Age-related macular degeneration (ARMD) is a degenerative eye disease that affects the macula and can cause vision loss, with risk factors including aging, smoking, and family history. It has early and late stages, with the late stage including dry ARMD characterized by retinal pigment epithelium and photoreceptor atrophy, and wet ARMD involving abnormal blood vessel growth beneath the retina. Treatment options depend on the stage and type of ARMD, with anti-VEGF injections and photodynamic therapy used for wet ARMD to prevent further vision loss.

1. PRESENTED BY:
ANIS SUZANNA BINTI MOHAMAD
Optometrist and Contact Lens Consultant
B.Sc (Hons) Optometry UKM

2. Healthy retina

3. ANATOMY OF RETINA

4. AGE RELATED MACULAR
DEGENARATION
• Definition:
– A DEGENERATIVE eye disease that AFFECT MACULA
– which responsible to the central vision
• Types of ARMD
– Early stage
– Late stage
• Dry ARMD
• Wet ARMD

5. • Bruch membrane become less permeable
– Blocks nutrition from RPE, prevent waste product from retina escaping
• The quality of retina deteriorate (dry armd)
• New blood vessel are stimulated into retina to clear away the waste
products (wet armd)

6. Early stage ARMD
SIGN
• Drusen
– Discrete yellow spot at macula
– The accumulation occurs as bruch's membrane becomes
thicker
• prevents the free flow of materials to and from photoreceptors
layer.
– Also, the retinal pigment cells accumulate lipofuscin.
• This pigment will also slow down the passage of chemicals to
and from the retina.

7. SYMPTOM
• Usually has normal vision
• Difficult driving, recognizing dimly
road sign
– Loss of rod photoreceptors
(earlier than cones)

8. Late stage: DRY ARMD
• Slowly progressive atrophy of photoreceptor,
RPE, and choriocappilaries
• Tissue has thinned and lost pigment
• Also known as atrophic AMD,
nonexudatives AMD,
nonvascular AMD
• Progress over month, years
• Bilateral
– Severity and progress may
different between BE

9. • SIGN
– Usually assoc with hard drusen
• Small, round, discrete, yellow white
spot asocc with focal disfunction of
RPE
– Atrophy of RPE
– Enlargement of atrophic area,
pre-existing drusen appear,
choroidal vessel visible 
geographic atrophy
Geographic atrophy
Dry ARMD

10. • SYMPTOM
– Slow and progressive loss central vision
• Called central scotoma
– Vision distorted
• Called metamhorphopsia
• Drusen has expand and increase in no.

11. Late stage: Wet ARMD
• New blood vessel growth
underneath the retina
• body's misguided way of
attempting to create a new
network of blood vessels
– to supply more nutrients and
oxygen to the retina.
• Called choroidal
neovascularization (CNV)
– leak fluid under the macula
– then form scar tissue leading to
central vision loss.
• Also known as exudatives AMD,
neovascular AMD

12. Sign
• Soft drusen appear
– Larger and have indistinct margin
– May slowly enlarged and coalesce to form solid
drusenoid detachment of RPE
• area of the macula is elevated by subretinal fluid
or blood, often associated clumps of exudates
Soft drusen in wet ARMD Wet ARMD or neovascular ARMD

15. • Symptom
– Profound central vision impairment
• Sudden decrease (weeks)
– Vision distorted

16. Risk factors
1. Aging
2. Smoking
3. Obesity and inactivity
4. High blood pressure
5. hereditary

17. Complications of ARMD
1. Decreased contrast sensitivity
2. Decreased visual acuity
3. Metamorphopsia
4. Central scotoma

18. Decreased contrast sensitivity
– It occurs at early
phase of onset.
– The macular at this
stage has discrete
yellow spots or
drusen.
– The
hyperpigmentation
of RPE can
decreased contrast
sensitivity of the eye.

