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Flashcards in Maculopathy & AMD Deck (33):
1

Age-related maculopathy (ARM)

  1. Definition?
  2. Characteristics? RPE changes?

  1. Exaggeration of the 'normal' ageing process 
  2. Characterised by
    Drusen
    Hyperpigmentation
    or  depigmentationof the RPE associated with drusen

 

 

2

Age-related macular degeneration (AMD)

  1. Definition? In relation to ARM?
  2. Characterised by? (4) 
    G
    P
    S
    S

 

  1. Advanced, sight-threatening stage of ARM
  2. Characterised by
  • Geographic atrophy of the RPE with visible underlying choroidal vessels
  • Pigment epithelial detachment (PED)
  • Subretinalor sub-RPE choroidal neovascularization (CNV)
  • Scar tissue, haemorrhage and exudates 

 

 

3

AMD risk factors?

 

  1. Age 
  2. ARM
  3. Race
  4. Positive family history
  5. Cataract
  6. Biomarkers for cardiovascular disease
  7.  Smoking
  8. Obesity
  9. Hypertension

 

4

Drusen

  1. What cause it?
  2. If not cleared, consequence?
  3. Made up of?
  4. Effect of Brunch's membrane?
  5. Appearance of lesions?

  1. RPE removes & processes the discs of the outer segments of the photoreceptors
  2. If not cleared by the RPE, deposits accumulate in Bruch’s membrane
  3. Made up of lipids
  4. Bruch’s membrane thickens as a result of the deposits
  5. Discrete, sub-retinal yellow lesions

5

Drusen

  1. Symmetrical?
  2. Number, size, shape?
  3. Relationship to age?

  1. Usually symmetrical in both eyes
  2. Can vary in number, size, shape etc
  3. Rarely seen before age 45 years
    Increase in size & number with advancing age

6

Drusen types?

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7

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Drusen and AMD 

8

Atrophic AMD

  1. Other name? Aka?
  2. Why atrophic?
  3. Affect what structures?
  4. Patient present with?
  5. Affect one or both eye? Symmetrical or not?

 

  1. “dry” AMD
  2. Atrophy which progresses slowly
  3. Affects: 
    Photoreceptors
     RPE 
    Choriocapillaris
  4.  Gradual vision impairment. Over months or years
  5. Affects both eyes (often asymmetrically) 

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9

Sign?

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Atropic AMD 

Greyish 

Can't really see where macula is 

10

Sign?

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Atropic AMD 

Can see edges of atrophy

If look clearly, can see blood vessels of choroid 

11

Sign?

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Atrophic AMD 

Big scar over macula 

Majority of rods and cones ( haemorrhage) 

Progress slowly over time. 

Jean below 

yellowish, atrophic , drusen not obvious, vision affected severely 

12

Sign?

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Atrophic AMD 

Window defect 

Brightness of choroidal vessels

Ischaemic area - More profound appearance 

Artifarct 

13

RPE detachment

What structure involve? What cause changes?

Pt complant of?

Vision affected?

 

 

  1. Bruch’s membrane thickens up & impedes movement of fluid from RPE to choroid
  2. Patient c/o Metamorphopsia
  3. Central vision affected

 

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14

Describe the follow pictures 

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15

RPE detachment 

Course?

RPE detachment

  1. Spontaneous resolution
  2. Geographic atrophy
  3. Sensory retinal detachment
  4. RPE tear

 

16

1. RPE TEAR 

  1. Where does it occur?
  2. How does it happen?

 

RPE tear

  1. Occurs at the junction of the attached & detached RPE
  2. Happens if stress causes the tissue to rupture
    Can happen spontaneously or following laser Tx1
    Instead of everythin pushed upward, there's a tear. RPE tears and detachment usually seen in wet AMD 

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17

Describe image?

