Age-related Macular Degeneration

Reference: Ape RS 2021 in NEJM

AMD appears to affect men and women similarly

AMD severity has been associated with

There is also a strong genetic predisposition

Age related eye disease studies (AERDS and AERDS2)

advanced amd is classified as

neovascular AMD is characterised by neovascular proliferation underneath the neuroretina. This is also called choroidal neovascularisation.

atrophic AMD is characterised by atrophy of the RPE and overlying neurosensory retina. This is also called geographic atrophy

choroidal neovascularisation and geographic atrophy may develop in the same eye, because they are on the same continuum of disease activity

In addition to choroidal neovascularisation, there are two other forms of AMD-associated neovascularisation - polypoidal choroidal vasculopathy - retinal angiomatous proliferation

neovascular amd is responsible for the majority of severe vision loss

historically, angiography with fluorescein or indocyanine was used to assess the choroidal or retinal vasculature

Indocyanine was particularly useful for identifying the choroidal vasculature for polypoidal choroidal vasculopathy or retinal angiomatous proliferation

This has now largely been replaced by optical coherence tomography

fundus autofluorescence is useful to assess the health of the retinal pigment epithelium

the age related eye disease studies showed that oral supplementation may be helpful in preventing progression from intermediate to advanced disease

the supplementation included:

However, beta carotene has been associated with an increased risk of lung cancer amongst current or past smokers

In the age related eye disease study 2, beta carotene was replaced with

Other modifiable risk factors include:

The fluid in macular degeneration can be due to leaky blood vessels or haemorrhage

identifying polypoidal choroidal vasculopathy is important because when present, treatment with photodynamic therapy may be beneficial

This involves an intravenous injection of verteporfin, a compound which can be photoactivated and selectively binds to abnormal blood vessels. Verteporfin is then activated with a lower power laser to induce vascular regression

a combination of photodynamic therapy and anti-VEG thearpy results in greater gain in visual acuity in polypoidal choroidal vasculopathy. This benefit has been observed when photodynamic therapy is used in conjunction to ranibizumab but not with aflibercept