Age Related Macular Degeneration (ARMD)

• the destruction and deterioration of the dense neurosensory layer specific to the macula
• Painless bilateral condition
• leads to slow central vision loss
• Leading cause of blindness in > 65yrs
• Dry or wet (exudative)

Risks

• HTN
• Hchol
• Smoking
• family history
• northern european

Two types

• Dry
• WET

• dry ARMD
  • 85–90% of cases
  • Graduate degeneration of the retinal pigment epithelium (RPE) underneath the macula results in the step wise degradation of vision over many years. 
  • RPE undergoes mixed atrophy and hypertrophy, and end stage disease is clinically described as ‘geographic atrophy’.
• Wet ARMD
  • 10–15% of cases refers to the development of a choroidal neovascular membrane underlying the RPE. 
  • Leakage of fluid from new vessels into or under the retina causes distortion of the photoreceptor alignment, with an accompanying precipitous drop in VA. 
  • End stage disease is characterised by contraction of the fibrovascular membrane and the formation of a disciform scar. 

• The conversion of dry to wet forms is about 2% per year

Symptoms

• Early ARMD
  • asymptomatic. 
• Late ARMD
  • Characterized by loss of central vision while peripheral vision remains intact.
  • scotomata in the central vision
    • Peripheral vision generally preserved, therefore and independent living preserved
  • Metamorphopsia is vision dysfunction that causes objects — specifically straight lines — to appear warped, distorted or bent
  • Gradual decrease in visual acuity, particularly affecting tasks requiring fine vision (e.g., reading, recognizing faces).
  • Photopsia: atients may experience flashes of light or photopsia

Differentials

Condition	Signs and Symptoms	Management
Age-Related Macular Degeneration (ARMD)	– Loss of central vision – Peripheral vision generally preserved – Gradual decrease in visual acuity	– Anti-VEGF therapy – Lifestyle modifications – Low vision aids
Glaucoma	– Peripheral vision loss – Increased intraocular pressure – Optic nerve cupping	– Medications to lower IOP – Laser therapy – Surgical intervention
Diabetic Retinopathy	– Presence of microaneurysms, hemorrhages, and exudates – Vision loss throughout the visual field – Possible retinal detachment	– Control of blood sugar levels – Laser therapy – Intravitreal injections – Vitrectomy for severe cases
Cataracts	– Clouding of the lens – Overall vision blurring – Gradual vision loss affecting all fields	– Corrective surgery (cataract extraction and lens replacement)
Retinal Hemorrhage	– Sudden or gradual decrease in vision – Floaters (dark spots, strings, or cobweb-like structures) – General blurring of vision	– Treatment of underlying cause (e.g., diabetes, hypertension) – Observation – Laser therapy – Vitrectomy for severe cases
Retinal Detachment	– Sudden onset of floaters and flashes – Shadow or curtain effect over part of the visual field	– Immediate medical intervention – Laser therapy or cryopexy – Surgical repair (e.g., scleral buckle, vitrectomy)

diagnosis 

• clinical appearance of the retina.
• Fundus fluorescein angiography
• optical coherence tomography
• Amsler Grid Eye Test 

Treatment

• no treatment options available for dry ARMD.
• wet ARMD is aimed at preservation of vision rather than cure. 
• Early detection of the conversion from dry to wet forms, or the progression of wet ARMD, is crucial for preservation of vision.

Advice for Patients with Age-Related Macular Degeneration

Lifestyle Modifications

1. Smoking Cessation:
   • Recommendation: Quit smoking and avoid exposure to secondhand smoke.
   • Evidence: Smoking is a significant risk factor for AMD progression. Quitting smoking can slow the progression of the disease .
2. UV Protection:
   • Recommendation: Wear sunglasses with UV protection when outdoors.
   • Evidence: UV light can contribute to retinal damage. Protecting the eyes from UV rays can help preserve vision .
3. Physical Activity:
   • Recommendation: Engage in regular physical activity.
   • Evidence: Regular exercise is associated with a lower risk of AMD progression and can improve overall health .

Dietary Changes

1. Omega-3 Fatty Acids:
   • Recommendation: Include omega-3 fatty acids in the diet, found in fish (e.g., salmon, mackerel) or supplements.
   • Evidence: Omega-3 fatty acids may reduce the risk of AMD progression

Regular Monitoring and Eye Care

1. Regular Eye Examinations:
   • Recommendation: Schedule regular eye exams with an ophthalmologist.
   • Evidence: Regular monitoring allows for early detection of changes in AMD and timely intervention .
2. Use of Amsler Grid:
   • Recommendation: Use an Amsler grid at home to monitor for any sudden changes in vision.
   • Evidence: An Amsler grid can help detect early signs of wet AMD, which requires prompt treatment .

Managing Visual Function

1. Low Vision Aids:
   • Recommendation: Utilize low vision aids such as magnifying glasses, large-print books, and specialized lighting.
   • Evidence: Low vision aids can help patients maintain independence and improve quality of life .
2. Assistive Technologies:
   • Recommendation: Explore assistive technologies like screen readers and voice-activated devices.
   • Evidence: Assistive technologies can enhance daily functioning for patients with significant vision loss .

Medical Treatments

1. Anti-VEGF Therapy:
   • Recommendation: Follow through with anti-VEGF injections if diagnosed with wet AMD.
   • Evidence: Anti-VEGF (vascular endothelial growth factor) therapy can reduce vision loss and, in some cases, improve vision in wet AMD .
2. Laser Therapy:
   • Recommendation: Discuss laser therapy options if recommended by an ophthalmologist.
   • Evidence: Certain types of laser therapy can slow the progression of AMD in selected cases .

By following these evidence-based recommendations, patients with AMD can take proactive steps to manage their condition, slow its progression, and maintain their quality of life.