Age-Related Macular Degeneration

Abstract

A 78-year-old woman presents with vision changes in the right eye for one week. Specifically, she describes central blurring in her vision and bending or waviness in straight lines. She also reports increasing difficulty reading print and often feels that there are blind spots in her vision. How would you diagnose and treat this patient?

Figure 1:

A sagittal section of the normal human eye is represented on the top left. Light photons enter the eye and visual transduction begins in the neurosensory retina (top left). Slit lamp biomicroscopic examination allows examination of the patient retinas (top right panel; central part of the retina called macula = dashed circle, center of the macula called fovea = black arrowhead, optic nerve head = white arrowhead). Fundus photographs illustrate features of AMD visualized by slit lamp biomicroscopy (bottom panel): (left) Intermediate AMD identified by yellowish deposits underneath the retina called drusen, (middle) advanced non-neovascular AMD characterized by geographic atrophy (arrowheads) in the setting of drusen, and (right) neovascular AMD diagnosed by hemorrhage and fluid associated with choroidal neovascularization

Figure 2

Age-Related Eye Disease Study (AREDS) Simplified Severity Scale for AMD (adapted from 11). This simplified scoring system allows the examining physician to estimate the risk of AMD progression in an individual patient. *Large druse ≥ 125 microns; a patient with intermediate drusen (63–124 microns) in both eyes also gets a score of 1 for drusen; ^#a patient with advanced AMD in one eye gets a score of 2 for that eye. An individual patient score facilitates an informed discussion about micronutrient supplementation and counseling regarding progression of disease with the patient.

Figure 3:

A normal Amsler grid (left), and a grid as it may appear to someone with AMD (right) are shown below.

Figure 4:

An optical coherence tomography (OCT) scan of the macula shows the retinal layers (NFL = nerve fiber layer, RGCL = retinal ganglion cell layer, IPL = inner plexiform layer, INL = inner nuclear layer, OPL = outer plexiform layer, ONL = outer nuclear layer, EZ = ellipsoid zone, RPE = retinal pigment epithelium/Bruch’s membrane complex, CC = choriocapillaris). Optical coherence tomography allows high resolution cross-sectional imaging through the retina in order to identify, characterize and follow AMD characteristics. These include drusen in intermediate AMD (top panel - arrowheads), geographic atrophy (bracket) within a setting of surrounding macular drusen in non-neovascular, advanced AMD (middle panel), and intra-retinal (arrowhead), sub-retinal fluid (arrow) or hemorrhage (star) associated with choroidal neovascularization in neovascular, advanced AMD (bottom panel)

Figure 4:

An optical coherence tomography (OCT) scan of the macula shows the retinal layers (NFL = nerve fiber layer, RGCL = retinal ganglion cell layer, IPL = inner plexiform layer, INL = inner nuclear layer, OPL = outer plexiform layer, ONL = outer nuclear layer, EZ = ellipsoid zone, RPE = retinal pigment epithelium/Bruch’s membrane complex, CC = choriocapillaris). Optical coherence tomography allows high resolution cross-sectional imaging through the retina in order to identify, characterize and follow AMD characteristics. These include drusen in intermediate AMD (top panel - arrowheads), geographic atrophy (bracket) within a setting of surrounding macular drusen in non-neovascular, advanced AMD (middle panel), and intra-retinal (arrowhead), sub-retinal fluid (arrow) or hemorrhage (star) associated with choroidal neovascularization in neovascular, advanced AMD (bottom panel)

Figure 5:

Optical coherence tomography-angiography Image of the normal retinal superficial capillary plexus (left) superimposed over the fundus image compared to choroidal neovascularization in the deep vascular plexus in neovascular AMD (right)