ARMD (Age-Related Macular Degeneration)

Age-related macular degeneration, often called AMD or ARMD, is the leading cause of vision loss and blindness of people who are age 65 and older. Because people in this group represent an increasingly larger percentage of the general population, vision loss from macular degeneration is a growing problem.

AMD is degeneration of the macula, which is the part of the retina responsible for the sharp, central vision needed to read or drive. Because the macula primarily is affected in AMD, central vision loss may occur.

Wet and Dry Forms of Macular Degeneration

• Macular degeneration is diagnosed as either dry (non-neovascular) or wet (neovascular). Neovascular refers to growth of new blood vessels in an area, such as the macula, where they are not supposed to be.
• The dry form is more common than the wet form, with about 85 to 90 percent of AMD patients diagnosed with dry AMD. The wet form of the disease usually leads to more serious vision loss.

Dry Macular Degeneration (non-neovascular).

• Dry AMD is an early stage of the disease and may result from the aging and thinning of macular tissues, depositing of pigment in the macula or a combination of the two processes.
• Dry macular degeneration is diagnosed when yellowish spots known as ‘drusen’ begin to accumulate in and around the macula. It is believed these spots are deposits or debris from deteriorating tissue. Gradual central vision loss may occur with dry macular degeneration but usually is not nearly as severe as wet AMD symptoms. However, dry AMD through a period of years slowly can progress to late-stage geographic atrophy (GA) – gradual degradation of retinal cells that also can cause severe vision loss.
• No FDA-approved treatments are available for dry macular degeneration, although a few now are in clinical trials.
• A major National Eye Institute study (AREDS) has produced strong evidence that certain nutrients such as beta carotene (vitamin A) and vitamins C and E may help prevent or slow progression of dry macular degeneration. These findings have led to development of a number of different AREDS nutritional formulas for macular degeneration prevention.
• The AREDS study shows that taking high dose formulas of certain nutritional supplements found in eye vitamins may reduce risk of early stage AMD progression by 25 percent.Eye doctors also recommend that dry AMD patients wear sunglasses with UV protection against potentially harmful effects of the sun.
• Wet Macular Degeneration (neovascular). In about 10 percent of cases, dry AMD progresses to the more advanced and damaging form of the eye disease. With wet macular degeneration, new blood vessels grow beneath the retina and leak blood and fluid. This leakage causes permanent damage to light-sensitive retinal cells, which die off and create blind spots in central vision.
• Choroidal neovascularization (CNV), the underlying process causing wet AMD and abnormal blood vessel growth, is the body’s misguided way of attempting to create a new network of blood vessels to supply more nutrients and oxygen to the eye’s retina. Instead, the process creates scarring, leading to sometimes severe central vision loss.

Wet macular degeneration falls into two categories

Occult

New blood vessel growth beneath the retina is not as pronounced, and leakage is less evident in the occult CNV form of wet macular degeneration, which typically produces less severe vision loss.
Classic. When blood vessel growth and scarring have very clear, delineated outlines observed beneath the retina, this type of wet AMD is known as classic CNV, usually producing more severe vision loss.

ARMD: Symptoms and Signs

• Age-related macular degeneration usually produces a slow, painless loss of vision. In rare cases, however, vision loss can be sudden. Early signs of vision loss from AMD include shadowy areas in your central vision or unusually fuzzy or distorted vision.
• An Amsler grid consists of straight lines, with a reference dot in the center. Someone with macular degeneration may see some of the lines as wavy or blurred, with some dark areas at the center.
• Viewing a chart of black lines arranged in a graph pattern (Amsler grid) is one way to tell if you are having these vision problems.
• Eye care practitioners often detect early signs of macular degeneration before symptoms occur. Usually this is accomplished through a retinal exam. When macular degeneration is suspected, a brief test using an Amsler grid that measures your central vision may be performed.
• If your eye doctor detects some defect in your central vision, such as distortion or blurriness, he or she may order a fluorescein angiography to examine the retinal blood vessels surrounding the macula.

Though macular degeneration is associated with aging, research suggests there also is a genetic component to the disease. Duke University and other researchers have noted a strong association between development of AMD and presence of a variant of a gene known as complement factor H (CFH). This gene deficiency is associated with almost half of all potentially blinding cases of macular degeneration.

