RCSI Royal College of Surgeons in Ireland Coliste Roga na Minle in irinn

Age related macular

degeneration
Senior cycle 1
2016-17

Learning Outcomes
At the end of this tutorial, you will be able to:
Describe the basic epidemiology of ARMD as a major cause
of blindness
Explain the basic pathology that damages the retina in ARMD
Assess a patient presenting with ARMD, including taking a
relevant history and performing the appropriate examination
and investigations
Describe treatment regimens for ARMD and advise patients
on recognised preventative measures

The Retina

LIGHT

Retinal Transparency
Required for normal function
allows light through
Unmyelinated axons
Low density blood vessels
Blood retinal barriers
Loss of transparency
Haemorrhage
Oedema
Visual loss

The Normal Retina

Optic disc
Retinal blood vessels
Macula
Peripheral retina
Fovea

Retinal Disease
Clinical assessment
History
VA
Amsler grid
Ophthalmoscopy
Retinal imaging
FFA
OCT

Age Related Macular Degeneration

Leading cause of blindness > 50
Risk Factors

Age
Caucasian
Smoking
Diet

Symptoms
Distortion of vision
Central scotoma (blind spot)
Reading difficulties

Amsler grid

http://www.nei.nih.gov/health/maculardegen/armd_facts.asp

Sight loss in AMD

http://www.nei.nih.gov/health/maculardegen/armd_facts.asp

Age Related Macular Degeneration

Divided into dry (atrophic) (90%) and wet (exudative)
(10%)
Wet ARMD presents with more rapid loss of vision and
distorted vision over days compared with months for dry

ARMD
Wet ARMD is more damaging to vision

Causes of Sight Loss in Ireland

Impact of population growth and ageing

225,000 people in Ireland who are blind or visually impaired

Personal, social and economic impact
Population growth
2011
(000)

2021
(000)

2026
(000)

Total Population 4,738

5,687

6,068

28.1%

65-69

173.5

236.8

267.5

54.2%

70-74

130.8

201.8

224.8

71.9%

75-79

101.7

146.3

183.7

80.7%

80-84

70.3

95.6

123.6

75.8%

+85

60.4

94.3

118.6

96.3%

Age Group

% Change 2011/2026

By 2020, 272,000 people will be blind or visually impaired based on

estimates

ARMD
Pathology
Retinal pigment epithelial (RPE) cell loss
Drusen = deposits between RPE and photoreceptors
Photoreceptor loss

Dry ARMD
Drusen
Lipofuscin in RPE
Pigmentary changes
Mild visual impairment at this stage

Dry ARMD

Geographic atrophy
- leads to greater vision loss
- Develops slowly

Dry ARMD

Wet ARMD
Choroidal neovascular membrane
Haemorrhage
Oedema
Inflammation

Distortion
Central visual loss

Wet ARMD

Submacular haemorrhage
Macular exudates and oedema
- Indicate choroidal neovascular membrane

Wet ARMD

End-stage ARMD
Geographical atrophy
Scarring
Irreversible loss of central
vision

End-stage wet ARMD

Submacular fibrosis

ARMD
Investigations

OCT
3D imaging
Retinal thickness
Fluid
Fluorescein Angiography
Leakage
hyperfluorescence

Treatment of ARMD
Early
Lifestyle changes stop
smoking
Diet
Exogenous antioxidants
Vitamins C, E
-Carotene
Zinc
Macular pigments
Lutein
Zeaxanthin

Treatment of ARMD
Wet ARMD
Intra-vitreal anti-VEGF therapy
Loading therapy x 3 months
Maintenance therapy
2/3 stabilise
1/3 improve

Treatment of ARMD
Dry ARMD
Low vision magnifying aids
Social services
Vitamin supplements unproven benefit

Learning Outcomes
At the end of this tutorial, you will be able to:
Describe the basic epidemiology of ARMD as a major cause
of blindness
Explain the basic pathology that damages the retina in ARMD
Assess a patient presenting with ARMD, including taking a
relevant history and performing the appropriate examination
and investigations
Describe treatment regimens for ARMD and advise patients
on recognised preventative measures