Updated: 6/4/2018

Age-Related Macular Degeneration (ARMD)

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Snapshot
  • A 72-year-old male presents with progressive bilateral loss of central vision. This has made driving difficult, and often finds himself needing a bright light to look at objects. He reports that his peripheral vision is intact. When looking at a specific region at line grid, he reports a dark “spot” in the center, with bent lines. Dilated ophthalmic examination is shown.
Introduction
  • Degenerative disease involving the macula loss of central vision
    • peripheral and navigational vision is uninvolved
  • Classification
    • wet (neovascular, exudative)
      • pathogenesis involves choroidal neovascularization
        • secondary to vascular endothelial growth factor (VEGF)
      • disease progression usually occurs over months
    • dry (atrophic)
      • pathogenesis unclear
      • drusen deposition (early in disease), retinal atrophy, central retinal degeneration
      • disease progression usually occurs over decades
  • Epidemiology
    • mostly affects those > 50 years old
    • a leading cause of blindness
Presentation
  • Symptoms
    • wet-ARMD
      • acute visual distortion
      • central vision loss
        • secondary to fluid accumulation
      • usually affects one eye
      • metamorphopsia
        • can appear early in disease
    • dry-ARMD
      • gradual vision loss
      • metamorphopsia
Evaluation
  • Clinical diagnosis
    • retinal examination
      • wet-ARMD
        • hemorrhage or fluid in subretina
        • neovascularization
          • macular grayish-green discoloration
      • dry-AMD
        • drusen deposition 
        • areas of retinal atrophy (depigmentation)
        • retinal pigment epithelium motteling (pigmentation)
  • Fluorescein retinal angiography
  • Optical coherence tomography (OCT)
  • Amsler grid
    • line distortion seen on grid
Differential
  • Vascular tumors of the retina
    • e.g., von Hippel-Lindau disease
Treatment
  • wet-ARMD
    • VEGF inhibitors (e.g., bevacizuzmab)
    • photodynamic therapy
    • zinc and antioxidant vitamins
  • dry-ARMD
    • zinc and antioxidant vitamins 
Prognosis, Prevention, and Complications
  • Prevention
    • certain vitamin supplements, and dietary factors may reduce the risk of ARMD
  • Complications
    • blindness
 

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(M2.OP.17.4754) A 69-year-old male presents to your clinic with complaints of seeing “wavy lines” in the vision of his left eye. He is not sure when it started, but does believe it has gotten progressively worse. He denies pain, photophobia, or other ocular symptoms. His past medical history is significant for type II diabetes mellitus and hypertension. His current medications include metformin and lisinopril. On examination, his visual acuity is 20/400 in the left eye and 20/70 in the right eye. His pupils are 2 mm bilaterally and equally reactive to light with accommodation. There are no extraocular motor deficits. A fundoscopic exam of his left eye is shown in Figure A. What is the best next step in management? Tested Concept

QID: 108990
FIGURES:
1

No treatment indicated

12%

(17/143)

2

Massage the globe and start hyperbaric oxygen therapy

10%

(14/143)

3

Start multivitamin and antioxidant supplements

32%

(46/143)

4

Start bevacizumab

24%

(35/143)

5

Start acetazolamide drops

21%

(30/143)

M 7 D

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