Review Question - QID 108990

This patient is presenting with visual distortion, bilateral decrease in vision, and a fundoscopic exam positive for “drusen,” suggesting the diagnosis of dry age-related macular degeneration. The best initial therapy is a multivitamin and antioxidant supplements.

Dry ARMD is non-neovascular/non-exudative, and presents as a gradual central vision loss (scotomas) over decades. Wet ARMD involves choroidal neovascularization and can cause a more rapid loss of vision caused by bleeding secondary to the new vessel formation. Both dry and wet ARMD can present with metamorphopsia or visual distortions. Dry ARMD on fundoscopic exam will show drusen deposition (Figure A) and areas of retinal pigmentation and de-pigmentation. Wet ARMD will show choroidal neovascularization (Illustration A). Dry ARMD is treated with zinc and antioxidant vitamins to prevent progression. Wet ARMD is additionally treated with vascular endothelial growth factor (VEGF) inhibitors and laser photocoagulation therapy.

Figure A shows fundoscopy with yellow extracellular material deposits known as “drusen,” characteristic of dry age-related macular degeneration. Illustration A shows fundoscopy with choroidal neovascularization, which can be seen in wet age-related macular degeneration.

Incorrect Answers:
Answer 1: No definitive treatment is indicated for retinal vein occlusion. Retinal vein occlusion presents as sudden, painless, monocular vision loss. Fundoscopic exam would show retinal hemorrhage and venous dilation.

Answer 2: Massaging the globe and hyperbaric oxygen therapy has shown to be beneficial in central retinal artery occlusion. Symptoms include acute, painless, monocular vision loss. Fundoscopic exam would show a cloudy retina with attenuated vessels and a “cherry-red” macula.

Answer 4: Bevacizumab is a VEGF inhibitor, which can be used to treat wet ARMD and is also part of treatment for proliferative diabetic retinopathy. Both wet ARMD and proliferative diabetic retinopathy will show forms of neovascularization on fundoscopic exam.

Answer 5: Acetazolamide is a diuretic used to treat open-angle glaucoma by inhibiting carbonic anhydrase, which then decreases aqueous humor synthesis. Open-angle glaucoma presents as painless, peripheral vision loss, resulting in “tunnel vision.” Optic disc atrophy causes an increased cup-to-disk ratio on examination.

Bullet Summary:
Dry-ARMD, characterized by "drusen" on fundoscopic exam, is treated with zinc and antioxidant vitamins to prevent progression.