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GPEP Ophthalmology > Age Related Macular Degeneration > Flashcards

Age Related Macular Degeneration Flashcards

BPAC

1
Q

What is age related macular degeneration (AMD)?

A

Progressive condition
Results in loss or distortion of the central visual field (and reduced visual acuity)

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2
Q

AMD is the leading cause of ___________ in NZ

A

Blindness

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3
Q

Key risk factors for the development of AMD?

A

Age
Family hx
Smoking

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4
Q

Other risk factors include…

A

Diabetes
Sunlight exposure
Diets low in fish, fruit and vegetables
Previous cataract surgery

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5
Q

How can people reduce their risk of AMD or reduce the rate of progression?

A

Avoiding smoking (most important)
Consuming a diet with a variety of fruits and vegetables and regular fish intake
Avoiding exposure to UV light
Dietary supplements (particularly containing lutein and zeaxanthin)

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6
Q

New ____________ are highly effective at reducing vision loss in patients with neovascular (“wet”) AMD

A

Anti-VEGF intravitreal injections

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7
Q

In advanced disease people retain their peripheral vision but
are legally blind due to ___________

A

A loss of central vision

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8
Q

Is risk of AMD greater in males or females?

A

Equal

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9
Q

Māori are known to have
higher rates of vision loss from _____

A

Any cause

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10
Q

Impact on quality of life?

A

May experience little impact on their daily life in early stages of disease
Considerable changes in their quality of life, independence and relationships with advanced disease

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11
Q

The rate of progression is
highly variable, but most visual loss occurs when?

A

Once the disease has progressed to “late” AMD

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12
Q

AMD increases risk of what mental health conditions

A

People with AMD have an increased risk of depression and are likely to experience anxiety about progression of their condition and future vision
loss

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13
Q

A patient will not necessarily
have the same _______ or _______ of macular degeneration in both
eyes.

A

Stage or type

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14
Q

Pathogenesis in early/intermediate stages of AMD

A

Lipid deposits known as drusen form in the retinal layers and changes may occur in the retinal pigment epithelium resulting in areas of darkening or lightened pigment

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15
Q

The stage of disease is defined by ______________

A

The size of drusen deposits in the retina and the presence of retinal pigmentation changes

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16
Q

Early AMD is defined as

A

Presence of medium-sized drusen in one or both eyes

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17
Q

Intermediate AMD is defined as

A

Presence of large drusen (>125 μm), or the presence of hypo- or hyperpigmentation in the retinal
pigment epithelium

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18
Q

Medium vs large drusen

A

Medium = 63 – 125 μm
Large = >125 μm

125 μm is approximately the size of a large vein at the border of the optic disc

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19
Q

Early and intermediate stages of the disease may also be referred to as ____________

A

“Early/intermediate dry age-related
macular degeneration” (due to absence of exudate or haemorrhage)

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20
Q

The risk of progression for patients with early to intermediate AMD is ________

A

Highly variable

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21
Q

Who should be referred to an ophthalmologist?

A

Only patients for whom
treatment can be offered would benefit from referral to an ophthalmologist, i.e. those with possible neovascular (wet) AMD

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22
Q

The advanced stages of AMD are classified as…

A

Geographic atrophy (also known
as “late or advanced dry”)
Neovascular (also known as
“wet”)

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23
Q

Can you have both types of advanced AMD?

A

In some cases both types develop in the same eye

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24
Q

Geographic atrophy makes up approximately _____ of cases of late AMD

A

80%

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25
Q

Severe vision loss and blindness is more likely to occur in people with what type of advanced AMD?

A

Neovascular

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26
Q

People with __________ (type of advanced AMD) usually experience slow and progressive loss of vision

A

Geographic atrophy

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27
Q

People with _______ (type of advanced AMD) can experience a sudden loss or deterioration of vision due to exudate or retinal haemorrhage

A

Neovascular

28
Q

Left untreated ____% of people with wet/neovascular AMD have been reported to develop severe vision loss by 6 months increasing to _____% by 3 years

A

21%
42%

29
Q

Neovascular AMD can be further subdivided into variants such as retinal angiomatous proliferation, or polypoidal choroidal vasculopathy, which may influence ___________

A

Response to anti-VEGF antibodies and treatment decisions in secondary care

30
Q

How are early changes of AMD usually identified?

A

Early changes in AMD can be detected in a regular eye examination by an optometrist

31
Q

Recommended frequency of review by an optometrist (general adult population, no visual problems)

A

Recommended to undergo a general eye examination with an optometrist by the age of 45 years
Then every 5 years until age 60 years, once every 3 years thereafter

32
Q

GP role in screening for AMD

A

GPs should enquire whether older patients have had an eye examination recently
For patients who have not, consider conducting visual acuity testing and direct fundoscopy

33
Q

Regularly recording visual acuity will facilitate detection of __________ in older patients

A

Gradual visual deterioration

34
Q

AMD is rare in people ____ years old or younger

A

50

35
Q

Fam hx of AMD increases risk by approx _________

A

6x

36
Q

Smoking increases risk of AMD by approx _______

A

1.9x

37
Q

Diabetes increases risk of AMD by approx ________

A

1.7x

38
Q

Is there an association between cardiovascular risk factors and AMD?

