May 2012 discussion of age related macular degeneration to a lay audience by 5 different doctors

5. Trouble with vision as
we get older...
• Is not always due to Age-
related macular
degeneration !
• Your doctor needs to
perform a complete eye
exam before reaching a
diagnosis

6. Eye Examination -
Diagnosis
Visual Acuity, Color Vision, Amsler Grid,
Fundus Camera, Fluorescein Angiography,
Optical Coherence Tomography

9. Amsler Grid Testing

11. Drusen, the yellow spots so characteristic
of Age-related Macular Degeneration

12. Drusen are sometimes more easily detected
On Color Fundus photos than doctor’s exam

13. Fluorescein
Angiography

14. Colour photography is
routinely undertaken with
angiography. It helps to
determine the nature of
changes seen on the
angiogram… particularly
the cause of blocked
fluorescence due to
haemorrhage, pigment or
other cause.

15. Side by side
comparison
of the color photo
and
the fluorescein
picture
often complement
each
other !

18. -

20. Optical Coherence
Tomography

21. • Diagnostic imaging technique that examines
living tissue non-invasively. It is based on a
complex analysis of the reflection of low
coherence radiation from the tissue under
examination.
• Real time cross sectional analysis

37. • Macular Degeneration
Leading cause of
blindness in people
over 55
• 1:10 people over
55
• Increases by a
factor of 6 in
people over 80
• 1.75 million
Americans over
age 40 have severe
AMD
• Estimated that 2.95
million people
affected by 2020

38. How Does the Eye
Work?

39. • What is Macular
Idiopathic
• Central vision
Degeneration?
loss
• Peripheral vision
preserved
• Two forms
• Dry
(Nonexudative)
• 90% of people
• Wet (Exudative)
• Affects 10% of
people

40. What does my Doctor
•
•
Drusen
see?
Metabolic waste
products
accumulating under
the retina
• Pigment clumping
and atrophy
• Death of support
cells under retina
• Geographic atrophy
• Large areas of cell
death
• Hemorrhage
(blood)
• Hallmark of wet
AMD

41. My Doctor told me I have Macular
Degeneration. Will I go blind?
• Not necessarily
• Only 10% develop
the wet form which
is responsible for
90% of blindness
from AMD
• Newer treatments
may reduce risk of
blindness
• Only 10% of the dry
patients will develop
severe vision loss

42. Risk factors for Vision
• Non-modifiable:
things we cannot loss
change
• Age
• (If you figure out how
to stop aging, please let
me know)
• Caucasian race
• Female gender
• Family history
• 2.5x increased risk of
first degree family
relative

43. Risk factors for Vision
• Modifiable
• Smoking Loss
• Hypertension
• High
Cholesterol
• Obesity
• Sedentary
Lifestyle
• Heart Health= Eye

44. What about those
AREDS study
• Vitamins? II
Followed 3640 patients
for average 6.3 years
• AREDS
• High doses of
antioxidant vitamins • Started in 2006 –
ongoing
• Hope they will reduce
oxidative stress in • Added
macula
• Lutein: forms macular
• Vitamin A pigment
• Vitamin C • Zeaxanthin
• Vitamin E • Subtracted
• Zinc: antioxidant in • Vitamin A: Potential
conjunction with C and increased risk of lung
E cancer in smokers
• Copper

45. • Vitamins
Not found helpful for
everyone
• No benefit
• No AMD • Benefit:
• Mild AMD • If everyone took AREDS,
• Beneficial
300,000 people could be
prevented from developing
• Moderate AMD
advanced AMD over 5 year
• Severe AMD
• Persons with wet AMD • Unfortunately will not stop
progression of AMD in all
• Benefit patients
• Reduced risk of
progression of AMD by
25%
• Reduced risk of vision

46. Which is the best
Multivitamin?
• They are all basically the
same as long as they have
the AREDS formula
• Differences in brands
• AREDS I vs AREDS II formula
• Dosing
• Price
• Packaging
• Advertising

47. • Stop Smoking Summary
• Exercise
• Heart Healthy Diet
• Eat leafy green
vegetables
• Control blood
pressure and
cholesterol
• AREDS
Multivitamin if
indicated by your
eye doctor
• Monitor vision and
regular eye checks

