7 - Age Macular Degeneration

Question 1

What are the two genes explaining AMD?

Answer 1

Tyr402His(5 fold) and Ala69Ser(7 fold) Note: Both are complement of the H gene

Question 2

What is the risk of a Smoker getting AMD?

Answer 2

Twice Note: Reduces chorodial blood flow, decreases pigment in RPE, depresses antioxidants levels and imune system activation

Question 3

What is the biggest factor for AMD?

Answer 3

Age Note: Risk increases with advancing age Race: Caucasian is another demographic Gender: Female

Question 4

What is the hallmark for Dry AMD?

Answer 4

Drusen RPE Hyperpigmentation RPE atrophy

Question 5

What are the hallmark findings for WET AMD?

Answer 5

Choroidal NV Subretinal/SUB RPE fluid or blood

Question 6

What is the most common type of AMD?

Answer 6

Dry AMD Note: Non exudative, Atrophic, non bleeding and is about 85 to 90% of cases

Question 7

Which layer of the retina will have lipid deposits?

Answer 7

Bruch’s membrane

Question 8

What vasculature is effected in AMD?

Answer 8

Choriocapillaris

Question 9

What are the balance molecules for Bruch’s membrane?

Answer 9

Collagen (Type 1 Increase with aging and Type 4 decrease as one ages) Laminin (Decrease as aging occurs) Fibronectin (Decrease as aging occurs) GAG’s (Increase with aging) Matrix Metalloproteinases

Question 10

What is a distinction of the Pathophysiology of DRY AMD?

Answer 10

Photoreceptor function is decreased Note: Usually due to OXIDATIVE STRESS (RPE) and INFLAMMATION (Choriocapillaris)

Question 11

Oxidative stress produces what type of product which impacts the RPE?

Answer 11

Free radicals

Question 12

Injury of endothelial cells of the choriocapillaris and RPE results from inflammation. What is happening?

Answer 12

Activation of complement cycle which results in the formation of the Membrane Attack Complex (MAC) –> Lyses pathogens

Question 13

What is damaged first in the inflammation?

Answer 13

Choriocapillaris

Question 14

What specific protein is damaged in the RPE?

Answer 14

Matric metalloproteins (MMP’s) Note: Products are backed up in the basal lamina of the RPE and Bruch’s membrane and get stuck on the RPE

Question 15

What are the two types of Drusen deposits?

Answer 15

1. Basal Laminar deposits (Lipid and Collagen) 2. Basal Linear deposits (phosopholipid vesicles and granules)

Question 16

What is the size criteria for Drusen?

Answer 16

small (usually

Question 17

What is the boundary criteria for Drusen?

Answer 17

1. hard (discrete and well demarcated) 2. soft (amorphous and poorly demarcated) 3.confluent (contiguous boundaries between drusen)

Question 18

What are the two main materials Drusen is made of?

Answer 18

Lipid and Hyalin Material

Question 19

What is the predisposing formation from hydrophillic drusen?

Answer 19

Chorodial Neovascularization will occur

Question 20

NV occurs during WET AMD and what product does the new vessels contain to create a membrane (network)?

Answer 20

Fibroblasts

Question 21

What is the most common VGF?

Answer 21

Vascular Endothelial Growth Factor

Question 22

True or False. Pt will not exhibit vision loss?

Answer 22

True

Question 23

What are the two types of CNV?

Answer 23

1. Classic - Uniform lesion with typical IVFA pattern 2. Occult - Irregular lesion with typical IVFA

Question 24

What is a Disciform scar?

Answer 24

Fibrous tissue proliferation (Hemorrhage or Hyperplasia of the RPE)

Question 25

What is the classification of AMD Criteria?

Answer 25

Question 26

Since IVFA use to the be Gold standard, what mechanism or machine which deminished the usage of IVFA?

Answer 26

OCT

Question 27

What is the benefit of using ICG FA?

Answer 27

Finding Occult CNVM

Question 28

What type of defect will you notice on the OCT if there is an RPE Atrophy?

Answer 28

Window Defect

Question 29

True or False. With RPE Atrophy, the image of the Dry AMD can be seen upto the choroid?

Answer 29

True.

Question 30

An OCT image shows complete irregularity in the the macula area. What is usually directly correlated to Wet AMD and this irregularity?