19. Decreased visual acuity
– Common in late stage.
– It is due to slowly
progressive atrophy of
photoreceptors, RPE
and choriocapillaries.
– RPE detachment can
occur.
– The gradual vision
impairment occurs
gradually over months
or years.
– Normally both eye is
affected but
asymmetry.

20. Metamorphopsia
• It occurs due to thickened Bruch membrane of the
eye.
• It may cause unilateral metamorphosia and lead to
impairment of central vision.
Patient complains of all the object seen smaller than actual size. (micropsia)

21. Central scotoma
– It occurs when the
foveal area is affected.
– The scotoma, or
central blind spot, can
be due to geographic
atrophy or to the
damage of
photoreceptor cells
from choroidal
neovascularization
(leaking blood
vessels).
Patient complaints of difficult to recognize the

22. Clinical manifestations of age-related macular degenerationClinical manifestations of age-related macular degeneration
Phase Clinical manifestation Associated visual defect
Early
stage
Focal drusen
Irregular pigmentations of
the retinal pigment
epithelium
Good visual function
Abnormal dark adaptation
Reading problem in dark
room
Blue-yellow defect
Driving car at night is
impaired
Late
stage
Detachment of the retinal
pigment epithelium
Rip in the retinal pigment
epithelium
Choroidal neovascularization
Disciform scar
Geographic atrophy of the
RPE
Decreased visual acuity
Metamorphopsia
Central scotoma

23. EARLY DETECTION OF ARMD
• Purposes:
– To monitor the progression of the sign of small
drusen form in the macula.
– Can give appropriate management to the
patient according to their stage.
– To prevent the dry ARMD progression from
develop into the wet ARMD.
– Wet ARMD is progresses much more quickly
and can cause severe damage of vision.

24. Spontaneous modifications of drusen
DrusenDrusen
Choroidal
neovascularization
Choroidal
neovascularization
RPE detachmentRPE detachment
Geographic
atrophy
Geographic
atrophy
Disciform scarDisciform scar

26. ASSESSMENT OF AGE-RELATED
MACULAR DEGENERATION

27. Patient’s History
• Purpose:
– A careful review of the patient’s family history can help
differentiate the ARMD or the other macula associated disease.
• Questions:
– Chief complaint
• Ask patient about chief complaint carefully.- onset and course of
symptom.
– Symptoms
• Ask patient whether they have see object blurred or distorted.
• Ask patient if they notice any missing part or wavy of a straight line.
• Ask about glaring problems especially when driving at night, early
morning or early-evening hours
– Ocular history
– Medications and allergies
– Family History
• Any family members have the ARMD disease?

28. Ocular Examination
• Visual acuity
– Pinhole visual acuity test
• Contrast sensitivity
– loss of contrast sensitivity at high spatial frequencies
– loss of peak contrast sensitivity with increasing drusen
severity
• Pupillary responses
– To differentiate the central scotoma due to optic nerve
disease or macular disease
• Biomicroscopy
– to examine other factor that contribute to disability
glare
• Color Vision
- For screening and diagnosis of color vision defect on the
ARMD patient.

29. Visual acuity
• At early onset of the disease, visual acuity will be slightly
decreased. (VA=<6/9)
• Pinhole visual acuity must be done at distance with habitual
correction.
The expected findings:
• If the patient decreased visual
acuity due to pathological disease
such as ARMD, pinhole visual acuity
is no improvement and possibly a
further decrease will occur.
• A refraction should improve acuity
level of the patient at least to the
level obtained through the pinhole.

30. Contrast sensitivity
• Patient with ARMD is often complaint of blurring
at distance, difficulties to see face and road
signboard due to decreased in contrast sensitivity.
• Contrast sensitivity reduced when there are
changes happened on RPE.
• Test for contrast sensitivity must be done in
order to see the severity of the morphological
changes at the macular.
• Expected findings:
– Patient with ARMD usually demonstrates
profound loss of acuity on contrast sensitivity
test.

