Age-Related Macular Degeneration

Age-Related Macular Degeneration (AMD) is a progressive eye condition affecting as many as 15 million Americans and millions more around the world. The disease attacks the macula of the eye, where our sharpest central vision occurs. This is the vision we use to drive, read, recognize faces and perform daily tasks. AMD does not cause complete blindness, only central blindness. It spares the peripheral vision (around the edges), leaving only dim images or black holes at the center of vision.

Symptoms include: A dark area in the center of vision, blurred or wavy vision and/or distortion

AMD is the number one cause of severe vision loss and legal blindness in adults over 60 in the U.S. It escalates with age. It affects 14%-24% of the U.S. population aged 65-74 years and 35 – 40% of people aged 74 years or more have the disease. In other words, more than one person in three can develop signs of age-related macular degeneration, with over 200,000 new cases diagnosed every year.

There are two types of AMD – “wet” or neovascular and “dry” or atrophic. There is no cure for AMD, but, a variety of therapies are available for wet macular degeneration, with intravitreal injections the standard of care. There is no treatment for the dry form of macular degeneration …yet. The good news is Pepose Vision is at the forefront in exciting new clinical research studies and offers an opportunity for our patients to benefit from these studies. Please see below to learn more about our AMD studies and how you could possibly participate.

Even with vision loss, training and special devices can promote independence and a return to favorite activities.

The human retina is made up of layers of cells that line the entire inside of the globe of the eye.The macula is the most sensitive part of the retina, located in the very center of the retina. When light strikes the back of the eye, the cells of the macula and the rest of the retina send electrical signals to the brain through the optic nerve which leads to the brain. The brain translates the electrical signals into the images we see. It is about the size of the head of a straight pin and contains millions of light-sensing cells that provide sharp, detailed central vision. If the macula is damaged, the images received by the brain are distorted or not clear.

The eye

How do I know if I have Age-Related Macular Degeneration?

Many people do not realize they have a macular problem until they notice they have blurred or distorted vision. Regular eye exams by an ophthalmologist may help to detect problems or early stages of macular degeneration before you are even aware of them.

Dry macular degeneration: Detection with an ophthalmoscope

To check for macular degeneration, we will dilate (widen) your pupils using eyedrops and examine your eyes with an ophthalmoscope, a device that allows us to see your retina and other areas at the back of your eye. If macular degeneration is detected, we may have you use an Amsler grid to check for macular degeneration symptoms such as wavy, blurry or dark areas in your vision.

Wet macular degeneration:
Detection with fluorescein angiography and optical coherence tomography

If we suspect you may have the wet form of macular degeneration, we will take special photographs of your eye with fluorescein angiography and optical coherence tomography (OCT). OCT scanning is a sophisticated and exact tool that detects abnormal blood vessels by creating a special picture of your macula.

amd fluorescein angiographyDuring fluorescein angiography, a fluorescein dye is injected into a vein in your arm. The dye travels throughout the body, including your eyes. Photographs are taken of your eye as the dye passes through the retinal blood vessels. Abnormal areas will be highlighted by the dye, showing us whether wet macular degeneration treatment is possible and, if so, where to treat the abnormal vessels.

 


The Macular Disease Society has published this helpful video entitled “Living with Macular Degeneration.”

Frequently asked questions

Age-related macular degeneration (AMD) is the leading cause of legal blindness in the United States for persons aged 65 or older. It is an age-related degeneration of the macula, or center of the retina. (The macula allows for reading and driving vision.) AMD is described in 2 forms: Dry and Wet. In dry AMD, the retina will have age-spots called drusen in the macula. The drusen are compatible with good vision, but place an individual at risk for progressing to wet AMD. Wet AMD is a condition in which abnormal blood vessels grow underneath the macula and cause a bleeding and leakage (hence the term “wet”) that destroys central vision.
No, if you have wet age-related macular degeneration (AMD), monthly shots are the standard of care for however long your doctor determines you need them. In the clinical trials that showed these shots were safe and effective for wet AMD, patients received 24 monthly shots with no adverse effects on the eye. Outside of the clinical trials, some patients have required more than 30 or 40 shots into one eye and have done well. However, if you have been receiving a lot of shots, you may wish to get a second opinion as there are other macular conditions that may mimic wet AMD that do not respond to shots
Wet age-related macular degeneration (AMD) has a whole spectrum of severity. At the outset of treatment, neither the patient nor the doctor knows how many shots it will take to render wet AMD dry again (which is the goal of treatment). Some patients have wet AMD that resolves after a single shot. Some patients have recalcitrant disease and will receive monthly shots for an extended period of time, even years. Your retina specialist will put your affected eye through monthly testing in the office to determine if your macular degeneration is wet or dry. If it is wet, then your condition will continue to require shots. As stated above in answer 9, if you have concerns, you may wish to get a second opinion to make sure the condition being treated truly is wet macular degeneration.
Yes, that is the official recommendation arising from a national randomized prospective clinical trial on the treatment of wet AMD. This trial showed that monthly monitoring with shots as needed was not inferior to monthly shots (the previous standard of care), but stipulated the importance of both the doctor and the patient being compliant with the monthly visits for the best visual outcome.