56. • Macular Degeneration
Leading cause of
blindness in people
over 55
• 1:10 people over
55
• Increases by a
factor of 6 in
people over 80
• 1.75 million
Americans over
age 40 have severe
AMD
• Estimated that 2.95
million people
affected by 2020

57. How Does the Eye
Work?

58. • What is Macular
Idiopathic
• Central vision
Degeneration?
loss
• Peripheral vision
preserved
• Two forms
• Dry
(Nonexudative)
• 90% of people
• Wet (Exudative)
• Affects 10% of
people

59. What does my Doctor
•
•
Drusen
see?
Metabolic waste
products
accumulating under
the retina
• Pigment clumping
and atrophy
• Death of support
cells under retina
• Geographic atrophy
• Large areas of cell
death
• Hemorrhage
(blood)
• Hallmark of wet
AMD

60. My Doctor told me I have Macular
Degeneration. Will I go blind?
• Not necessarily
• Only 10% develop
the wet form which
is responsible for
90% of blindness
from AMD
• Newer treatments
may reduce risk of
blindness
• Only 10% of the dry
patients will develop
severe vision loss

61. Risk factors for Vision
• Non-modifiable:
things we cannot loss
change
• Age
• (If you figure out how
to stop aging, please let
me know)
• Caucasian race
• Female gender
• Family history
• 2.5x increased risk of
first degree family
relative

62. Risk factors for Vision
• Modifiable
• Smoking Loss
• Hypertension
• High
Cholesterol
• Obesity
• Sedentary
Lifestyle
• Heart Health= Eye

63. What about those
AREDS study
• Vitamins? II
Followed 3640 patients
for average 6.3 years
• AREDS
• High doses of
antioxidant vitamins • Started in 2006 –
ongoing
• Hope they will reduce
oxidative stress in • Added
macula
• Lutein: forms macular
• Vitamin A pigment
• Vitamin C • Zeaxanthin
• Vitamin E • Subtracted
• Zinc: antioxidant in • Vitamin A: Potential
conjunction with C and increased risk of lung
E cancer in smokers
• Copper

64. • Vitamins
Not found helpful for
everyone
• No benefit
• No AMD • Benefit:
• Mild AMD • If everyone took AREDS,
• Beneficial
300,000 people could be
prevented from developing
• Moderate AMD
advanced AMD over 5 year
• Severe AMD
• Persons with wet AMD • Unfortunately will not stop
progression of AMD in all
• Benefit patients
• Reduced risk of
progression of AMD by
25%
• Reduced risk of vision

65. Which is the best
Multivitamin?
• They are all basically the
same as long as they have
the AREDS formula
• Differences in brands
• AREDS I vs AREDS II formula
• Dosing
• Price
• Packaging
• Advertising

66. • Stop Smoking Summary
• Exercise
• Heart Healthy Diet
• Eat leafy green
vegetables
• Control blood
pressure and
cholesterol
• AREDS
Multivitamin if
indicated by your
eye doctor
• Monitor vision and
regular eye checks

67. Age-related Macular
Degeneration

68. What is Age-Related Macular
Degeneration?
• Age-related macular degeneration (AMD) is a
deterioration or breakdown of the eye's macula.
• The macula is a small area in the retina — the
light-sensitive tissue lining the back of the eye.
• The macula is the part of the retina that is
responsible for your central vision, allowing you
to see fine details clearly.
• American Academy of Ophthalmology

69. What is going on in the
eye?

70. Where exactly?

71. Where exactly?

72. Genetics
• DNA
• All information of life encoded in DNA and
expressed by proteins.
• James Dewey Watson (US) & Francis Crick
(UK) – Co-discoverers Structure of DNA
1953
• Awarded Nobel Prize in Physiology or
Medicine 1962

73. Before…

74. …After…Age-related
changes

75. Genetic Basics…get
small…
• The human body is made up of trillions of Cells,
• and with a few exceptions, each cell contains a
Nucleus
• and with a few exceptions, each nucleus contains
a COMPLETE set of Chromosomes
• And the chromosomes are made of DNA

76. From DNA…to You
and Me…

77. …and smaller…From Cells to
Nucleus to Chromosomes
• Every human cell contains 23 pairs of
chromosomes, for a total of 46 chromosomes.
• Each Chromosome is made up of
• a double- stranded,
• Tightly-coiled,
• helix of DNA

78. Human Chromosomes

79. …and smaller…
• A CHROMOSOME contains hundreds to
thousands of genes.
• A GENE is a segment of DNA containing
the code used to synthesize a protein.
• A TRAIT is any gene-determined
characteristic and is usually determined by
more than one gene.
• Some traits are caused by abnormal genes
that are inherited or that are the result of
a mutation.