31. Contrast sensitivity can be measured with the use of a
contrast sensitivity chart (A) or neutral density filters (B).
(A) (B)

32. Color Vision
• Color vision test:
– Clinical screening: Ishihara plate.
– Diagnosis: D-15 Color Test or FM 100 Hue Test
• Purpose:
– To detect the color vision defect that occur in ARMD
patient either red –green or blue-yellow defect.
– To classified as congenital or acquired color defect.
• Expected findings:
– Most of the ARMD patient suffered yellow-blue defect.
– But patient must be differentiate with other macular
disease such as diabetic retinopathy.

33. Supplemental testing
• Visual Field
– Facial Amsler
– Amsler grid
– Goldmann perimetry
– Automated Perimetry
• All Fundus Related Procedures
• Fundus Biomicroscopy
• Fundus photography
• Opthalmoscopy
• Fundus Fluorescein angiography
• Optical coherence tomography (OCT)

34. Visual Field
There are number of different ways to
evaluate the visual field of age-related macula
degeneration patient.
These include:
1. Facial Amsler
2. Amsler grid
3. Goldmann perimetry
4. Automated Perimetry
No one type of visual field is good for all situations.

35. Facial Amsler
• Purpose:
– It is very useful for
patient with cognitive
impairment.
– Detect gross
monocular visual field
of the patient.
• The central visual field can then be tested by asking the
patient to report any defects in your facial features while
they look toward your nose.

36. Simultaneously present targets
• Purpose:
– Alternative method to get grossly detection of patient’s
visual field
– Patient have to report the existence of the object that
shown.
– Each of the object held in different visual quadrant.

37. Amsler Grid
• Purpose:
– It can give useful
information regarding
central scotoma, areas of
missing, blurred, or
distorted lines.
– It is sensitive to small
scotoma within central 10°
of visual field.
– The test is also useful for
differentiating neuro-
ophthalmic and macular
disease.
Patient experienced deep dark spot at the center of the Amsler Grid

38. • Instruction:
1. Hold the chart at a reading distance
of 30 cm; adequate and even lighting
is important.
2. You should wear your fully
prescribed spectacles and for elderly,
their reading glasses, during the test.
3. Cover the left eye, and use your right
eye to focus on the center dot.
4. If patient difficult to see the white
dot at the center, ask them to
imagine the intersect of the two line
at the center.
5. Ask patient: Do you notice any wavy,
broken or distorted lines or blurred or
missing areas of vision within the
chart?
6. Repeated the above examining on
your left eye.
It is a 10 x 10 cm square grid
formed by multiple white lines on
a black background and with a
white dot at the center.

39. Goldmann perimetry
• Advantages:
– Ability to directly
monitor patient
attention
– Present custom test
points
– Test the complete
visual field.
Large central scotoma seen with Goldmann perimetry test.

40. Automated perimetry
• It is difficult to do with
patient ARMD because
they reduced in contrast
sensitivity.
• The test can be done on
short-wavelength
automated perimetry.
• If possible to be done, the
result is very useful
especially in detecting
presence of the central
scotoma in advanced
cases of ARMD.
Automated visual field machines
allows standardized testing and
statistical analysis .

41. All Fundus Related Procedures
I. Opthalmoscopy
– Direct
– Indirect
I. Fundus photography
II. Fundus Biomicroscopy
III. Fundus Fluorescein angiography
IV. Optical coherence tomography
(OCT)

42. Fundus Related Examinations
• Purpose:
– To see fundus and macula for both eyes.
• Clinical findings:
Clinical features Signs
Hard drusen
(nodular)
Small, round, discrete, yellow-white lesions, and usually located at
the macula.
Soft drusen
(Exudative)
Larger lesions with ill-defined edges associated with exudative
ARMD.
Non-exudative
ARMD
Hyperplastic changes of RPE associated with slowly progressive
degeneration of the overlying neuroretina and underlying
choriocapillaries.
Exudative ARMD Present with elevated macular area with subretinal fluid or blood
associated with clumps of exudates. If the lesion recover, it will
leave with subretinal ‘disciform’ scarring.

