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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
Severe vision loss and blindness is more likely to occur in people with what type of advanced AMD?
Neovascular
26
People with __________ (type of advanced AMD) usually experience slow and progressive loss of vision
Geographic atrophy
27
People with _______ (type of advanced AMD) can experience a sudden loss or deterioration of vision due to exudate or retinal haemorrhage
Neovascular
28
Left untreated ____% of people with wet/neovascular AMD have been reported to develop severe vision loss by 6 months increasing to _____% by 3 years
21% 42%
29
Neovascular AMD can be further subdivided into variants such as retinal angiomatous proliferation, or polypoidal choroidal vasculopathy, which may influence ___________
Response to anti-VEGF antibodies and treatment decisions in secondary care
30
How are early changes of AMD usually identified?
Early changes in AMD can be detected in a regular eye examination by an optometrist
31
Recommended frequency of review by an optometrist (general adult population, no visual problems)
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
GP role in screening for AMD
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
Regularly recording visual acuity will facilitate detection of __________ in older patients
Gradual visual deterioration
34
AMD is rare in people ____ years old or younger
50
35
Fam hx of AMD increases risk by approx _________
6x
36
Smoking increases risk of AMD by approx _______
1.9x
37
Diabetes increases risk of AMD by approx ________
1.7x
38
Is there an association between cardiovascular risk factors and AMD?
Research has produced inconsistent results Meta analysis suggests risk not significantly altered by high BP or cholesterol/triglycerides
39
Are people with early AMD usually symptomatic?
Usually asymptomatic
40
When do symptoms usually occur with AMD? And what is the hallmark symptom?
Late AMD Loss or distortion of the central visual field
41
Are all patients with late AMD symptomatic?
No - if changes in one eye only may not notice any alteration of visual acuity or problems with eyesight
42
Symptoms of AMD
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
Signs of AMD
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
The _________ may be useful to assess a distortion of the central visual field, but it is not an essential part of diagnosis
Amsler grid
45
How to use Amsler grid
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
Patients with a gradual loss of visual acuity where AMD is suspected should be referred to ________
Optometrist
47
Red flags for urgent referral to ophthalmologist in patients with AMD
Sudden onset distortion or loss of vision
48
Differential diagnoses for a sudden distortion or loss of vision
Haemorrhage or exudate caused by neovascular AMD Diabetic macular oedema Hypertensive retinopathy Occlusion of the retinal artery Retinal detachment Acute angle glaucoma
49
Advice to give patients re reducing UV light to help prevent / reduce progression of AMD
Wear UV-blocking sunglasses when outdoors Avoid unprotected exposure to UV light (e.g. welding or UV lamps)
50
What are Lutein and zeaxanthin
Carotenoids which form components of the macula
51
Dietary sources of Lutein and zeaxanthin
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
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
26%
53
Dietary advice to help reduce risk of AMD
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
Supplements to reduce rate of progression
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
Supplements with no evidence of benefit
Omega-3 fatty acids and fish oils Bilberry, marigold or blackcurrant extracts
56
Supplements to avoid
β-carotene - some studies have found links with increased rates of lung cancer in both smokers and non-smokers
57
What is the standard first-line treatment for neovascular AMD worldwide
Intravitreal anti-VEGF injections
58
What are the benefits of anti-VEGF
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
Which anti-VEGF treatments are available in NZ
Bevacizumab and ranibizumab
60
Treatment interval with anti-VEGF
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
Patients undergoing treatment with anti-VEGF should expect ________ injections in their first year of treatment, and treatment to last ______ years.
9 -12 injections in 1st year Treatment to last 1-2 years
62
Common adverse effects from anti-VEGF injections that the patient should be reassured about
Subconjunctival haemorrhage Foreign body sensation Transient “bubbles” in the inferior visual field (from inadvertently-injected air bubbles)
63
Rare adverse effects from anti-VEGF injections
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
Charles Bonnet syndrome
People with sight loss can experience visual hallucinations ranging from shapes or lines to images of people or buildings
65
Prevalence of visual hallucinations in patients with AMD has been reported to be....
5-40%
66
Criteria for referral to the Blind Foundation of New Zealand
Visual acuity ≤ 6/24 in the better eye with corrective lenses Or with major visual field defects
67
What does the Blind Foundation of NZ do?
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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