80. From Chromosomes to
Genes

81. WhatStudies we know?…
• Genetic do
• 1988-2010 so far
• DNA and Gene-Environment Data
Collection
• Twin Study – WWII Registry
• 1997 Familial Aggregation Study – Relatives of
Cases with Wet AMD. Relatives of controls.
• 1997 Phenotypic Heterogeneity in Families
with AMD
• Johanna M. Seddon, M.D., Sc.M.

82. What do we know?…
so far
• From the US Twin Study, we’ve learned
• Substantial Genetic Component –
• 46 to 71% of the variation in
phenotype
• Important Environmental Influence:
19 to 37%

83. OK…what “Genetic
Factors”?...
• It’s not so much as a “bad” gene, but rather
• Variations of “normal genes” that influence
the risk of developing AMD.
• Specific DNA chromosomes associated
with the defective genes are located on
chromosomes
• 1q and 10q

84. From Chromosomes to
Genes

85. Genes associated…so
• CFH – Y402H far
• CFH – rs1410996
• Hepatic Lipase C (LIPC)
• CFB
• CETP
• C2
• ABCA1
• Complement Component
• TIMP 3 / SYN3
3 (C3) • VEGFA
• Complement Factor I CFI • COL10A1
• ARMS2/HTRA1 gene • COL8A1
region
• TNFRSF10A

86. Gene location… leads
to therapy
• For example, the VEGFA locus and the
development of
• Avastin
• Lucentis and recently
• Eylea

87. Antigen/Antibody cell
membrane
Bayer Healthcare – Bayer Schering Pharma

88. Surface
antigens/antibodies
Eylea.com

89. Relative risk of Genetic
loci
Nature Genetics 38: 1057, 2006

90. Epidemiology
• Epidemiology is the study of
• the distribution and patterns of health-events,
• health-characteristics and
• their causes or influences in well-defined
populations.

91. Epidemiology
• It is our principal method of public health
research, and
• helps us make policy decisions as well as
evidence-based medicine
• by identifying risk factors for disease and
helps us with recommendations for
appropriate preventive medicine.

92. Epidemiologic studies looking at
• Meta-analysis of 15 genome-wide
the genetics of AMD
association studies
• Began in 2009
• 8,000 cases and 50,000 controls
• 19 groups from 13 countries
• 19 genomic loci associated with AMD
• Six novel loci not previously associated
with disease
• Pathways similar to other known genes.
• ASHG Oct 2011

93. Epidemiology and
Causation
Risk factors for cardiovascular disease (CVD)
are associated with age-related AMD;
• Smoking
• Dietary antioxidants, fats, omega-3 fatty
acids
• Physical activity
• Obesity, abdominal adiposity
• Hypertension
• Cholesterol
• CRP (C-reactive protein)

94. Epidemiology and
Causation
• For the homozygous (pure trait) risk
genotype
• Risk of AMD was
• Increased for BMI (Body Mass
Index) and
• Increased with smoking

95. So what can we say?
• Genetic mutations make us susceptible to
the development of AMD
• Multiple genetic factors are at work
• Risk profiles help us to change life style to
decrease the chance of AMD development
• Which leads us to…

96. The big question (at least for the
retina specialists)
• What information from
• TV,
• Radio,
• Internet,
• YouTube,
• Email,
• Fax, Photocopy, Text, Blog,
Wikipedia….etc
• Should You believe?