43. Fundus Fluorescein
Angiography
• Purposes:
– To see the leakage of the blood vessels around
the macula.
– The test is done to help the doctor confirm a
diagnosis, to provide guidelines for treatment,
and to keep a permanent record of the vessels
at the back of the eye.
– This test carry out mostly in cases of advanced
cases of ARMD for further treatment.

44. Procedure:
• Pupil dilated with the
mydriatics drop before
the florescein injected
into the body.
• Fluorescein dye injected
into bloodstream via
hand or arm.
• Following the injection,
the fundus photo are
taken quickly within 60
seconds during dye
enters blood vessels at
the back of the eyes. Fluorescein Angiogram of ARMD

45. Optical coherence tomography (OCT)
– It useful in detecting
small changes in
retinal thickness,
subretinal and sub-
RPE fluid and
choroidal
neovascularization in
ARMD.
– It also useful to
monitor response to
therapeutic
intervention.

46. PREVENTION

47. • Using the Amsler grid may help detect subtle
changes in vision
• A healthy lifestyle helps to prevent ARMD
- Stop smoking
- Regular exercise
- Reduce risk by 70%
- Keep your blood pressure low
- Salt and more than 2 units of alcohol a day may cause
BP to rise

48. - Avoid obesity
- Take a balanced diet
- Fruit and vegetables- prevent 36-50% of ARMD
- Oily fish twice a week reduces ARMD by 40%
- Vitamin supplements
Eg. Antioxidants plus zinc
• Protect eyes from sun exposure with
sunglasses

49. Management
1. Basic Treatment
2. Available Treatment Options
3. Patient Education
4. Prognosis and Follow up

50. Basic Treatment
• There is NO CURE
• T(x) : - slow the progression of disease
- prevent the vision loss
• Wet AMD : - a lot of treatments are available
- mainly for stopping the growth of
new blood vessels
- if delayed t(x), scar formation

51. • Dry AMD: - no treatment available
- does not involve new blood vessels
growing
- Low vision aids may be helpful

52. Treatment of Wet ARMD
1. Anti-VEGF treatment
- The most recent treatment
- Use anti-vascular endothelial growth factor
(anti-VEGF) drug such as Lucentis, Macugen,
Avastin
- Injects into the eyeball (IV) under local
anaesthetic
- Cause constriction and closure of the leaking
blood vessels
- Prevent further damage of vision

53. Cont..
- Begins with a course of three monthly
injections
- Monitor every months
- High success rate
- Most effective when treating blood vessels
that are ‘active’ or ‘leaking’
- Stop sight getting worse
- Improvement of vision- 40%
- Complication: ↑ IOP, RD, eye infections

54. 2. Photodynamic Therapy (PDT)
• A type of laser t(x)
• Use a combination of a light sensitive drug
(Verteporfin) and a low energy (non -thermal)
laser
• To stop new blood vessels growing
• Adv: the ability to selectively damage tissue
• Indication: classic CNV-subfoveal type
• SE: transient decrease in vision, sensitivity to
bright light for 24-48 hours.

55. Classic sub-foveal CNV
-Most people with neovascular
ARMD have CNV in the centre of
the retina
- Regular laser cannot be used
as it would destroy the central
vision
-Thus, photodynamic laser (PDT)
is used.
-But still causing some vision
loss
Yellow spot:
fovea
Red area:
CNV

56. Classic extra-foveal CNV
-CNV are not in the centre of
fovea
-Can be treated by regular laser
therapy
-Argon Laser
Photocoagulation. High-energy
laser light - used to destroy
actively growing abnormal
blood vessels

