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Ophthalmology > Age-Related Macular Degeneration > Flashcards

Age-Related Macular Degeneration Flashcards

1
Q

What does the term age-related macular degeneration (AMD) refer to?

A

Ageing changes that occur in the central area of the retina in people aged 55 years or older

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2
Q

What needs to be true of the changes in the central area of the retina to be classified as AMD?

A

Must not have any other obvious precipitating cause

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3
Q

What kind of disease is AMD?

A

Progressive, chronic disease of the central retina

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4
Q

Why is AMD important?

A

It is a leading cause of vision loss worldwide

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5
Q

What is AMD characterised by?

A

Appearance of drusen in the macula

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6
Q

What is the appearance of drusen in the macula accompanied by in wet AMD?

A

Choroidal neovascularisation

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7
Q

What is the appearance of drusen in the macula accompanied by in dry AMD?

A

Geographic atrophy

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8
Q

In what respects do the forms of AMD differ?

A

In pathophysiology and progression

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9
Q

What are the characteristic lesions of dry AMD?

A
  • Soft drusen

- Changes in pigmentation (hypopigmentation and/or hyperpigmentation) of the retinal pigment epithelium

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10
Q

Where does the drusen accumulate in dry AMD?

A

Between the retina and choroid

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11
Q

What does the accumulation of drusen between the retina and choroid in dry AMD cause?

A

Atrophy and scarring of the retina

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12
Q

What happens to the atrophy in AMD over time?

A

The atrophy becomes more extensive with time

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13
Q

Can dry AMD progress and cause vision loss without turning into the wet form?

A

Yes

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14
Q

What % of cases of AMD are the dry form?

A

90%

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15
Q

Describe the progression of dry AMD

A

Progression to visual loss is usually gradual, but eventually there is an area of partial or complete atrophy of the retinal pigment epithelium

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16
Q

Does the atrophy of the RPE in dry AMD involve the fovea?

A

May or may not

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17
Q

What chance to those with dry AMD have of developing wet AMD?

A

4-12% chance/year

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18
Q

What happens in wet AMD?

A

New blood vessels grow in from the choriocapillaris under the retina

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19
Q

In relation to the RPE, where to the blood vessels grow in wet AMD?

A

Spread under or over the RPE, or both

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20
Q

Describe the abnormal blood vessels in wet AMD

A

Fragile and easily leak

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21
Q

Describe the location of growth of blood vessels in wet AMD

A

They start off to the side of the retina and grow towards the centre, eventually growing under the macula

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22
Q

How long does the process of blood vessel growth take in wet AMD?

A

Can take from days to weeks

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23
Q

What are the consequences of abnormal vessel formation in wet AMD?

A
  • Haemorrhage

- Scar formation

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24
Q

What % of cases of AMD are wet AMD?

A

10%

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25
Q

What % of cases of wet AMD are advanced?

A

60%

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26
Q

How quickly will wet AMD progress to cause severe visual impairment without treatment?

A

Approx 2 years

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27
Q

What is the end point of wet AMD?

A

Scar formation, known as disciform macular degeneration

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28
Q

What % of patients who have had wet AMD in one eye will develop it in their second eye within 5 years?

A

Approx 50%

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29
Q

What can the severity of AMD be classified?

A
  • No AMD
  • Early AMD
  • Intermediate AMD
  • Advanced AMD
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30
Q

What is classified as no AMD?

A

None or small drusen

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31
Q

What is classified as early AMD?

A

Multiple small or a few intermediate drusen, with or without abnormalities of the retinal pigmented membrane

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32
Q

What is classified as intermediate AMD?

A

Extensive intermediate or 1+ large drusen, with or without GA not involving the fovea

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33
Q

What is classified as advanced AMD?

A

GA involving the fovea, with or without any features of wet AMD

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34
Q

What is the result of features of wet AMD be classified as advanced?

A

All cases of wet AMD are advanced at presentation

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35
Q

What causes AMD?

A

AMD is a multifactorial disease, with both environmental and genetic components playing a role in its development, however the specific causes are not known

36
Q

What theories have been proposed regarding the cause of AMD?

A
  • Oxidative stress
  • Mitochondrial dysfunction
  • Inflammatory processes
37
Q

What are the risk factors for AMD?

A
  • Increasing age
  • Smoking
  • Family history
  • Cardiovascular risk factors (for wet AMD)
  • Light coloured eyes
  • Diets high in fat, cholesterol, and high glycaemic index foods
  • Obesity
  • Ethnicity
38
Q

What is smoking a risk factor for in AMD?

A

New-onset and progression

39
Q

What ethnicity is AMD most common in?

A

Caucasians

40
Q

What does AMD cause?

A

Painless deterioration of central vision

41
Q

How might asymptomatic AMD be identified?

A

Retinal signs may be detected incidentally during a routine eye test

42
Q

What are the general symptoms of AMD?

A
  • Reduction in visual acuity
  • Loss of or decreased contrast sensitivity
  • Size or colour of objects appearing different with each eye
  • Abnormal dark adaptation
  • Photopsia
  • Light glare
  • Visual hallucinations
43
Q

What are the more specific symptoms of dry AMD?

A
  • Gradual visual deterioration

- Potentially loss of central vision

44
Q

How does gradual visual deterioration present in dry AMD?

A

Difficulty reading with small to large print over time

45
Q

When can dry AMD cause deterioration of central vision?

A

When there is bilateral geographic atrophy of the fovea

46
Q

What are the more specific symptoms of wet AMD?

A
  • Central vision blurring and distortion

- Potentially rapid visual deterioration

47
Q

What is the main identifying complaint of central blurring and distortion in patients with wet AMD?

