .

All Fundus Related Procedures

I. Opthalmoscopy– Direct– Indirect

II. Fundus photographyIII.Fundus BiomicroscopyIV. Fundus Fluorescein

angiographyV. Optical coherence tomography

(OCT)

Fundus Related Examinations

• Purpose:– To see fundus and macula for both eyes.

• Clinical findings:Clinical features

Signs

Hard drusen(nodular)

Small, round, discrete, yellow-white lesions, and usually located at the macula.

Soft drusen(Exudative)

Larger lesions with ill-defined edges associated with exudative ARMD.

Non-exudative ARMD

Hyperplastic changes of RPE associated with slowly progressive degeneration of the overlying neuroretina and underlying choriocapillaries.

Exudative ARMD

Present with elevated macular area with subretinal fluid or blood associated with clumps of exudates. If the lesion recover, it will leave with subretinal ‘disciform’ scarring.

Fundus Fluorescein Angiography

• Purposes:– To see the leakage of the blood vessels

around the macula.– The test is done to help the doctor confirm a

diagnosis, to provide guidelines for treatment, and to keep a permanent record of the vessels at the back of the eye.

– This test carry out mostly in cases of advanced cases of ARMD for further treatment.

Procedure:• Pupil dilated with the

mydriatics drop before the florescein injected into the body.

• Fluorescein dye injected into bloodstream via hand or arm.

• Following the injection, the fundus photo are taken quickly within 60 seconds during dye enters blood vessels at the back of the eyes. Fluorescein Angiogram of ARMD

Optical coherence tomography (OCT)

– It useful in detecting small changes in retinal thickness, subretinal and sub-RPE fluid and choroidal neovascularization in ARMD.

– It also useful to monitor response to therapeutic intervention.

PREVENTION

• Using the Amsler grid may help detect subtle changes in vision

• A healthy lifestyle helps to prevent ARMD- Stop smoking- Regular exercise

- Reduce risk by 70%- Keep your blood pressure low

- Salt and more than 2 units of alcohol a day may cause BP to rise

- Avoid obesity- Take a balanced diet

- Fruit and vegetables- prevent 36-50% of ARMD- Oily fish twice a week reduces ARMD by 40%

- Vitamin supplementsEg. Antioxidants plus zinc

• Protect eyes from sun exposure with sunglasses

Management

1. Basic Treatment2. Available Treatment Options3. Patient Education4. Prognosis and Follow up

Basic Treatment

• There is NO CURE • T(x) : - slow the progression of disease - prevent the vision loss• Wet AMD : - a lot of treatments are available - mainly for stopping the growth of new blood vessels - if delayed t(x), scar formation

• Dry AMD: - no treatment available - does not involve new blood vessels growing - Low vision aids may be helpful

Treatment of Wet ARMD

1. Anti-VEGF treatment- The most recent treatment- Use anti-vascular endothelial growth factor

(anti-VEGF) drug such as Lucentis, Macugen, Avastin

- Injects into the eyeball (IV) under local anaesthetic

- Cause constriction and closure of the leaking blood vessels

- Prevent further damage of vision

Cont.. Begins with a course of three monthly

injections Monitor every months High success rate Most effective when treating blood vessels

that are ‘active’ or ‘leaking’ Stop sight getting worse Improvement of vision- 40% Complication: IOP, RD, eye infections

2. Photodynamic Therapy (PDT)

• A type of laser t(x)• Use a combination of a light sensitive drug

(Verteporfin) and a low energy (non -thermal) laser

• To stop new blood vessels growing• Adv: the ability to selectively damage tissue• Indication: classic CNV-subfoveal type• SE: transient decrease in vision, sensitivity to

bright light for 24-48 hours.

Classic sub-foveal CNV-Most people with neovascular ARMD have CNV in the centre of the retina

- Regular laser cannot be used as it would destroy the central vision

-Thus, photodynamic laser (PDT) is used.