57. Photodynamic Therapy (PDT)
a) Small dirty grey lesion at the fovea surrounded by blood
b) Fundus Angiography venous phase shows hyperfluorescence from classic
subfoveal CNV surrounded by a hypofluorescent ring

58. Photodynamic Therapy (PDT)
c) measurement of greatest linear dimension of the lesion;
d) FA 3 months following successful treatment shows hypofluorescence of the lesion
(Courtesy of S Milewski)

59. 3. Anti-angiogenic drug
- Used to slow down or prevent the growth of
the abnormal blood vessels within the eye
- Eg. Intravitreal steroid (triamcinolone
acetonide)
- SE: ocular hypertension, cataract
- Submacular: removal of the subfoveal CNV
- Macular translocation: is aimed at surgically
moving the fovea away from the CNV
4. Surgery

60. 5. Vitamin Supplements
• Age-Related Eye Disease Study (AREDS) showed
that for certain individuals, antioxidants such as
– 500 g of vitamin C
– 400 IU of Vitamin E
– 15 mg of beta-carotene
– 80 mg of Zinc oxide
– 2 mg of Copper
• can decrease the risk of vision loss in patients
with intermediate to advanced dry age-related
macular degeneration.

61. 6. Refractive correction or low vision
aids
• Prescribe and increasing near addition for
reduced acuity in patient with macular
degeneration
• Other options:
- Telescope
- Hand magnifiers
- Enlarged size print
- Enlarged screen size for television or computer
screen
- Closed-circuit television (CCTV) or computer
magnification system

62. Advice for ARMD patient
• Consume fruit on daily basis and quit smoking
• Exercise regularly
• Monitor vision- regular eye examination
• Adapt to low vision- eg.making changes to
lighting, using contrast in objects that often used
such as door frames and light switches, do
labeling and marking medicines and food, and
getting rid of potential hazards.
• Counseling, rehabilitation, and training can help
with managing household, cooking, shopping,
personal grooming and others.
• Develop a personal support network-deal with
fear and anxiety-maintain quality of life

63. Prognosis and Follow up
• Dry ARMD:
- slow progression- keep most of the vision
- may develop the wet form- pt should monitor vision
daily-KIV annually
- attend to clinic immediately if signs of reduced
vision or distortion are noted.
• Wet ARMD and have had laser treatment:
- can be recur-should test vision to see if any blind
spots grow bigger or if any new blind spots appear.
- New blood vessels can emerge months or years after
have had successful laser treatment.
• If only one eye is affected:
- A regular eye examination on the other eye is
needed to discover any sign of new problems.

64. Summary
• ARMD is the most common cause of irreversible vision
loss in people over 50 years of age in Western countries.
• 2 types of ARMD: a) Dry and b) Wet
• Currently no other t(x) is available for dry ARMD except
of visual aids and lifestyle advice.
• Early detection is critical for successful t(x) of wet
ARMD.
• Consultation is very important – to cope with low vision
• Rehabilitation and training can make their living with
low vision more easier and safer.

65. References
• Jack J Kanski. 2007. Kanski Clinical Ophthalmology 6th
edition: Butterworth-
Heinemann
• Adrian S Bruce. 2008. Posterior Eye Disease and Glaucoma A-Z : Butterworth-
Heinemann
• Theodore Grosvenor. 2007. Primary Care Optometry. Fifth Edition. St. Louis,
Missouri: Butterworth-Heinemann.
• http://www.goodhope.org.uk/departments/eyedept/armdwet.htm
(9.00a.m,20/2/2011)
• http://www.webrn-maculardegeneration.com/central-scotoma.html(10.00 a.m,
22/2/2011)
• http://www.mdsupport.org/library/angio.html (11.00 a.m,21/2/11).
• http://www.myvisiontest.com/newsarchive.php?id=1219 (10.00 a.m, 22/2/2011)
• http://bjo.bmj.com/content/85/12/1432.abstract(10.00 a.m, 22/2/2011