Age Related Macular Degeneration

Question 1

What is ARMD?

Answer 1

Degeneration in the macular that causes a progressive deterioration in vision

-SUDDEN PAINLESS LOSS OF VISION

Question 2

What is ARMD the most common cause of?

Answer 2

Blindness

Question 3

What is a key finding in age related macular degeneration?

Answer 3

Drusen seen during fundoscopy

Question 4

2 types of age related macular degeneration?

Answer 4

WET - 10%

DRY - 90%

Question 5

Which type of ARMD is worse?

Answer 5

Wet

Question 6

What is the macular made up of?

Answer 6

4 key layers 
From bottom to top there is: 
- Choroid layer
-Bruch's membrane 
-Retinal pigment epithelium 
-Photoreceptors

Question 7

What does the choroid layer contain?

Answer 7

Blood vessels that provide blood supply to the macula

Question 8

What are Drusen?

Answer 8

Yellow deposits of proteins & lipids that appear between retinal pigment epithelium & Bruch’s membrane

Question 9

When are drusen common?

Answer 9

Wet and dry macular degeneration

Question 10

When can drusen be common?

Answer 10

<63 micrometres

Question 11

What can large numbers of large drusen be a sign of?

Answer 11

Macular degeneration

Question 12

Features common to both wet and dry macular degenration?

Answer 12

Drusen
Atrophy of retinal pigment epithelium
Degeneration of photoreceptors

Question 13

How is wet MD different to dry MD?

Answer 13

Development of new vessels growing from choroid

Question 14

What does new vessel growth result in in Wet MD?

Answer 14

The vessels can leak and cause oedema

- Key chemical which stimulates new vessel development is VEGF

Question 15

What is VEGF?

Answer 15

Vascular endothelial growth factor

Question 16

Risk factors of age related macular degeneration?

Answer 16

• Age
• Smoking
• White/Chinese ethnic origin
• Family history
• Cardiovascular disease

Question 17

Presentation of Wet or dry ARMD?

Answer 17

• Gradual worsening central visual field loss
• Reduced visual acuity
• Crooked or wavy appearance to straight lines

Question 18

Presentation specific to Wet ARMD?

Answer 18

More acute presentation

• Loss of vision over days
• Often progresses to bilateral

Question 19

Examination findings for ARMD?

Answer 19

Reduced acuity using Snellen chart
Scotoma (central patch of vision loss)
Amsler grid tests (assesses distortion of straight lines)
Fundoscopy (findings=drusen)

Question 20

Investigations for ARMD?

Answer 20

• Slit lamp biomicroscopic fundus examination (Can diagnose AMD)
• Optical coherence tomography (Diagnoses Wet ARMD)
• Fluorescein angiography (looks in detail at the retinal blood supply)

Question 21

What is Fluorescein angiography and what does it show?

Answer 21

Photographs retina

• Looks in detail @ blood supply to retina
• Reveal oedema & neovascularisation

Question 22

Management of dry ARMD?

Answer 22

No specific treatment

- Lifestyle changes eg stop smoking, control BP, Vitamin supplements

Question 23

Management of wet ARMD?

Answer 23

-Anti-VEGF meds injected directly into vitreous chamber once a month

They slow down progression and can sometimes reverse the disease, typically need to be started within 3 months though

Question 24

Examples of anti-VEGF meds?

Answer 24

Ranibizumab
Bevacizumab
Pegaptanib

Question 25

Pathophysiology of ARMD?

Answer 25

New blood vessels grow under the retina | Leakage causes fluid build-up ad eventually scarring

Question 26

Symptoms of ARMD (wet)?

Answer 26

- Blurred vision - Diminished or change colour perception - Visual disturbance - Visual hallucinations

Question 27

Treatment of age related macular degeneration wet?

Answer 27

- Anti-VEGF (vascular endothelial growth factor) injection | - Laser coagulation therapy

Question 28

Presenting complaint of age-related macular degeneration (dry)?

Answer 28

Gradual, painless loss of central vision

Question 29

Causes of ARMD dry?

Answer 29

- Damage to the cells of the macula as a result of build up of waste products called drusen - Thickened retina

Question 30

Symptoms of ARMD dry?

Answer 30

Blurring central vision | Can occur over 5-10 years

Question 31

Diagnosis of dry agmd?

Answer 31

Amsler grid testing | Fundoscopy

Question 32

Treatment for Dry ARMD?

Answer 32

Irreversible damage | Treatment based on helping person make the most of their remaining vision

Question 33

What is dry ARMD?

Answer 33

Accumulation of drusen (proteins, lipids and inflammatory mediators which are by products of retinal epithelial cells

Question 34

Presnetation of dry ARMD?

Answer 34

Gradual decline in vision | Central vision missing

Question 35

Investigation of dry ARMD?

Answer 35

On fundoscopy: - Drusen - Atrophic patches of retina

Question 36

Treatment for dry ARMD?

Answer 36

No cure - Supportive with low vision aids - Vitamin supplementation

Question 37

What is Wet ARMD?

Answer 37

Vascular haemorrhages due to neovascularisation in choroid

Question 38

Why are new vessels in wet ARMD leaky?

Answer 38

They are new and small (like a baby)

Question 39

What is wet ARMD mediated by?

Answer 39

VEGF

Question 40

Presentation of wet ARMD?

Answer 40

Rapid central loss of vision Distortion - Metamorphosia - Show them amsler grid to point out distortion

Question 41

Wet ARMD findings on fundoscopy?

Answer 41

Haemorrhage | Exudate (causes paleness)

Question 42

Treatment of wet ARMD?

Answer 42

Monoclonal antibodies to VEGF