97. Types of Optical Devices
Near Devices

98. Stand Magnifier

99. Dome Magnifier

100. Illuminated Stand
Magnifier

101. Hand Held Pocket
Magnifier

102. Hand Held
Illuminated

103. Microscopes or Reading Glasses

104. Types of Optical Devices
Distance Devices

105. Binoculars

106. Monocular

107. Full-Field Telescopic
Systems

108. Bioptic Systems

109. Sunfilters

110. Night Vision Scopes

111. Getting the Right
Device(s)devices
• Because there is such a variety of
available, it can be somewhat overwhelming to
locate the correct device.
• Individuals should receive an evaluation from an
Optometrist who specializes in treating
individuals with low vision.
• This assures that the individual receives the
correct device with consideration of all goals
and needs.

112. What’s New in
Low Vision Technology

113. Handheld Magnifying Cameras
• Miracle Mouse
Electronic TV
Magnifier
• MonoMouse-RM B&W
Electronic Magnifier
• Max Digital Color
Magnifier
• Primer 2 Color
Electronic Magnifier

114. Traditional CCTV Video
Magnifiers reading
• Increased
speed
• Increased duration
• Reduced visual effort
• Comfortable
• Desktop systems working position
• Variable
Magnification
• Color, W/B, B/W
• Large Field of View

115. Magnifiers
Integrated LCD
• Available from all major vendors
Displays
• Sizes: 17” to 24” + with WS
• Adjustable height screens
• High contrast
• Flicker free
• Improved response rates
• Well received by consumers

116. Integrated LCD Systems

117. Video
Magnification
• Variable Systems
Magnification
• Adjustable brightness
• Selectable contrast
setting
• Wide field of view
for better viewing
abilities

118. Magnification

119. Brightness

120. Contrast

121. Windowing and
Underlining

122. Portable Video
• More Compact, 7-inch screens
Magnifiers
• Extensive reading tasks
• Two handed use
• Optelec Traveler
• FS Sapphire
• EV Amigo
• Fusion 7” LCD Portable Video Magnifier

123. Compact Video
Magnifiers:
• Variable Magnification
• Replaceable Batteries
• Longer battery life
• Image Freeze
• Color Select
• Light off mode: for reading cell phones, other
displays
• Writing Cameras
• Distance Viewing
• Smaller Designs

124. Compact/Pocket
Video Magnifiers
• Advantages
• Wide field of view
• Image at display level
• Use at arms-length
• Reverse contrast available
• Cell phone, PDA displays!
• Short-term writing tasks
• Kids reading comic books
under the blanket

125. Compact Systems with
Distance Capabilities
• Near and distance capabilities
• Read mail, products on a shelf and get a
better view of distance object.
• Allows users to see an object that is at
distance close up on the screen
• Limited clarity and magnification at a
distance

126. GW Micro
Sense View Duo
• Two cameras
• Stores up to 20 images
• 3X to 13X magnification
• Lights off mode
• Image panning
• 7 Viewing modes, 4
Brightness levels
• 4.5 hour battery life,
integrated, rechargeable
• Cost: $1299.00

127. Ash Technology
Quicklook Focus

128. Desktop Video Magnifiers
• Full Size screen
Features
• Full Features
• Remote Controllable
• Near and Distance Viewing
• For Classroom, Conference or In- Service
Training Activities
• Transportable “Luggable”
• AC or optional battery

129. Vision Technology: VIEW

130. Enhanced Vision
Acrobat LCD

131. Onyx Deskset

132. Laptop Compatible Video
Magnifiers
• Most students
use laptop
computers
• Video
magnification
could be helpful
• Portable camera
using notebook
display

133. Clarity PCMate
• Powered by USB
• Requires 2 USB 2
ports
• Sequence, setup
• Remote control
camera
• Keyboard
controlled
software

134. Optelec
ClearNote
• Ease of camera
aiming
• Built in Light source
• Camera control
positioning
• Keyboard controlled
software
• Keyboard controlled
camera
• Dolphin, Zoom Text
compatible

135. Freedom Scientific Onyx
PC Edition arm and flex
• Swing
arm models
• Remote control
• MAGic with
EyeMerge software
included
• Camera can be
powered by USB port
• Distance, desktop, self
view modes
• Cost: $2895.00