-But still causing some vision loss

Yellow spot: fovea

Red area: CNV

Classic extra-foveal CNV

-CNV are not in the centre of fovea

-Can be treated by regular laser therapy

-Argon Laser Photocoagulation. High-energy laser light - used to destroy actively growing abnormal blood vessels

Photodynamic Therapy (PDT)

a) Small dirty grey lesion at the fovea surrounded by blood

b) Fundus Angiography venous phase shows hyperfluorescence from classic subfoveal CNV surrounded by a hypofluorescent ring

Photodynamic Therapy (PDT)

c) measurement of greatest linear dimension of the lesion;

d) FA 3 months following successful treatment shows hypofluorescence of the lesion

(Courtesy of S Milewski)

3. Anti-angiogenic drug - Used to slow down or prevent the growth of

the abnormal blood vessels within the eye- Eg. Intravitreal steroid (triamcinolone

acetonide)- SE: ocular hypertension, cataract

- Submacular: removal of the subfoveal CNV- Macular translocation: is aimed at surgically

moving the fovea away from the CNV

4. Surgery

5. Vitamin Supplements• Age-Related Eye Disease Study (AREDS) showed

that for certain individuals, antioxidants such as– 500 g of vitamin C – 400 IU of Vitamin E– 15 mg of beta-carotene – 80 mg of Zinc oxide– 2 mg of Copper

• can decrease the risk of vision loss in patients with intermediate to advanced dry age-related macular degeneration.

6. Refractive correction or low vision aids• Prescribe and increasing near addition for

reduced acuity in patient with macular degeneration

• Other options:- Telescope- Hand magnifiers- Enlarged size print- Enlarged screen size for television or computer

screen- Closed-circuit television (CCTV) or computer

magnification system

Advice for ARMD patient• Consume fruit on daily basis and quit smoking• Exercise regularly• Monitor vision- regular eye examination• Adapt to low vision- eg.making changes to

lighting, using contrast in objects that often used such as door frames and light switches, do labeling and marking medicines and food, and getting rid of potential hazards.

• Counseling, rehabilitation, and training can help with managing household, cooking, shopping, personal grooming and others.

• Develop a personal support network-deal with fear and anxiety-maintain quality of life

Prognosis and Follow up• Dry ARMD:- slow progression- keep most of the vision- may develop the wet form- pt should monitor vision

daily-KIV annually- attend to clinic immediately if signs of reduced

vision or distortion are noted.• Wet ARMD and have had laser treatment: - can be recur-should test vision to see if any blind

spots grow bigger or if any new blind spots appear.- New blood vessels can emerge months or years after

have had successful laser treatment.• If only one eye is affected: - A regular eye examination on the other eye is

needed to discover any sign of new problems.

Summary• ARMD is the most common cause of irreversible vision

loss in people over 50 years of age in Western countries.• 2 types of ARMD: a) Dry and b) Wet• Currently no other t(x) is available for dry ARMD except

of visual aids and lifestyle advice.• Early detection is critical for successful t(x) of wet

ARMD.• Consultation is very important – to cope with low vision • Rehabilitation and training can make their living with

low vision more easier and safer.

References• Jack J Kanski. 2007. Kanski Clinical Ophthalmology 6thedition: Butterworth-

Heinemann• Adrian S Bruce. 2008. Posterior Eye Disease and Glaucoma A-Z : Butterworth-

Heinemann• Theodore Grosvenor. 2007. Primary Care Optometry. Fifth Edition. St. Louis,

Missouri: Butterworth-Heinemann.• http://www.goodhope.org.uk/departments/eyedept/armdwet.htm

(9.00a.m,20/2/2011)• http://www.webrn-maculardegeneration.com/central-scotoma.html(10.00 a.m,

22/2/2011)• http://www.mdsupport.org/library/angio.html (11.00 a.m,21/2/11).• http://www.myvisiontest.com/newsarchive.php?id=1219 (10.00 a.m, 22/2/2011)• http://bjo.bmj.com/content/85/12/1432.abstract(10.00 a.m, 22/2/2011