Age-Related Macular Degeneration

 

What is Age-Related Macular Degeneration (ARMD)?

 

ARMD is a common eye disease associated with aging that can destroy central vision. Central vision is the vision we use when looking directly at something, or for common daily tasks such as reading and driving. In some people, ARMD advances so slowly that it will have little effect on their vision throughout their lives, and in others it may not advance at all. In a small percentage, ARMD can progress to a complete loss of central vision, either rapidly or gradually.

 

How does ARMD damage vision?
The retina is a paper-thin lining inside the back wall of the eye. It is a part of the brain that is specialized for sensing vision. You can think of the retina as being like the film in the back of your camera. Unlike your camera’s film, though, the retina has a small area in its very center called the macula. This is the only part of the retina that can see with good detail, and it gives us our “straight ahead” or “central” vision.

 

ARMD damages the macula and therefore harms our central vision. This damage can occur in two different forms:

 

Dry ARMD: 90% of all people with ARMD have this type. Although scientists do not know what the basic cause of ARMD is, we know that there can be a gradual deterioration of the light-sensing cells in the macula leading to central vision loss. Most people with dry ARMD have mild vision problems and won’t know they have it unless they have had a thorough eye exam with dilation of the pupils to examine the retina. People with dry ARMD typically have changes in the coloring of the central retina, with specks of yellow or gray-brown pigment that gradually develop over many years. These are called drusen and are the hallmark finding of dry ARMD. There may also be the gradual development of lighter-colored areas where the retina has become thinned or atrophic. The atrophic form of dry ARMD can gradually result in severe central vision loss over many months or years. Only a small percentage of all people who suffer severe vision loss from ARMD have the atrophic type.

 

Wet ARMD: Although only 10% of all people with ARMD have this type, it accounts for 90% of all people with severe vision loss from ARMD. Anyone who develops wet ARMD started with dry ARMD first; the wet type develops from the dry type. In some people with dry ARMD, new blood vessels may begin to grow between the retina and the wall of the eye. Imagine tree roots growing up under your sidewalk, lifting and distorting it; or picture a blister of water between your wallpaper and the wall, gradually expanding. These new blood vessels are very fragile and often leak blood, lipids and clear fluid under the macula. This “blister” of blood, fluid and new blood vessels separates the macula from the wall of the eye. The cells in the macula that sense vision need to be in contact with the wall of the eye to get oxygen and nutrition. When separated, the vision cells in the retina gradually suffer permanent damage, resulting in central vision loss.

 

Who is most likely to get ARMD?
The greatest risk factor for developing ARMD is age. Although ARMD can occur in middle age, the risk increases greatly with advancing age. Most people with ARMD are over age 60, and the risk becomes higher in later years.

 

Other factors that increase the risk of developing ARMD and tend to make it progress are:
Smoking
Race – White/Caucasian people are at greater risk than African-Americans
Family history – people with ARMD in their immediate family are at greater risk, although most cases of ARMD cannot be related to an inherited gene at this time.
Gender – women appear to be at slightly greater risk that men
Obesity, high blood pressure, high cholesterol & heart disease – there is gradually more evidence being discovered that conditions which harm the circulation tend to worsen ARMD

 

What are the symptoms of ARMD?
There is no pain with either wet or dry ARMD. The only symptoms are changes in the vision. The most symptom of early dry ARMD is mild blurring of vision, and frequently a need to have more light to see by.

 

If ARMD worsens, distortion or a wavy/crooked appearance may develop. For example, straight lines like doorframes or telephone poles may appear to have a bend in them. A gray or dark spot can appear in the center of the vision. These symptoms may be more noticeable in different lighting conditions or with certain activities.

 

What should I do if I notice changes in my vision?
If you have vision loss from ARMD in one eye only, you might not be aware of it as long as the other eye sees well. Many people have been unaware that one eye had severe vision loss until their second eye began to see poorly. Since the treatments for wet ARMD are most effective at preventing further vision loss, it is critical that problems be detected as early as possible to preserve vision. Because of this, it is important that people with ARMD check their own vision in each eye independently every day. This is usually done with an Amsler grid. If any sudden visual changes develop, such as missing spots, distortion, or an area of blurring, you should immediately contact your retinal specialist. If you don’t have a retinal specialist, contact your general eye doctor and he/she can refer you to a retinal specialist. Just because the vision changes doesn’t always mean that there is a serious problem, but it does mean your eyes should be examined because there might be a new problem that could be treated.

 

How can dry ARMD be treated?
There is currently no proven treatment for vision loss from the dry form of ARMD, but thankfully the vast majority of people with dry ARMD will never have severe vision problems. There is some experimental work being done on new treatments for vision loss from dry ARMD, but as yet none of these have been proven to be helpful.

 

There is evidence that people with moderate or advanced dry ARMD may benefit by taking antioxidant vitamins and minerals. These supplements will not restore vision already lost, but they do reduce the risk of intermediate further vision loss. There is no evidence at present that these supplements are helpful for people with early dry ARMD or at preventing people without any ARMD from developing it. The only way to know what stage of ARMD (early, intermediate or advanced) you have is to be examined by a retinal specialist, or a general eye doctor with experience and training in diagnosing and treating ARMD.

 

There is also good evidence that a diet rich in leafy, dark green vegetables (such as spinach), fruits and fish helps to prevent the development and progression of ARMD. Since we also know that conditions such as high blood pressure, heart disease and smoking tend to worsen ARMD, it also makes sense to control these diseases and stop smoking. These steps would obviously need to be taken under the guidance of your family physician. For more information please see our ARMD Vitamin Fact Page.