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RPE TEAR 

Detachment= dome ( fluid pushed up)

Tear= flap  

Patient c/o vision loss 

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18

AMD Review 

  1. Common leading to ?
  2. Relationship to aging? Uni or bilateral?
  3. Affect what part vision?
  4. Classification?

 

AMD review

  1. Common cause of VIP and blindness in the western world
  2. Associated with ageing, usually bilateral
  3. Affects only central vision
    Peripheral vision remains intact
  4. Classification:
  • ​Dry:  Slowly-progressing deterioration of vision
  • Wet: Neovascularisation & CNVM causes sudden loss of vision

 

 

19

AMD Review 

  1. Principle feature? Location?
  2. Changes in photoreceptor outer segment?
  3. If wet, what can grow?

 

 

  1. Drusen between the RPE and Bruch’s membrane
  2. RPE atrophy & degenerative change in photoreceptor outer segment
  3. If “wet”,  a vascular membrane can grow from the choroid towards the retina

20

AMD Review 

  1. Difference between vision loss in DRY vs WET AMD ?
  2. Effect what aspect of vision? (M) 

AMD review

  1. DRY : Progressive, gradual central vision loss 
    OR
    WET: Sudden, profound vision loss
  2. Affects reading & object recognition
    Metamorphopsia

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21

Neovascular “wet” AMD

Cause by? Originate from where?

List 3 growth patterns?

Neovascular “wet” AMD

  1. C/b CNV originating from the choriocapillaris: grows through defects in Bruch membrane
  2. 3 growth patterns:
  • Sub-RPE: Most common in AMD
  • Sub-retinal: Less common in AMD
    Likely in younger patients with myopia or chorioretinitis
  • Combination of 1 & 2

 

22

23

MECHANISM OF VISION LOSS?

  1. Principle factor?
  2. How does it develop? Where?
  3. Can vision reverse? 
  4. Consequence of persistency?

 

Mechanism of vision loss

  1. CNV = Choroidal Neovascularisation  
  2. develops as a result of leakage of blood & serum
    Under the retina
    Into the retina
    Under the RPE
  3. Vision loss from accumulated fluid can be reversed
  4. If persists =Loss of photoreceptors & RPE
    Discformscar forms
    Permanent vision loss
    IMAGE: 

    - RPE detach, fluid accumulated & pushed up 
    - RPE tears both - loss of foveal contour/foveal pit. Macula on either side- as soon as that in gene --> Vision loss

 

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24

Clinical Presentation of Neovascular AMD?
Vision? Visual field defect? (3) 

  1. Metamorphopsia
  2. Positive scotoma
  3. Blurred central vision  

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25

Neovascular AMD 

Clinical sign?

Sub-retinal: RPE leak out pigment 

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26

Neovascular AMD 

FFA Investigation 

  1. Role of FFA in FAZ?
  2. Type of CNV? (3) 

 

  1. FFA important to detect & precisely locate the CNV in relation to the FAZ
    Urgent FFA if patient presents with recent onset of symptoms
  2. Types of CNV 
  • 1. Classic
    Extrafoveal
    Juxtafoveal
    Subfoveal
  • 2. Occult
  • 3. Fibrovascular PED

 

27

Types of CNV -Classic

  1. Sign on FFA? 

Location of CNV in: 
Extrafoveal?

Juxrafoveal?

Subfoveal?

 

  1. Well-defined membrane which fluoresces brightly on FFA
  • Extrafoveal: CNV is > 200μm from centre of FAZ
  • Juxtafoveal:  CNV closer than 200μm from centre of FAZ
  • Subfoveal: Centre of the FAZ is involved

 

 

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28

Types of CNV

Occult & Fibrovascular PED ( Pigment Epithelial detachment) 

  1. Characteristics of Occult compared to classic? Sign on fundus? 
  2. Fibrovascular PED?

 


 

  1. Occult: Membrane not well defined (compared with classic) and shows multiple areas of leakage
  2. Fibrovascular PED: Combination of CNV & PED

29

Sign?

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Pocket of fluid need to be dried up with anti VEGF 

Also happen in DR and CRVO 

30

Course of untreated CMV

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Haemorrhagic PED

C/b blood vessel rupture within the CNV

VA= HM at best

 

31

Course of untreated CMV

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Vitreous haemorrhage
Blood breaks through to the vitreous

Rarely occur 

32

Course of untreated CMV

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Sub-retinal (disciform) scarring
Occurs after haemorrhage

In-growth of new vessels from the choroid causes a fibrous scar at the fovea

 

33

Course of untreated CMV

  1. What is present? Cause?
  2. Progression if more severe?

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  1. Massive exudation develops sometimes if disciformscars are present
    C/b chronic leakage from CNV
  2. If severe, sub-retinal fluid spreads beyond macula = peripheral VA ↓