6.1.9: Manages pxs with macular degeneration

Question 1

Describe the Bruch membrane in AMD?

Answer 1

– Bruch membrane is basement membrane between RPE and Choroid and maintains microenvironment of the photoreceptors.
Changes to bruchs membrane such as thickening lead to problems. Fovea supplied by rich blood supply from choriocapilliary arteries.
Functionality of Bruchs membrane and RPE decrease with age

Question 2

What is dry AMD?

Answer 2

Dry is more common than wet
A natural dysregulation of biological retinal processes with time causes a build-up of
waste product generated by the photoreceptors.
This product sits between the RPE and Bruch’s membrane and is called Drusen

Question 3

What is the NICE classification of normal eyes?

Answer 3

o No signs of AMD.
o Small (hard) drusen (<63 micrometres (1/2 a vein width (look at central vein))) only.

Question 4

What is the NICE classification of early (dry) AMD?

Answer 4

o Low risk of progression:
 Medium drusen (≥63 but <125 micrometres), or
 Pigmentary abnormalities.
o Medium risk of progression:
 Large drusen (≥125 micrometres), or
 Reticular drusen, or
 Medium drusen with pigmentary abnormalities.
o High risk of progression:
 Large drusen (≥125 micrometres) with pigmentary abnormalities, or
 Reticular drusen with pigmentary abnormalities, or
 Vitelliform lesion without significant visual loss (best-corrected acuity better than 6/18), or
 Atrophy <175 micrometres and not involving the fovea.

Question 5

What is the NICE classification of late (dry) AMD?

Answer 5

o Geographic atrophy (in the absence of neovascular AMD).
o Significant visual loss (6/18 or worse) associated with:
 Dense or confluent drusen, or
 Advanced pigmentary changes and/or atrophy, or
 Vitelliform lesion.

Question 6

What is reticular drusen? What is hard drusen? What is soft drusen?

Answer 6

Reticular drusen are located superficial to RPE
Yellowish
Hard drusen - smaller, well-defined, normal degeneration
Softt drusen - larger, ill-defined, aMD

Question 7

What are the symptoms of dry AMD?

Answer 7

difficulty reading/missing words, struggle to recognise faces

Question 8

What is the management of dry AMD?

Answer 8

• Smoking cessation & advice on driving –> smoking promotes ischaemia, slows down choroidal blood flow & reduces macular pigment
• Leafy green vegatables & oily fish
• Counselling - diagnosis can be a shock
• Provide information (large print) - direct to Macular Society
• Monitor disease progression - give Amsler
• AREDS 1/2 studies have shown supplements have best prognosis if used in: lutein & zeaxanthin
  o extensive medium sized drusen
  o multiple large drusen
  o non-central geographic atrophy in one eye or both
  o advanced AMD or decreased VA due to AMD in 1 eye
  o best for inteermediate or advanced AMD sufferers
• Contraindications of supplements:
  o Smoking & beta-carotene –> more likely to trigger luung failure/lung cancer
  o Genitourinary problems & zine –> may cause kidney stones or UTI
  o Heart failure & Vitamin E –> increase risk of heart failure
  o Px should speak to GP/pharmacist before taking supplements
  Referral:
  o Low Vision Services
  o To social services -> eye care liason officer, occupational therapist to help around house
  o For SI or SSI registration (Ophthalmology)

Question 9

What is wet AMD?

Answer 9

VEGF release causes angiogenesis, triggering neovascular vessels to grow within the
choriocapillaris and through into bruch’s membrane.
These vessels are extremely fragile, causing breakage and subsequent fluid leak of fluid &
blood beneath the macula

Question 10

What is the NICE classification of late AMD (wet active)?

Answer 10

o Classic choroidal neovascularisation (Choroidal Neovascularisation (CNV)).
o Occult (fibrovascular Pigment Epithelium Detachment (PED) and serous PED with neovascularisation).
o Mixed (predominantly or minimally classic CNV with occult CNV).
o Retinal angiomatous proliferation (RAP).
o Polypoidal choroidal vasculopathy (PCV).

Question 11

What is the NICE classification of late AMD (wet inactive)?

Answer 11

o Fibrous scar.
o Sub-foveal atrophy or fibrosis secondary to an RPE tear.
o Atrophy (absence or thinning of RPE and/or retina) – geographic atrophy
o Cystic degeneration (persistent intraretinal fluid or tubulations unresponsive to treatment).

Question 12

What are the signs of wet AMD?

Answer 12

• Drusen
• Hard exudates
• Haemorrhages
• Sub-retinal fluid
• Sub-RPE fluid
• Hyper & Hypopigmentation

Question 13

What is choroidal neovascularisation (AMD)?

Answer 13

– CNV lesion are classified according to their location relative to the fovea and NaFl angiographic leakage. Telltale sign is a sub retinal haemorrhage and a subtle grey-green discolouration due to CNV. Angiography shows extent of lesion.

Question 14

Management of wet AMD?

Answer 14

• Urgent referral - if new presentation (via macular pathway)
• Px nees seen at macular clinic (OCT & NaFl angiography - to show if wet active or wet inctive)
• Anti-VEGF injections: lucentis, avastin (Bevacizumab (not used on NHS), eyelea –> 3 sets of monthly injections
• Following this, if more are needed (maintenance dose):
  o Lucentis (Ranibizumab) every 4 wks: 6/12 - 6/96
  o Eyelea (Afibercept) every 8 wks: 6/12 - 6/96
• Toxicity/Complications:
  o Endophthalmitis
  o Traumatic cataract
  o Retinal detachment
  o Mild inflammation
  o Increased IOP
  o Stroke/heart attack
• Discharge of AMD pxs:
  o based on stability of condition or if tx will bring any further benefit
  o Pxs should return ASAP if new sxs develop
  o Monitor px who have AMD in one eye closely - likely to develop in other eye
  o Up to date Rx as recommended by consultant
  o Support services (RNIB/macular society)

Question 15

Describe macular hole - RFs, sxs, signs, differential, managment, treatment?

Answer 15

A macular hole is a retinal break that involves the fovea, most macular holes are idiopathic
however it could also be due to traction between the posterior hyaloid membrane and parafovea and this occur as
complication of a posterior vitreous detachment (PVD)
* Risk Factors – age, myopia, trauma or ocular inflammation (most common in females over 60)
* Symptoms – Metamorphopsia (distortion of central vision), central vision loss or scotoma
* Signs – depending on the stage of the MH, a subfoveal lipofuscin-colour spot or ring can be noted. In more
advanced cases, a partial or full thickness macular break is observed
* DD – epiretinal membrane with pseudohole, lamellar hole, vitreomacular traction, CMO, subfoveal drusen, central
serious chorioretinopathy, adult vitelliform macular dystrophy
* Management – URGENT REFERRAL (within one week) – ophthalmologist will determine if treatment necessary
* Treatment – idiopathic MH may be followed closely to see if it closes spontaneously. Surgical options for MH is a
vitrectomy with a tamponade with/without ILM peel.
* Prognosis – the visual outcomes following vitrectomy is very favourable