136. Specialty Video
Magnifiers
• Flipper
• Shoppa

137. Headborne Low Vision
System
• Eyetonomy SightMate LV920
• www.vuzix.com/medical/lv920.h
tml
• Zoom at near: 3X optical, 4X
digital
• Zoom at distance: 0.5X to 6X
• Edge contrasting, Inverse mode
• Sleek design, 8 ounces
• $3499.00
• Not yet available for purchase
or review

139. Scan and Read Devices
• Kurzweil 1000 (software)
• ABiSee Zoom-Ex, EyePal Vision (portable,
Solo)
• FS Pearl (laptop compatible)
• KNFB Reader (smartphone)
• AI Squared ZoomReader (app)

140. Assessment functioning
• Evaluation of visual Factors
• Response to low vision approaches
• Analysis of tasks, task specific
• Required performance level
• Integration of systems
• Training
• Trial of system; speed, duration,
productivity
• Modifications
• Provision

141. Types of Optical Devices
Near Devices

142. Stand Magnifier

143. Dome Magnifier

144. Illuminated Stand
Magnifier

145. Hand Held Pocket
Magnifier

146. Hand Held
Illuminated

147. Microscopes or Reading Glasses

148. Types of Optical Devices
Distance Devices

149. Binoculars

150. Monocular

151. Full-Field Telescopic
Systems

152. Bioptic Systems

153. Sunfilters

154. Night Vision Scopes

155. Getting the Right
Device(s)devices
• Because there is such a variety of
available, it can be somewhat overwhelming to
locate the correct device.
• Individuals should receive an evaluation from an
Optometrist who specializes in treating
individuals with low vision.
• This assures that the individual receives the
correct device with consideration of all goals
and needs.

156. What’s New in
Low Vision Technology

157. Handheld Magnifying Cameras
• Miracle Mouse
Electronic TV
Magnifier
• MonoMouse-RM B&W
Electronic Magnifier
• Max Digital Color
Magnifier
• Primer 2 Color
Electronic Magnifier

158. Traditional CCTV Video
Magnifiers reading
• Increased
speed
• Increased duration
• Reduced visual effort
• Comfortable
• Desktop systems working position
• Variable
Magnification
• Color, W/B, B/W
• Large Field of View

159. Magnifiers
Integrated LCD
• Available from all major vendors
Displays
• Sizes: 17” to 24” + with WS
• Adjustable height screens
• High contrast
• Flicker free
• Improved response rates
• Well received by consumers

160. Integrated LCD Systems

161. Video
Magnification
• Variable Systems
Magnification
• Adjustable brightness
• Selectable contrast
setting
• Wide field of view
for better viewing
abilities

162. Magnification

163. Brightness

164. Contrast

165. Windowing and
Underlining

166. Portable Video
• More Compact, 7-inch screens
Magnifiers
• Extensive reading tasks
• Two handed use
• Optelec Traveler
• FS Sapphire
• EV Amigo
• Fusion 7” LCD Portable Video Magnifier

167. Compact Video
Magnifiers:
• Variable Magnification
• Replaceable Batteries
• Longer battery life
• Image Freeze
• Color Select
• Light off mode: for reading cell phones, other
displays
• Writing Cameras
• Distance Viewing
• Smaller Designs

168. Compact/Pocket
Video Magnifiers
• Advantages
• Wide field of view
• Image at display level
• Use at arms-length
• Reverse contrast available
• Cell phone, PDA displays!
• Short-term writing tasks
• Kids reading comic books
under the blanket

169. Compact Systems with
Distance Capabilities
• Near and distance capabilities
• Read mail, products on a shelf and get a
better view of distance object.
• Allows users to see an object that is at
distance close up on the screen
• Limited clarity and magnification at a
distance

170. GW Micro
Sense View Duo
• Two cameras
• Stores up to 20 images
• 3X to 13X magnification
• Lights off mode
• Image panning
• 7 Viewing modes, 4
Brightness levels
• 4.5 hour battery life,
integrated, rechargeable
• Cost: $1299.00

171. Ash Technology
Quicklook Focus

172. Desktop Video Magnifiers
• Full Size screen
Features
• Full Features
• Remote Controllable
• Near and Distance Viewing
• For Classroom, Conference or In- Service
Training Activities
• Transportable “Luggable”
• AC or optional battery