A

Research has produced inconsistent results
Meta analysis suggests risk not significantly altered by high BP or cholesterol/triglycerides

39
Q

Are people with early AMD usually symptomatic?

A

Usually asymptomatic

40
Q

When do symptoms usually occur with AMD? And what is the hallmark symptom?

A

Late AMD
Loss or distortion of the central visual field

41
Q

Are all patients with late AMD symptomatic?

A

No - if changes in one eye only may not notice any alteration of visual acuity or problems with eyesight

42
Q

Symptoms of AMD

A

Difficulty reading fine print, or worsening difficulty extending to larger print
A dark area in the central visual field at night or in dark environments (may resolve as vision adjusts to a lower level of light)
Blurred or wavy vision in the centre of the visual field
Loss of vision

43
Q

Signs of AMD

A

Deterioration of best corrected visual acuity
Does not improve with pinhole (as in refractive error) - may be worse
Fundoscopy - drusen (yellow dots), retinal haemorrhage or exudate

44
Q

The _________ may be useful to assess a distortion of the central visual field, but it is not an essential part of diagnosis

A

Amsler grid

45
Q

How to use Amsler grid

A

Patient should be approx reading distance from the grid
Cover one eye while using the grid to assess each eye individually
Wear any reading glasses or corrective lenses they normally use
May see straight lines on the grid as wavy or blurry

46
Q

Patients with a gradual loss of visual acuity where AMD is suspected should be referred to ________

A

Optometrist

47
Q

Red flags for urgent referral to ophthalmologist in patients with AMD

A

Sudden onset distortion or loss of
vision

48
Q

Differential diagnoses for a sudden distortion or loss of vision

A

Haemorrhage or exudate caused
by neovascular AMD
Diabetic macular oedema
Hypertensive retinopathy
Occlusion of the retinal artery
Retinal detachment
Acute angle glaucoma

49
Q

Advice to give patients re reducing UV light to help prevent / reduce progression of AMD

A

Wear UV-blocking sunglasses when
outdoors
Avoid unprotected exposure to UV light (e.g. welding or UV lamps)

50
Q

What are Lutein and zeaxanthin

A

Carotenoids which form components of
the macula

51
Q

Dietary sources of Lutein and zeaxanthin

A

Egg yolk
Corn
Kiwifruit
Dark green leafy vegetables
Green and orange capsicum
Red grapes
Pumpkin
Broccoli
Green beans
Zucchini
Honeydew melon, apples and oranges

52
Q

Meta analysis has shown people with higher intakes of lutein and
zeaxanthin had a ___% reduction in their risk of progression of
macular degeneration compared to people with low intakes

A

26%

53
Q

Dietary advice to help reduce risk of AMD

A

Fsh and omega-3 fatty acids (in oily fish)
3.5 servings of fruits and 5 servings of vegetables per day (two of which
are dark green or orange coloured, or legumes)

54
Q

Supplements to reduce rate of progression

A

Vitamin C
Vitamin E
Zinc
Copper
Lutein
Zeaxanthin

(AREDS-2 study)
Two tablets per day of Blackmores Macu-Vision with 1 tab per day of Blackmores Lutein Defence

55
Q

Supplements with no evidence of benefit

A

Omega-3 fatty acids and fish oils
Bilberry, marigold or blackcurrant extracts

56
Q

Supplements to avoid

A

β-carotene - some studies have found links with increased rates of lung cancer in both smokers and non-smokers

57
Q

What is the standard first-line treatment for neovascular AMD worldwide

A

Intravitreal anti-VEGF injections

58
Q

What are the benefits of anti-VEGF

A

High rates of success in stabilising vision (preventing further visual loss in ~95% of patients) but can also improve visual acuity in 2/3 of cases

59
Q

Which anti-VEGF treatments are available in NZ

A

Bevacizumab and ranibizumab

60
Q

Treatment interval with anti-VEGF

A

Monthly initially
Most ophthalmologists use a “treat and extend” regimen, where a patient is treated and monitored at each clinic visit, to determine the interval to the next appointment

61
Q

Patients undergoing treatment with anti-VEGF should expect ________ injections in their first year
of treatment, and treatment to last ______ years.

A

9 -12 injections in 1st year
Treatment to last 1-2 years

62
Q

Common adverse effects from anti-VEGF injections that the patient should be reassured about

A

Subconjunctival haemorrhage
Foreign body sensation
Transient “bubbles” in the inferior visual field (from inadvertently-injected air bubbles)

63
Q

Rare adverse effects from anti-VEGF injections

A

Retinal detachment, retinal/
vitreous haemorrhage and damage to the lens are possible if the needle is not inserted correctly (or if the patient moves). (~2%)
Most serious complication is endophthalmitis (<0.1%)

64
Q

Charles Bonnet syndrome

A

People with sight loss can experience visual hallucinations ranging from shapes or lines to images of people or buildings

65
Q

Prevalence of visual hallucinations in patients with AMD has been reported to be….

A

5-40%

66
Q

Criteria for referral to the Blind Foundation of New Zealand

A

Visual acuity ≤ 6/24 in the better eye with corrective lenses
Or with major visual field defects

67
Q

What does the Blind Foundation of NZ do?

A

Skills for adapting to life with reduced vision, and techniques to assist with mobility and orientation
Helps patients obtain equipment, access financial assistance and receive peer support and counselling

GPEP Ophthalmology (2 decks)

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