AMD

Question 1

What are the modifiable risk factors for AMD?

Answer 1

Smoking
Weight
Lack of exercise
Hypertension
(Sunlight exposure)
(Heavy alcohol consumption)

Question 2

What are the unmodifiable risk factors for AMD?

Answer 2

Age
Family history
(Caucasian race)
(Female gender)

Question 3

What clinical features are present in early AMD?

Answer 3

Drusen
Pigmentary changes

Question 4

What clinical features are present in late AMD?

Answer 4

Geographic Atrophy
Choroidal Neovascularisation

Question 5

What clinical features are present in dry AMD?

Answer 5

Drusen
Pigmentary changes
Geographic Atrophy

Question 6

What clinical features are present in wet AMD?

Answer 6

Choroidal Neovascularisation

Question 7

What are drusen and where do they form?

Answer 7

Lipid/protein extracellular deposits between Bruch’s membrane and the RPE

Question 8

What size are drusen compared to to determine if they’re hard or soft?

Answer 8

63um (width of a blood vessel)
If under: hard AKA drupelets
If over: soft

Question 9

What is geographic atrophy?

Answer 9

Loss of PRs, revealing area of depigmentation so choroid is visible, well-circumscribed

Question 10

What is choroidal neovascularisation?

Answer 10

Neovasc originating from the choroid which breach Bruch’s membrane and invade sub-RPE/retina

Question 11

What can CNV lead to?

Answer 11

Fibrovascular Proliferation (leads to vitreous haem and tractional retinal detachment)

Question 12

What is Fibrovascular Proliferation?

Answer 12

Growth of fibrous elements from new blood vessels which could contract, leading to vitreous haem and RD

Question 13

What causes VEGF release?

Answer 13

Abnormal retinal changes seen in AMD

Question 14

What happens as a result of VEGF release?

Answer 14

Neovascularisation, inflammation and increased vessel permeability

Question 15

How can AMD be imaged?

Answer 15

OCT
Fundus photography
Fluorescein angiography
Indocyanine green angiography

Question 16

How is Fluorescein angiography helpful to assess AMD?

Answer 16

Can visualise CNV more easily as can view blood flow into choroid

Question 17

How is Indocyanine green angiography helpful in assessing AMD?

Answer 17

Visualises poorly circumscribed areas more easily due to longer wavelength of green dye (compared to NaFl)

Question 18

What are some previous treatments for AMD?

Answer 18

Surgical movement of macular
Photodynamic therapy

Question 19

How does anti-VEGF work?

Answer 19

The drug injected binds to receptor sites on VEGF, stopping it from binding - so stopping neovasc, inflammation and increased vessel permeability

Question 20

What is the brand name of Ranibizumab?
What is it licensed for?
What is injected?
How often is it injected?

Core

Answer 20

Lucentis
Wet AMD
Antibody fragment
Monthly injection

Question 21

What is the brand name of Bevacizumab?
What is it licensed for?
What is injected?
How often is it injected?

Further

Answer 21

Avastin
Oncology but used in AMD
Full length antibody
Monthly injection

Question 22

What is the brand name of Aflibercept?
What is injected?
How often is it injected?

Core

Answer 22

Eylea
‘VEGF trap’ fusion protein - decoy receptor
Injected every 8 weeks

Question 23

What is the brand name of Brolucizumab?
What is injected?

Further

Answer 23

Beovu
Single chain antibody fragment - small so penetrates and leaves circulation quickly

Question 24

What is the brand name of Faricimab?
What is injected?
How often is it injected?

Further

Answer 24

Vabysmo
Bispecific antibody - inhibits angoprotein-2 and VEGF
Injected every 16 weeks

Question 25

What is the brand name of Pegaptanib? What is injected? When did NICE stop recommending its use?

Answer 25

Macugen RNA fragment 2015

Question 26

What are the NICE guidelines for treatment of AMD?

Answer 26

VA - between 6/12 and 6/96 No permanent structural damage to central fovea lesions are less than or equal of 12 disc areas Evidence of recent disease progression (neovasc, VA changes, Amsler distortion)

Question 27

What are possible future treatments?

Answer 27

Gene therapy Anti-inflammatory therapy (corticosteroids) Combination of anti-VEGF and corticosteroids Stem cell therapies

Question 28

What nutritional guidance should you give to patients with AMD?

Answer 28

Eat lots of dark green leafy veg and orange/yellow foods Fish 3-4 times per week Supplements of vitamins/minerals (not specific brands!)

Question 29

What nutrients help to defend against oxidative damage in the retina?

Answer 29

Vitamins C and E Beta-carotene Zinc Omega-3 fatty acids Carotenoids (Lutein and Zeaxanthin)