age related macular degeneration
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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.
age related macular degeneration
- 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
- 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
- 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. [email protected]
- 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