Answer 30

CNVM

Question 31

True or False. Hard exudates will stain later in stage compared to soft exudates?

Answer 31

False. Hard will immediatly Fluoresce and Soft will copulate over time. Leakage will occur in soft exudates

Question 32

What is the follow up protocol for Dry AMD?

Answer 32

* 6-12 months, Depends on appearance * Early hard drusen only-about 12 months * Some soft drusen-about 9 months * Extensive soft drusen-about 6 months * Geographic atrophy-6-12 months

Question 33

What is the protocol for follow up of a WET AMD?

Answer 33

* Confirm fundoscopic findings with ancillary tests * Any new area of CNVM, bleeding, fluid, etc MUST be referred to OMD for treatment –Treatment of Wet AMD is outside of scope of OD in all 50 states * OMD will proceed with treatment * OMD will follow-up every 1-3 months until CNVM inactive

Question 34

What is follow up protocol for Disciform Scar?

Answer 34

* If scarring extensive, new treatment won’t be very effective * Monitor based on risk of more visual impairment * Usually every 12 months * If extensive scarring, extensive VI

Question 35

What is the most common testing conducted on AMD pts?

Answer 35

Amsler Grid

Question 36

What is the benefit of PHP; in regards to photoreceptors?

Answer 36

Sensitivity to photoreceptors

Question 37

What is the treatment of Dry and Wet AMD?

Answer 37

•Dry –Oral vitamins –Experimental treatments •Wet –Oral vitamins –Intravitreal injections –(laser, PDT)

Question 38

What was the most effective measure for individuals with Int. AMD or Advanced AMD in 1 eye?

Answer 38

High levels of antioxidants and zinc Formula: AREDS 1 Formula * 500 milligrams of vitamin C * 400 international units of vitamin E * 15 milligrams of beta-carotene (concern in smokers developing lung cancer) * 80 milligrams of zinc as zinc oxide * 2 milligrams of copper as cupric oxide –Prevent copper deficiency, which may be associated with high levels of zinc •OK to take multivitamin in addition

Question 39

What is the formula in AREDS 2?

Answer 39

* 500 milligrams of vitamin C * 400 international units of vitamin E * 80 milligrams of zinc as zinc oxide * 2 milligrams of copper as cupric oxide –Prevent copper deficiency, which may be associated with high levels of zinc * 10 milligrams lutein * 2 miligrams zeaxanthin

Question 40

What is the protocol of IV injections in AMD pts?

Answer 40

1. Upon sign of CNVM, injection monthly for 3-6 months, then as needed after 2. “Treat and extend”-after initial treatment and stabilization, intervals are adjusted based on clinical signs: extended 2 weeks if no bleeding, shortened by 2 weeks if bleeding

Question 42

What is Purtscher retinopathy?

Answer 42

Loss of vision after acute compression injuries to the thorax or head Presentation: CWS, Heme and retinal edema FA: Arteriolar obstruction and leakage May occur: APD and disc edema

Question 43

What is Valsalva or Venous retinopathy?

Answer 43

IO Venous pressure increases. Around macula, you will see a hemes. Located on the NFL, Ex: Large amount of blood right infront of the macula (fundus photo).

Question 44

What is hyperviscosity syndrome?

Answer 44

Vascular occlusion, therefore a flow decrease damage vessels with leakage and ischemia; usually due to high protein (hyperglobulinemia)

Question 45

What is HIV retinopathy?

Answer 45

Many hemes; CWS; decreased VA and advanced pts will have it. This will tell you that you will have an asymptomatic issues.

Question 46

What is the presentation of interferon retinopathy?

Answer 46

CWS, hemes, block FA but after discontinuation will stop all the symptoms. Note: Monitor monthly if there is retinopathy and if not 3 months RTC

Question 47

What is Talc Retinopathy?

Answer 47

Talc is inert filler in methylphenidate hydrochloride tablets: crushed for IV drug use IV to lungs: Infarcts to right to left and CRVO will occur

Question 48

What is Terson syndrome?

Answer 48

Vitresous and sub-ILM or subhyaloid hemorrhage (sub ILM) Usually occurs due to trauma 1/3 subarachnoid or subdural heme

Question 49

What is child abuse syndrome?

Answer 49

Due to trauma; you will see blood in the back of eye and this is the only sign that you could find. Heme's and 80% of shaken baby syndrome you will see this.