173. Vision Technology: VIEW

174. Enhanced Vision
Acrobat LCD

175. Onyx Deskset

176. Laptop Compatible Video
Magnifiers
• Most students
use laptop
computers
• Video
magnification
could be helpful
• Portable camera
using notebook
display

177. Clarity PCMate
• Powered by USB
• Requires 2 USB 2
ports
• Sequence, setup
• Remote control
camera
• Keyboard
controlled
software

178. Optelec
ClearNote
• Ease of camera
aiming
• Built in Light source
• Camera control
positioning
• Keyboard controlled
software
• Keyboard controlled
camera
• Dolphin, Zoom Text
compatible

179. Freedom Scientific Onyx
PC Edition arm and flex
• Swing
arm models
• Remote control
• MAGic with
EyeMerge software
included
• Camera can be
powered by USB port
• Distance, desktop, self
view modes
• Cost: $2895.00

180. Specialty Video
Magnifiers
• Flipper
• Shoppa

181. Headborne Low Vision
System
• Eyetonomy SightMate LV920
• www.vuzix.com/medical/lv920.h
tml
• Zoom at near: 3X optical, 4X
digital
• Zoom at distance: 0.5X to 6X
• Edge contrasting, Inverse mode
• Sleek design, 8 ounces
• $3499.00
• Not yet available for purchase
or review

183. Scan and Read Devices
• Kurzweil 1000 (software)
• ABiSee Zoom-Ex, EyePal Vision (portable,
Solo)
• FS Pearl (laptop compatible)
• KNFB Reader (smartphone)
• AI Squared ZoomReader (app)

184. Assessment functioning
• Evaluation of visual Factors
• Response to low vision approaches
• Analysis of tasks, task specific
• Required performance level
• Integration of systems
• Training
• Trial of system; speed, duration,
productivity
• Modifications
• Provision

185. Pharmacogenomics
• Treatment based on
genetic profile
• “Personalized
medicine”
• AREDS – 70% with
certain gene did not
progress (vs. 11%
without)
• Relationship between
certain genes and
outcomes with
Lucentis and Avastin

186. Gene Therapy for
retinal diseases

187. • Trials
Phase I Dose Escalation Safety Study
of RetinoStat in Advanced Age-
Related Macular Degeneration
(AMD) Oxford BioMedica
• Subretinal injection of virus vector that produces
anti-VEGF proteins
• Safety and Efficacy Study of
rAAV.sFlt-1 in Patients With
Exudative Age-Related Macular
Degeneration
• Intravitreal injection of a non-pathogenic virus to
express a therapeutic protein within the eye

188. Wet
Dry AMD
Atrophi
c

189. So What Have We
Learned?
Lory C. Snady-McCoy, MD

190. Answers to Common
Questions
What defines macular degeneration?

191. What tests are used?
Why are they necessary in the
diagnosis and management?
Not everything that looks like
macular degeneration
is macular degeneration
Importance of continued
monitoring and care
50% chance of developing wet AMD
in fellow eye over 5 years

192. What Should I Eat?

193. • Foods rich in antioxidants may delay the
progression of AMD
• Green leafy vegetables, berries, nuts, seaweed
(?) Beta-carotene, omega 3 fatty acids, lutein

194. Which vitamins should I use?

195. • AREDS vitamins shown to be beneficial in
patients with high risk AMD
• Vitamins slow the progression; they do not
stop it
• Benefits of AREDS II not proven yet

196. Will the high dose of vitamins in the
AREDS formula have side effects?
• Vitamin A in smokers - lung cancer
• Vitamins A and E stored in the liver - potential
liver toxicity
• Zinc - anemia if not taken with copper
• Vitamin E - cardiovascular issues not typical in
dose prescribed, prostate cancer?
• AREDS II - High dose Vitamin A removed; Lutein
and Zeaxanthin added

197. Is AMD hereditary?
Are my children at risk?

198. • Genetics of AMD is complex with many
associated genes
• Hereditary forms exist and can express
themselves at different ages and in different
degrees of severity
• Environmental factors may trigger the disease in
susceptible people

199. Known risk factors:
• Smoking, diet, exercise, obesity (BMI)
• Hypertension, Hypercholesterolemia
• Does this sound familiar??