 

How can wet ARMD be treated?
The wet type of ARMD can be treated by several methods; until recently however, none have been proven to be effective in preventing vision loss. With any of the treatments described below, there is a significant risk of the new blood vessels growing back, so continued exams and home vision testing (with the Amsler grid) are important. Finally, while new treatments may result in an average improvement in vision, not all patients experience improvement and it is unlikely for the vision to return to the level it was before the development of wet macular degeneration.

 

Injections of medication – Medications are commonly injected around or into the eye to treat many different eye diseases. The thought of “needles” and “eyes” together is frightening to many people, but the injections are performed with little or no sensation whatsoever. The eye is anesthetized (made numb) thoroughly, and usually the only side effect is a bloodshot, red, and mildly puffy appearance to the “white” part of the eye. This typically disappears within a few days to a week. Some people may notice new floaters temporarily in their vision after the injection. Your doctor will discuss the procedure with you in detail if it is an appropriate option.

 

Lucentis – This drug is currently the only drug approved by the FDA that can result in stabilization of vision and on average results in a gain in vision. It was approved in June 2006 and blocks the effect of VEGF. VEGF is a “growth factor”, a chemical signal in the body that plays a key role in the growth of the abnormal new blood vessels in ARMD. In the clinical trials for Lucentis, injections were given monthly for 2 years. A smaller study called the PrONTO study showed similar results with a significantly reduced number of treatments by treating only when the disease is active. It is not yet known how long injections need to continue.

 

Avastin – This drug also blocks the effect of VEGF, like Lucentis and Macugen. Avastin is the “parent” of Lucentis; Lucentis was created by splitting off a smaller, active part of the Avastin molecule. Avastin was approved by the FDA for treatment of certain types of cancer, and is given intravenously (by vein) for that use. In 2005, a few retinal specialists began experimenting with Avastin for treatment of wet ARMD, and many other retinal specialists have gained experience with it subsequently. While the early results with Avastin are quite promising, it has not yet undergone the rigorous scientific testing that Macugen, Lucentis, Photodynamic therapy, and even laser surgery have had. Therefore, the use of Avastin is considered “off-label”, as it has not been approved by the FDA for use in eyes or for treating ARMD. So far, there have been no reports of safety problems with Avastin, other than the potential risks of any injection, and results appear to be similar to those obtained by Lucentis. Furthermore, due to the similar results to Lucentis and apparent safety, Medicare has agreed to cover its use for wet ARMD despite it being “off-label”. The National Eye Institute is planning to compare the results of Avastin injections to Lucentis injections in a large trial over the next few years.

 

Photodynamic therapy (PDT) – This was approved by the Food & Drug Administration in 2000 for the treatment of certain types of wet ARMD. A medication called Verteporfin (brand name Visudyne) is injected into a vein in your arm and gradually collects in the abnormal new blood vessels in the eye over about 15 minutes. The Verteporfin drug is very sensitive to light, and it is activated in the abnormal blood vessels by shining a weak laser light onto the blood vessels for 83 seconds. The activated drug then causes the closure of the abnormal blood vessels. When used by itself, vision loss will continue for the average patient, however there is evidence that when PDT is used in combination with Kenalog (see below) or an anti-VEGF medication, the average number of treatments required may be decreased and vision can improve.

 

This is done in the office. The laser light is painless, and the injection of the drug is similar to when you have a blood test drawn from your arm. Because the verteporfin drug circulates throughout your bloodstream and is so sensitive to light, your skin and eyes must be protected from direct sunlight or intense indoor lights for 5 days after treatment. Generally multiple treatments are required, because the blood vessels tend to grow back. Eventually, though, the abnormal blood vessels close up permanently and no further treatments are needed.

 

Triamcinolone (Kenalog) – This steroidal anti-inflammatory medication is related to the cortisone that your body naturally makes every day. It is very effective at reducing inflammation and swelling, and has been used for many years in many branches of medicine, including for other eye diseases. A large percentage of retinal specialists have been using injections of this drug over the past few years to help in treating wet ARMD. It is most commonly given in combination with PDT (see above). There seems to be a need for fewer treatments with the combination, and there may be a better chance at vision improvements than with PDT alone. The use of this drug in and around the eye is considered “off-label” but is widely accepted.

 

Macugen – This drug was approved by the FDA in early 2005 for treatment of all types of wet ARMD. While its use results in an average visual loss and enlargement of the area affected by abnormal vessels, it can be useful in a few patients. It is similar to Lucentis in that it blocks VEGF, but it only blocks a fraction of the VEGF that Lucentis does. Macugen lasts for about six weeks, so injections need to be repeated every six weeks, often for at least two years.

 

Laser – For many years, laser surgery has been used to destroy the new blood vessels with a high-energy, highly-focused beam of light. This is currently used primarily when blood vessels are growing outside the very center of the macula. Most wet ARMD has blood vessels growing under the center of the macula, and newer, better treatments have replaced laser for this situation. The laser is typically done in a retinal specialist’s office, takes 5-10 minutes, and is generally painless.

 

For more information about ARMD, you may wish to visit/contact:

 

AMD Alliance International
1929 Bayview Avenue
Toronto , Ontario
Canada M4G 3E8
(877) 263-7171
(416) 480-7505
http://www.amdalliance.org

 

Macular Degeneration Partnership
8733 Beverly Boulevard, Suite 201
Los Angeles , CA 90048
(888) 430-9898
http://www.amd.org

 

Association for Macular Diseases
210 E. 64 th Street
New York , NY 10021
(212) 605-3719
http://www.macula.org

 

Macular Degeneration Foundation
P.O. Box 531313
Henderson , NV 89053
(888) 633-3937
http://www.eyesight.org

 

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National Eye Institute (NEI)
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