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Age-related macular degeneration

Last updated: March 24, 2021

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Age-related macular degeneration (AMD) is a degenerative disease of the retina and represents the most common cause of blindness in individuals > 65 years in developed countries. It is classified into two major forms: dry AMD and wet AMD. Dry AMD is caused by deposition of various metabolites under the retinal pigment epithelium (drusen) and usually develops over decades, while wet AMD is caused by neovascularizations growing into the subretinal space and manifests within weeks to months or even acutely. Both forms ultimately cause impaired central vision and can, in rare cases, lead to complete blindness. Patient history and clinical tools such as the Amsler grid can provide clues regarding visual impairment. Fundoscopy is needed to identify specific pathological changes. Fluorescein angiography may be used to confirm the diagnosis of wet AMD. Treatment focuses on slowing vision loss and/or improving vision.

AMD is the leading cause of blindness in individuals > 65 years in developed countries.

Epidemiological data refers to the US, unless otherwise specified.

AMD is characterized by progressive degenerative changes in the central part of the retina (macula) → visual impairment.

References:[3]

  • Painless central or pericentral visual impairment → reduced visual acuity, difficulty adapting to changes in lighting
    • Dry AMD: slow progressive visual impairment (usually over decades) and unilateral or bilateral onset
    • Wet AMD: acute or insidious onset (over weeks to months) and usually manifests in one eye first
  • Metamorphopsia; : type of visual distortion in which straight lines appear wavy, which can be tested for using an Amsler grid
  • Scotoma (blind spot)

References:[3]

Both, wet and dry AMD

If wet AMD is suspected

References:[3][4]

Differential diagnosis of vision loss
Condition Clinical features Fundoscopy
AMD
  • May be insidious (dry AMD) or rapid (wet AMD) onset
  • Impairment of central vision only (vision loss is rare)
Open-angle glaucoma
  • Insidious onset
  • Peripheral vision loss (tunnel vision)
Central vessel occlusion (retinal artery)
  • Acute or subacute onset
  • Complete vision loss
Retinal detachment
  • Acute onset
  • Partial or complete vision loss (falling curtain)
Cataract
  • Insidious onset
  • Blurred, dim vision, and a glare
  • Absent or opacified red-reflex
  • Retina may not be visible (in advanced disease)

The differential diagnoses listed here are not exhaustive.

No causal treatment is available.

  • Supportive treatment
    • Patient education
    • Visual and reading aids: magnifying glass
    • Avoid risk factors (e.g., smoking)
    • Improve diet (i.e., high in green leafy vegetables and fish)
    • Antioxidants therapy: vitamins A, C, and E, beta-carotene, zinc
  • Treatment of wet AMD
    • First-line: injection of VEGF inhibitors (ranibizumab, bevacizumab, pegaptanib) into the vitreous body
    • Second-line: when VEGF is contraindicated
      • Laser coagulation: direct thermal coagulation of neovascularization
      • Photodynamic therapy: intravenously administered dye is activated in the eye by laser light → local toxic effect → thrombosis of subretinal neovascularizations
  • Chronic progressive course for both types
  • Prognosis for dry AMD is significantly better than for wet AMD
  • Complete loss of central vision is possible but rare
  1. Coleman HR, Chan CC, Ferris FL 3rd, Chew EY. Age-related macular degeneration.. Lancet (London, England). 2008; 372 (9652): p.1835-45. doi: 10.1016/S0140-6736(08)61759-6 . | Open in Read by QxMD
  2. The Eye Diseases Prevalence Research Group. Prevalence of Age-Related Macular Degeneration in the United States. Arch Ophthal. 2004; 122 (4): p.564. doi: 10.1001/archopht.122.4.564 . | Open in Read by QxMD
  3. Age-Related Macular Degeneration (AMD or ARMD). https://www.merckmanuals.com/professional/eye-disorders/retinal-disorders/age-related-macular-degeneration-amd-or-armd. Updated: January 1, 2017. Accessed: May 17, 2017.
  4. O'Toole L. Fluorescein and ICG angiograms : still a gold standard.. Acta Ophthalmologica Scandinavica. 2007; 85 (240). doi: 10.1111/j.1600-0420.2007.01063_2988.x . | Open in Read by QxMD