200. Will I go totally blind?
• AMD causes central vision loss with
preservation of peripheral vision
• 90% of severe vision loss occurs in the wet
(neovascular) type. 10% of patients have wet
AMD
• 90% of patients have dry (atrophic) AMD. 10%
of these with develop severe vision loss

201. Are there any
new treatments
in the making?

202. • Millions of dollars have been appropriated to
AMD research
• Medications based on a person’s individual
genetic profile (pharmacogenomics)
• Gene therapy to enhance a person’s own
production of beneficial compounds
• Retina implant / retinal prosthesis
• Stem cells
• Antioxidant eye drops for dry / atrophic AMD

203. Which treatment is best for me
and why?
• Thermal “Hot” Laser (1970’s)
• PDT “Cold” Laser (Visudyne)
• Macugen - First anti-VEGF intraocular treatment
• Lucentis - First to show improved vision
95% stabilized 40% improved
• Avastin - Cost
• Eylea - Less frequent treatment

204. Argon/Krypton/Dye/Diode Laser
PDT Laser/Visudyne

205. Macugen
Lucentis/Avas
tin
Eylea

206. How many injections will I need? Is there a limit to the
number of treatments I can get? What is the side
effect of long-term treatment?
Lucentis Study - injection every 4 weeks. May still give best
outcome
Treat and Extend protocol
Double-dosing
Combined PDT with anti-VEGF therapy
Risks: Infection, Retinal detachment, Cataract, Inflammation,
Glaucoma
Therapy for a chronic condition requires long term treatment.
Underlying degenerative changes will continue with potential
gradual vision loss even with treatment.

207. What will happen if I do nothing?
• Natural history of AMD is to cause significant
and permanent loss of central vision leading to
legal blindness

208. Will changing my glasses help?
Multiple aids to help people with decreased vision with AMD:
• Spectacle-mounted magnifiers
• Hand-held and spectacle-mounted telescopes
• Hand-held and stand magnifiers
• Video magnification / Computer devices
• Importance of illumination, brightness and increased contrast
• Writings devices, voice command, “gadgets”
• Importance of early evaluation when moderate vision loss by a
low vision specialist
• Devices require training; use of eccentric vision

209. Congratulations!
You have now
earned your
diploma!

210. So What Have We
Learned?
Lory C. Snady-McCoy, MD

211. Answers to Common
Questions
What defines macular degeneration?

212. What tests are used?
Why are they necessary in the
diagnosis and management?
Not everything that looks like
macular degeneration
is macular degeneration
Importance of continued
monitoring and care
50% chance of developing wet AMD
in fellow eye over 5 years

213. What Should I Eat?

214. • Foods rich in antioxidants may delay the
progression of AMD
• Green leafy vegetables, berries, nuts, seaweed
(?) Beta-carotene, omega 3 fatty acids, lutein

215. Which vitamins should I use?

216. • AREDS vitamins shown to be beneficial in
patients with high risk AMD
• Vitamins slow the progression; they do not
stop it
• Benefits of AREDS II not proven yet

217. Will the high dose of vitamins in the
AREDS formula have side effects?
• Vitamin A in smokers - lung cancer
• Vitamins A and E stored in the liver - potential
liver toxicity
• Zinc - anemia if not taken with copper
• Vitamin E - cardiovascular issues not typical in
dose prescribed, prostate cancer?
• AREDS II - High dose Vitamin A removed; Lutein
and Zeaxanthin added

218. Is AMD hereditary?
Are my children at risk?

219. • Genetics of AMD is complex with many
associated genes
• Hereditary forms exist and can express
themselves at different ages and in different
degrees of severity
• Environmental factors may trigger the disease in
susceptible people

220. Known risk factors:
• Smoking, diet, exercise, obesity (BMI)
• Hypertension, Hypercholesterolemia
• Does this sound familiar??

