3. Introduction to AMD

Question 1

What is the most common cause of visual impairment in older adults in the Europe?

Answer 1

Late stage AMD

Question 2

AMD affects people of what age?

Answer 2

Affect people older then 50 years old

Question 3

Describe what AMD Means

Answer 3

A degenerative disease causing progressive damage to the macular area of the retina, leading to loss of central vision

Question 4

What are the common complains of patients with AMD?- symptoms

Answer 4

Blurred vision, reading difficulties, visual distortion, problems to adaptation after sunlight exposure.

Question 5

What are the modifiable and unmodifiable risk factors of AMD

Answer 5

Modifiable risk factors:
1. Smoking
2. Hypertension
3. (Sunlight Exposure)
4. (Heavy Alcohol Consumption)

Unmodifiable risk factors:
1. Age
2. Gender: Women at high risk
3. Genetic predisposition
4. Race: Caucasians

Question 6

What is seen when someone has early AMD? (2)

Answer 6

1. Drusen
2. Pigment changes

Question 7

2 features observed in late AMD

Answer 7

1. Geographic atrophy (GA)
2. Choroidal Neovasculariation (CNV)

Question 8

What falls under dry and wet AMD?

Answer 8

Dry AMD: GA, Drusen, pigment changes and Geographic atrophy.
Wet AMD: Choroidal neovascularization (CNV).

Question 9

What is Drusen?

Answer 9

Initial signs of AMD
Extracellular deposits located between RPE and brunch’s membrane

Question 10

AMD affects inner or outer retina?

Answer 10

Outer

Question 11

Describe the size of hard and soft drusen

Answer 11

Hard drusen <63 μm; Soft drusen >63 μm

Question 12

How are drusens classified depending on its edges?

Answer 12

Distinct or indistinct

Question 13

What is confluent drusen?

Answer 13

When drusens become bigger and join together- overlap together

Question 14

Describe the difference between hyperpigmentation and hypopigmentation

Answer 14

Hyperpigmentation: deposits of granules or clumps of gray or black pigment.
Hypopigmentation: RPE depigmentation is characterized by faint areas of various density and configuration without sharply defined borders.

Question 15

Can pigment changes occur at the same side as drusen?

Answer 15

YES, and presence of both indicates a great risk of progression to late stage AMD compared to seeing one sign alone.

Question 16

Describe GA

Answer 16

1. Well circumscribed areas of depigmentation
2. Underlying choroid becomes more visible

Question 17

Are pharmacological treatments available for GA and NV?

Answer 17

No for GA, yes for NV

Question 18

Describe CNV

Answer 18

Abnormal newly formed vessels originating from choroid, breach Bruch’s membrane and invade into sub-RPE space and into the subretinal space

The abnormal vessel growth can lead to fibrovascular proliferation, resulting in vitreous haemorrhage and tractional retinal detachment

Question 19

What is the full form of VEGF and what kind of a molecule is it?

Answer 19

Vascular endothelial growth factor and it is a naturally occurring lipoprotein molecule

Question 20

Role of VEGF in the pathological cause of AMD

Answer 20

The abnormal changes in the outer retina, due to AMD, stimulate the release of VEGF. VEGF stimulates abnormal neovascularisation (a key characteristic of neovascular AMD). VEGF also induces inflammation and increases vascular permeability

Question 21

Anti- VEGF Drugs role?

Answer 21

Block VEGF from binding

Question 22

What are the normal changes seen in the fundus of the eye in terms of drusen

Answer 22

Only druplets seen- small amount of drusen

Question 23

What is seen in the fundus of a patient with early AMD- drusen and pigment changes

Answer 23

Medium drusen and no pigment changes

Question 24

What is seen in the fundus of a patient with intermediate AMD- drusen and pigment changes

Answer 24

Large drusen and pigment changes

Question 25

What is seen in the fundus of a patient with late AMD?

Answer 25

Neovascular AMD and/ or geographic atrophy

Question 26

What are the 4 techniques used to image AMD, and which of these can be performed by optoms?

Answer 26

Performed by optoms:
1. Colour fundus photography
2. Optical coherence tomography (OCT)
Not performed by optoms:
3. Fluorescein Angiography (FA)
4. Indocyanine Green Angiography (ICGA)

Question 27

What is seen in the OCT in early AMD

Answer 27

1. Dorm shaped elevations in the RPE.
2. Hyper-reflective foci: corresponding to spots of hyper-pigmentation.

Question 28

What is seen in the OCT in late stage AMD

Answer 28

GA: Patches of GA seen as reflective spots on the choroid
CNV: Elevations seen in the RPE as “pointy” shaped (Elevations of the retina). Additionally, the CNV is invading the sub-retinal space- creating blood and fluid to accumulate in this space.

Question 29

Describe what kind of technique is OCTA and what is seen

Answer 29

This is a non- invasive technique. What is seen: Volumetric angiographic images are seen: showing the structural blood flow through the choroid.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY. this is a new type of OCT

Question 30

Describe the procedure for Fluorescein angiography and what observation is made?

Answer 30

Sodium fluorescein injected into patient arm. Image is captured to trace retinal and choroidal circulation. Images are studied for increased or decreased fluorescence: this is used to decided the type on CNV the patient has.

Question 31

Describe which one is better ICG or fluorescein?

Answer 31

ICG: this green dye has a longer wavelength than fluorescein. Longer wavelength, gives a better visualization of the choroid and this is used to image the ill-defined CNV.

Question 32

Why is early treatment of CNV important?

Answer 32

Early intervention is important for success of the treatment.

Question 33

• 2 previous treatments for CNV, not used anymore is?

Answer 33

1. PDT
2. Surgical e.g, macular translocation

Question 34

Signs of AMD

Answer 34

Loss of VA, loss of contrast sensitivity, distortion on amsler grid.