1. ADVANCES in AMD And OCT The Retina Centers Of Washington Georgetown University T.S. Melki, MD Mar 28, 2010 ARLINGTON, VA ROCKVILLE, MD

2. Anatomy of the Retina

3. Age-Related Macular Degeneration (AMD) Defined AMD= disease associated with aging that gradually destroy sharp, central vision. AMD can advance so slowly that people notice little change in their vision. In others, it can progresses much faster and may lead to a loss of vision in both eyes. Two types: Dry and Wet AMD

4. Dry AMD Occurs when the light-sensitive cells in the macular slowly breakdown, cause gradually blurring central vision. Three stages of dry AMD: 1- Early AMD: several small or medium-sized drusen. Patients have no symptoms. 2- Intermediate AMD: many medium-sized or one or more large drusen. They can see a blurred spot in the center of their vision. 3- Advanced Dry AMD: in addition to drusen, patients have a breakdown of light sensitive cells, causing blurred spot in the center and getting bigger over time.

5. Wet AMD Wet MD occurs when abnormal blood vessels behind the retina start to grow under the macular. These new blood vessels tend to be very fragile and often leak blood and fluid. The blood and fluid raise the macular from its normal place, causing macular edema. Loss of central vision occur quickly without treatment.

6. Wet AMD

7. Epidemiology The Beaver Dam Eye Study: 30% individuals aged >75 have some form of AMD 7% of those have an advanced form Recent studies: 8 million Americans to be at risk of developing advanced AMD in the next 5 years

8. Epidemiology The cause of AMD remains unknown Mild association between hypertension and AMD Smoking has been demonstrated to be the most consistence modifiable risk factors Greater levels of plasma vascular endothelial growth factor (VEGF), von Willebrand factor, and fibrinogen, as well as increased plasma viscosity, in patients with AMD

9. Treatment for Dry AMD Once dry AMD reaches the advanced stage, no treatment can prevent the vision loss. However, treatment can delay and possibly prevent intermediate AMD from progressing to the advanced stage. The National Eye Institute’s Age-Related Eye Disease Study (AREDS) : taking a specific high-dose formulation of antioxidants and zinc reduces the risk of advanced AMD.

10. Treatment for Wet AMD 1. Laser surgery: Using laser to destroy the fragile, leaky blood vessels. However, laser treatment may also destroy some surrounding healthy tissue and some vision. 2. Photodynamic therapy: using drug called verteporfin inject intravenous. The drug tends to stick to the surface of the new blood vessels, then a light is shined into the eye to activate the drug  destroy the new blood vessels.

11. Treatment for Wet AMD ( cont.) 3. Injections Using anti-VEGF drugs ( Avastin, Lucentis) to inject into the vitreous. These drugs act on blocking the effects of the growth factor which present with high level in AMD and promote the growth of abnormal new blood vessels

12. Intra-vitreal injection Avastin or Kenalog

13. Treatment for WET AMD 4-T.T.T. (TRANS-PUPILLARY-THERMAL-THERAPY) -USING THE DOIDE LASER TO HEAT AND COAGULATE THE CHOROIDAL ABNORMAL VESSELS, WITH MINIMAL DAMAGE TO THE NORMAL RETINAL TISSUE.

14. Avastin- Mechanic of Action

16. Hypoxia has been shown to be a major inducer of VEGF gene transcription.

17. All variants of VEGF (particularly VEGF-A) have been implicated in the occurrence of increased vascular permeability by affecting endothelial tight-junction proteins in ocular vascular diseases.

19. Pegaptanib sodium (Macugen, Melville, NY)

20. Ranibizumab (Lucentis, Genentech Inc.,San Francisco, CA)

21. Bevacizumab (Avastin; Genentech Inc., San Francisco, CA)

23. Wet AMD case 1

24. Wet AMD case 1- s/p 1st IVA

25. Wet AMD case 1-recurrent

26. Wet AMD case 1-s/p 2nd IVA

27. AMD case 2

28. AMD case 2 (cont.)

29. AMD case 2 – s/p IVA

30. Case 3-Before IVL

31. Case 3: After IVL – 5 weeks

32. Case 3: 2 mos- slightly increasing fluid

33. Case 3: after reinject IVA

34. Case 4: Before IVA

35. Case 4: After IVA – 6 weeks

36. Case 5

37. Case 5- Fluoresceine

38. Case 6- Before and after IVA

39. Newly defined: Age-related Choroidal Atrophy Spaide RF report: -Using Enhanced depth imaging spectral-domain optical coherence tomography (EDI OCT). -Age-related choroidal atrophy affects older individuals in whom posterior pole abnormalities develop that may mimic and also be associated with findings typical for AMD. -Decreasing choroidal thickness could represent an increasing risk of retinal degeneration.

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