221. Will I go totally blind?
• AMD causes central vision loss with
preservation of peripheral vision
• 90% of severe vision loss occurs in the wet
(neovascular) type. 10% of patients have wet
AMD
• 90% of patients have dry (atrophic) AMD. 10%
of these with develop severe vision loss

222. Are there any
new treatments
in the making?

223. • Millions of dollars have been appropriated to
AMD research
• Medications based on a person’s individual
genetic profile (pharmacogenomics)
• Gene therapy to enhance a person’s own
production of beneficial compounds
• Retina implant / retinal prosthesis
• Stem cells
• Antioxidant eye drops for dry / atrophic AMD

224. Which treatment is best for me
and why?
• Thermal “Hot” Laser (1970’s)
• PDT “Cold” Laser (Visudyne)
• Macugen - First anti-VEGF intraocular treatment
• Lucentis - First to show improved vision
95% stabilized 40% improved
• Avastin - Cost
• Eylea - Less frequent treatment

225. Argon/Krypton/Dye/Diode Laser
PDT Laser/Visudyne

226. Macugen
Lucentis/Avas
tin
Eylea

227. How many injections will I need? Is there a limit to the
number of treatments I can get? What is the side
effect of long-term treatment?
Lucentis Study - injection every 4 weeks. May still give best
outcome
Treat and Extend protocol
Double-dosing
Combined PDT with anti-VEGF therapy
Risks: Infection, Retinal detachment, Cataract, Inflammation,
Glaucoma
Therapy for a chronic condition requires long term treatment.
Underlying degenerative changes will continue with potential
gradual vision loss even with treatment.

228. What will happen if I do nothing?
• Natural history of AMD is to cause significant
and permanent loss of central vision leading to
legal blindness

229. Will changing my glasses help?
Multiple aids to help people with decreased vision with AMD:
• Spectacle-mounted magnifiers
• Hand-held and spectacle-mounted telescopes
• Hand-held and stand magnifiers
• Video magnification / Computer devices
• Importance of illumination, brightness and increased contrast
• Writings devices, voice command, “gadgets”
• Importance of early evaluation when moderate vision loss by a
low vision specialist
• Devices require training; use of eccentric vision

230. Congratulations!
You have now
earned your
diploma!

231. • Can only be used in patients with functioning inner
retinal cells – for example AMD and RP
• Uses an artificial means to detect light (video
camera)
• Converts light energy into an electrical signal
• Deliver the electrical signal to the retinal neurons
other than photoreceptors to elicit activity that is
interpreted as vision
• Vision equivalent to 20/1260

232. Retinal Implant

233. ARGUS II Implant
60 electrodes (16 in
ARGUS I)
250 electrode array in
development

234. Subretinal implant

235. Microprocessor power

237. Emerging treatments for
Dry AMD
Atrophic AMD AL-8309B (Alcon Laboratories)
• 2 year study evaluating an Eye drop
for dry AMD
• Primary endpoint is size of the
atrophic area
• Randomized, double blind
• 772 patients
• Study completed July 2011

238. ACU-4429 - Acucela
 Phase II granted fast track status
Fenretinide
 Phase III began 2011

239. Emerging treatments for dry
AMD
• Encapsulated human cells genetically modified
to secrete ciliary neurotrophic factor (CNTF)
• CNTF is a growth factor capable of rescuing
dying photoreceptors and protecting them from
degeneration

240. Emerging treatments
• OT- 551 Antioxidant Eye drops
for Dry AMD
• Othera Pharmaceuticals/ National Eye Institute
• A Multicenter, Proof-Of-Concept Study
Of Intravitreal AL-78898A In Patients
With Geographic Atrophy
• Alcon

241. Human embryonic
stem • Can differentiate into any of
cells
the 220 cell type in the
human body
• Cells acquired from
unwanted or discarded
embryo
• Can propagate indefinitely
• Proposed for regenerative
medicine and tissue
replacement after injury or
disease

242. Stem Cell Research

243. • hES Cells modified to become RPE cells which
nourish damaged photorecptors
•First study of human transplantation reported in
January 2012
• Study of safety and tolerability of subretinal
transplantation
• 2 patients studied, one with AMD and one with
Stargardt’s disease, vision did not worsen in either one
• No tumor formation or signs of rejection

244. Stem Cells – Current
• Rejection Problems
• Tumor formation
• Expense – producing and cultivating cell
lines is costly
• Intellectual property rights
• Ethics
• No good animal models of macular
degeneration