A

Straight lines appear crooked or wavy

48
Q

How can sudden visual deterioration present in wet AMD?

A

Suddenly unable to read, drive, or see fine detail

49
Q

When may rapid visual deterioration progress to sudden visual loss in wet AMD?

A

If there is a bleed

50
Q

What might sudden visual loss due to a bleed in wet AMD be preceded by?

A

A shower of floaters

51
Q

What can visual examination show in AMD?

A
  • Normal or decreased acuity

- Distortion of the Amsler grid

52
Q

What may be seen on examination of the fundus in AMD?

A
  • Drusen in the macular area
  • Sharply demarcated areas of hypopigmentation or hyperpigmentation of the peripheral retina
  • Well demarcated red patches (in wet AMD)
53
Q

What are drusen?

A

Discrete yellow deposits

54
Q

What do the red patches on the fundus in wet AMD represent?

A

Intraretinal, subretinal or sub-RPE hameorrhage or fluid

55
Q

What may be seen on fundus examination in late AMD?

A

A macular scar, appearing as a thick yellow patch over the macular area

56
Q

What is the aim of secondary care investigations in AMD?

A

Confirm the diagnosis, assess the extent of the disease and possibility of successful intervention, and measure progression over time

57
Q

What investigations may be used in AMD?

A
  • Slit-lamp biomicroscopy
  • Colour fundus photography
  • Fluorescein angiography
  • OCT
58
Q

What can be seen on slit-lamp biomicroscopy in AMD?

A
  • Drusden
  • Pigmentary changes
  • Exudate
  • Haemorrhages
  • Atrophic changes of the macula
59
Q

What is the purpose of colour fundus photography in AMD?

A

To record the appearance of the retina

60
Q

When is Fluorescein angiography required in suspected AMD?

A

When it is suspected wet AMD to confirm and assess lesion

61
Q

How is Fluorescein angiography performed?

A

Fluorescein dye is injected IV and photographs of the retina are taken serially to detect abnormal vasculature or leakage

62
Q

What is OCT?

A

Ocular coherence tomography

63
Q

What can cause painless loss of vision?

A
  • Refractive errors
  • Cataracts
  • Some corneal diseases
  • Posterior vitreous or retinal detachment
  • Retinal artery or vein occlusion
  • Cerebrovascular disease
  • Some drugs
  • Tumours
  • Papilloedema
  • Primary open-angle glaucoma
  • Optic atrophy
64
Q

What cerebrovascular disease can cause painless visual loss?

A
  • Amaurosis fugal

- TIA or stroke

65
Q

What drugs can cause painless visual loss?

A
  • Methanol
  • Chloroquine
  • Isoniazid
  • Isotretinoin
  • Tetracycline
  • Ethambutol
66
Q

What tumours can cause painless visual loss?

A
  • Pituitary tumour

- CNS tumour

67
Q

What conditions can cause similar retinal signs to AMD?

A
  • Diabetic maculopathy
  • Macular dystrophy
  • Rare Inflammatory syndromes causing choroidal neovascularisation
  • Macular telangiectasis
68
Q

In what time frame should patients with suspected AMD be referred?

A

Ideally within 1 week

69
Q

When is urgent referral for AMD particularly important?

A

When the patients has sudden distortion or rapid-onset visual loss as these suggest wet AMD

70
Q

What is the main management for dry AMD?

A

Lifestyle adjustments in an attempt to slow progression

71
Q

What does dry AMD management consist of?

A
  • Counselling
  • Smoking cessation
  • Visual rehabilitation
  • Nutritional supplements
  • Management of co-existing visual impairments
72
Q

What does visual rehabilitation for AMD revolve around?

A

Maximising any remaining visual function and assisting the person to maintain an independent life for as long as possible

73
Q

What can visual rehabilitation for AMD involve?

A
  • Refraction check

- Low visual aid clinic

74
Q

What can be provided by a low visual aid clinic for AMD?

A
  • Provision and training on use of optical aids e.g. magnifiers
  • Advice on lighting, tactile aids, electronic aids and other non-optical aids
75
Q

What legal responsibility do people with AMD have?

A

To ensure their eyesight is good enough to drive and if not contact the DVLA

76
Q

What is the current standard for treating wet AMD?

A

Intravitreal injections of anti-vascular endothelial growth factor agents

77
Q

How can anti-VEGF agents be administered in wet AMD?

A

In theatre or in a designated treatment ‘clean room’

78
Q

What anti-VEGF agents can be use in AMD?

A
  • Ranibizumab

- Bevacizumab

79
Q

How long are anti-VEGF treatments used for?

A

Monthly for 3 months and then at variable times after depending on response

80
Q

What proportion of patients will retain their current visual level in treatment of wet AMD?

A

Most

81
Q

What percentage of patients with wet AMD will not respond to anti-VEGF treatment?

A

10%

82
Q

What are the complications of intravitreal injections?

A
  • Hypersensitivity reaction
  • Endophthalmitis
  • Retinal detachment
  • Severe uncontrolled uveitis
  • Ongoing periocular infections
  • Thromboembolic phenomena
  • Traumatic cataract
83
Q

What older treatments can be used for wet AMD if anti-VEGF is not advisable?

A
  • Laser photocoagulation
  • Photodynamic therapy with verteporfin
  • Macular translocation
84
Q

What are the potential complications of visual impairment?

A
  • Depression
  • Visual hallucinations (Charles Bonnet syndrome)
  • Falls and fractures
  • Limitations in mobility, ADLs and physical performance
  • Reduced QoL
85
Q

What are the potential complications of wet AMD?

A
  • Serous retinal detachment

- Haemorrhage

Ophthalmology (16 decks)

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