Age-Related Macular Degeneration (AMD)

California Macular Degeneration Specialist

Age-related macular degeneration (AMD) is a disease of aging that is:

common
gradual
progressive
painless
characterized by deterioration of the macula, a small area in the center of the retina

When unmonitored and untreated, AMD results in vision loss, especially for daily tasks like driving, reading, etc. With appropriate monitoring and timely treatment, most patients can maintain vision for years to come.

Age-related macular degeneration affects the macula region of the retina.

What is the Retina?

If the eye were a camera, the retina would be the film of that camera
The retina is a thin sheet of nerve cells that lines the inside back wall of the eye
Light travels through the eye and ultimately reaches photoreceptors, the light-sensitive cells in the retina
The signal from the photoreceptors then travel along the optic nerve to the brain, where the signals are interpreted as vision

retina2

What is the Macula?

The macula is the center region of the retina
The macula is responsible for high detail vision, central vision, reading, etc. The rest of the retina is responsible for peripheral vision.
AMD affects the macula, and in turn, results in decreased vision for tasks like reading, driving, recognizing faces, etc.

What are the Symptoms of AMD?

What are the Types of AMD?

There are 2 types of AMD

Dry age-related macular degeneration (dry AMD)
- Milder, earlier, more common form of AMD
- Age-related deposits accumulate in the retina, causing mild to moderate vision symptoms
- In late stages, tissue loss (called “atrophy” or “geographic atrophy”) can occur, resulting in severe vision loss
- The dry form can convert to the wet form at any time
Wet age-related macular degeneration (wet AMD, also known as exudative AMD)
- Wet AMD has all the features of dry AMD, plus:
  - New blood vessels that grow under and/or into the retina. This abnormal blood vessel growth is called “choroidal neovascularization.”
  - The abnormal blood vessels leak fluid or blood into the retina, thus “wet” AMD
  - Vision decrease may occur gradually or it can occur suddenly, with potentially vision loss

Combined+drusen+photo+and+OCT — Left image: Photograph of the right eye of a patient with dry AMD with yellow drusen deposits visible under the retina (red arrow). Right image: Optical coherence tomography (OCT) scan of the same patient shows the retina in cross section through the area of drusen (red arrow).

Combined+image+of+dry+amd+w+GA — Left image: Photograph of the left eye of a patient with dry AMD with area of “geographic atrophy” (yellow patch, red arrow). Right image: Optical coherence tomography (OCT) scan of the same patient shows the retina in cross section and tissue loss is visible in the area of geographic atrophy (red arrow).

Combined+wet+AMD+image — Left image: Photograph of the left eye of a patient with dwet eye with pigmetary changes (dark spots) visible. Right image: Optical coherence tomography (OCT) scan of the same patient shows the retina in cross section. There is an abnormal blood vessel growth (red arrow), which is leaking fluid under the retina (dark black cleft, yellow arrow).

What are Risk Factors for AMD?

Older age
Female
Caucasian
Family history
Smoking
High cholesterol
High blood pressure

How Does My Doctor Diagnose AMD?

Dilated retinal examination
Optical coherence tomography (OCT) scan: painless photograph that provides a cross-sectional scan through the macula so that microscopic details of the macula can be discerned

Getting an OTC — Top image: An optical coherence tomography (OCT) scan is a safe and painless imaging test that allows for examination of microscopic changes in the retina. Bottom left image: Right eye retina. Left image: OCT-scan through a single slice of the retina shown in the left image. The OCT is normal. The downward dip in the retina is the normal foveal depression.

In some patients:

Fluorescein angiography
- A dye is injected into the arm, from which to travels through the blood to the eye.
- Photographs are taken of the eye which map out all the blood vessels and blood flow in the retina
- This test identifies areas of blood flow loss as well as areas of new blood vessel grown (neovascularization)

FA+procedure — Left image: A fluorescein dye is injected into the vein in the arm. The dye travels through the bloodstream to the eye and then photos are taken (middle image). Right top and bottom images: The resulting angiogram highlights blood vessels and blood flow in the retina. In this image, there is a choroidal neovascularization membrane (white area in middle of bottom image) characteristic of wet AMD.

How is Dry AMD Treated?

Patients with dry AMD are monitored for conversion to wet AMD (for which there is treatment, see below).
AREDS2 vitamins (over the counter) may reduce progression of dry AMD and thus may be recommended
An “Amsler grid” is provided to allow patients to monitor for subtle vision changes between appointments
If there is geographic atrophy present, treatments are now available to slow down the progression of geographic atrophy (Syfovre, Izervay)

How is Wet AMD Treated?

Wet AMD is treated with injections of medications (anti-VEGF medications) that block VEGF.
VEGF causes abnormal blood vessel growth and blood vessel leakage; thus, anti-VEGF agents reduce leaking from abnormal blood vessels and can even promote regression of abnormal blood vessels
There are several anti-VEGF medications
- Avastin (bevacizumab)
- Lucentis (ranibizumab)
- Eylea (aflibercept)
- Vabysmo (faricimab), which not only blocks VEGF but also blocks Ang2 which is involved in AMD
- And others

What is it Like to Get Intravitreal Injections in the Eye?

The injections are given into the eye (intravitreal injections) in the office, after drops are given to numb and clean the ocular surface.
The medications last several weeks in the eye.
- Some patients require injections every month to control the disease, while others require injections less often, and yet others are able to eventually stop injections and monitor for recurrence.
- The treatment is individualized to each patient’s disease and response to treatment.
There are new drugs in the research pipeline that may last longer.

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