A recent national prospective randomized clinical trial pitted Avastin against Lucentis in a head-to-head competition. Now famously referred to as the CATT Trial, the study found that Avastin was not inferior to Lucentis regarding visual outcome after 1 year when dosed in the same manner (There were 2 dosing regimens: mandatory monthly shots or monthly visits with shots as needed). There are two minor caveats: 1). Avastin may be associated with a higher incidence of systemic complications requiring hospitalization and 2). Lucentis may be slightly better at “thinning” the retina, a desirable anatomical outcome. However, these last two points require 2-year follow-up to see if the differences in the first year of the study hold true.

Avastin and Lucentis are closely related in that they are cousin molecules. They share the same grandparent molecule but have different parent molecules. Avastin is a larger molecule that was designed for stability in the blood stream, as it is FDA-approved for intravenous administration. Lucentis is a small molecule as it was designed to be injected into the vitreous cavity and penetrate into the retina. Both are drugs with anti-VEGF properties. The biggest difference between Avastin and Lucentis is price. Avastin can cost as little as $50. Lucentis costs roughly $2000.
VEGF stands for Vascular Endothelial Growth Factor. It causes abnormal blood vessels in the macula to grow and leak, essentially making wet macular degeneration “wet”. The purpose of treatment for wet AMD is to inject an anti-VEGF drug like Avastin or Lucentis into the eye in order to make the leaking blood vessels inactive and return the macula to being “dry”. It may take numerous injections to convert the “wet” form of AMD to dry again.
Yes, but not in the way that blond hair and blue eyes are hereditary. Macular degeneration is not autosomal dominant or recessive. Rather, DNA will carry variations that predispose a person to advanced forms of AMD. It has been determined that approximately 70% of a person’s risk for advanced forms of AMD are encoded in their DNA and that 30% is due to other factors like smoking, diet, and other environmental conditions. Currently, there are genes that have been identified, and are linked to advanced forms of AMD the same way smoking is linked to lung cancer.
Yes, there are two companies that offer genetic testing for AMD: Arctic Dx has a test called Macula Risk, and Sequenom has a test called Retna Gene. Both are offered at the Pepose Vision Institute. Both tests collect DNA by taking a gentle swab of the inside of the cheek. Both tests are covered by insurance if you have the diagnosis of AMD and a doctor orders the test. Both tests are thought to have an 83% positive predictive value for estimating an individual’s risk of developing advanced AMD by the age of 80.
An Amsler Grid is used to monitor the central 30 degrees of visual field for signs of distortion or visual abnormality that may signal the onset of wet macular degeneration. It is important to test each eye independently by covering one eye and then the other when using the Amsler Grid. With the Grid held reading distance away, look at the central dot and make sure all of the lines are straight and that the entire grid can be visualized. If straight lines become wavy or distorted, or a portion of the grid is missing, then you should call your ophthalmologist or retina specialist for an immediate evaluation. These changes will come on suddenly, even overnight, and merit urgent evaluation in someone with a known history of dry AMD.
The Foresee Home Device is a computerized, more sophisticated version of the Amsler Grid that has been FDA approved for early detection of wet AMD in patients who currently have dry AMD. It has been reported to detect early-onset wet macular degeneration before changes are evident on the amsler grid, visual acuity testing, or clinical examination by the doctor. It is well established that early detection leads to early treatment and a better outcome when treating wet macular degeneration.
The Foresee Home Device does not require a computer, but it does require familiarity with using a computer mouse. When using the device, a patient is asked to look into a monitor similar to the one used at the Department of Motor Vehicles when obtaining a driver’s license. The Foresee Home Device will flash a dotted line on to the screen. The dotted line will have a small distortion in it. The patient will use the mouse to click on the distortion. This is repeated multiple times. Each test takes about 2 minutes per eye. The information is sent via telephone to a central monitoring site that analyzes the test results on a daily basis. If the test results become abnormal, both the patient and the doctor are contacted to arrange an appointment.

Exciting Age-Related Macular Degeneration Clinical Studies at Pepose Vision.

This is an excellent opportunity to try tomorrow’s technology today.

In addition to a wide range of advanced vision services, Pepose Vision Institute is also a ophthalmological research center. We perform important clinical studies on new treatments for a variety of vision issues.  Some of our most exciting studies are for the treatment of the dry form of Macular Degeneration. This is exciting because at present there are no known treatments.

Our studies offer our patients a chance to experience the latest breakthroughs in the treatment of dry form of Macular Degeneration. And to play an important role in helping to potentially develop treatments for millions of people that experience this condition.

To learn more about our studies, please click here.

What's your next step?

If you have any of the symptoms we've discussed on this page, or you've been diagnosed by your eye doctor with macular degeneration, please come see us right away. Our experienced doctors will use advanced diagnostics to determine exactly how to help you see your very best, patiently answer your questions and carefully explain all your options, including our clinical studies.

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