Columbia University Medical Center and other investigators reported that variants of another gene, complement factor B, may be involved in development of AMD. Specific variants of one or both of these genes, which play a role in the body’s immune responses, have been found in 74 percent of AMD patients who were studied. Also, variants of complement factor C3 have been associated with increased risk of developing AMD.

Ophthalmology Clinics of North America reported that deteriorating, oxygen-starved cells within the retina likely help trigger neovascularization and accompanying damage in wet AMD. Neovascularization is activated by a protein called vascular endothelial growth factor (VEGF), targeted in macular degeneration treatments by anti-VEGF drugs.

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Who Gets Age-Related Macular Degeneration?

• Besides affecting older populations, ARMD occurs in whites and females in particular. The disease also can result as a side effect of some drugs, and it seems to run in families.
• New evidence strongly suggests smoking is high on the list of risk factors for macular degeneration. Other risk factors for macular degeneration include having a family member with AMD, high blood pressure, lighter eye color and obesity. Some researchers believe that over-exposure to sunlight also may be a contributing factor in development of macular degeneration, but this theory has not been proven conclusively. High levels of dietary fat also may be a risk factor for developing AMD.
• Yellowish spots (drusen) that form in the back of the eye or retina are an early sign of “dry” macular degeneration.
• “Wet” macular degeneration occurs with formation of abnormal blood vessels and leakage in the back of the eye (retina), affecting the macula where fine focusing occurs. Commonly named risk factors for developing macular degeneration include:
• Significant vision loss accompanying more advanced forms of AMD increases from fewer than 1 percent among people in their 60s to more than 15 percent among people in their 90s, according to the Canadian Medical Association Journal.

Obesity and Inactivity

Overweight patients with macular degeneration had more than double the risk of developing advanced forms of macular degeneration compared with people of normal body weight, according to one study reported in Archives of Ophthalmology . In the same study, those who performed vigorous activity at least three times weekly reduced their risk of developing advanced AMD, compared with inactive patients.

Heredity

As stated above, recent studies have found that specific variants of different genes are present in most people who have macular degeneration. Studies of fraternal and identical twins may also demonstrate that heredity is a factor in who develops AMD and how severe it becomes.

High Blood Pressure (Hypertension)

Investigative Ophthalmology and Vision Science reported a study in Rotterdam, The Netherlands demonstrating that high blood pressure may be associated with development of macular degeneration

Smoking

Smoking is a major risk factor found in one British study to be directly associated with about 25 percent of AMD cases causing severe vision loss. The British Journal of Ophthalmology in early 2006 also reported study findings showing that people living with a smoker double their risk of developing AMD.

Lighter Eye Color

Because macular degeneration long has been thought to occur more often in lighter skinned populations, particularly in people with light eye color, some researchers theorized that the extra pigment found in darker eyes was a protective factor against development of the eye disease during sun exposure. But no conclusive evidence as yet has linked excessive sun exposure to development of AMD.

A small study reported in the British Journal of Ophthalmology found no connection between the eye disease and sun exposure. In fact, the same study found no relation at all between lighter eye color, hair color and AMD. That finding is contradicted by several earlier studies indicating that lighter skin and eyes are associated with a greater prevalence of AMD.

Drug Side Effects

Some cases of macular degeneration can be induced from side effects of toxic drugs such as Aralen (chloroquine, an anti-malarial drug) or phenothiazine. Phenothiazine is a class of anti-psychotic drugs, including brand names of Thorazine (chlorpromazine, which is also used to treat nausea, vomiting and persistent hiccups), Mellaril (thioridazine), Prolixin (fluphenazine), Trilafon (perphenazine) and Stelazine (trifluoperazine).

The American Academy of Ophthalmology notes that findings regarding AMD and risk factors have been contradictory, depending on the study. The only risk factors consistently found in studies to be associated with the eye disease are aging and smoking.

Macular degeneration mainly affects central vision, causing “blind spots” directly ahead.

How Macular Degeneration Is Treated

There is as yet no outright cure for age-related macular degeneration, but some treatments may delay its progression or even improve vision.

Treatments for macular degeneration depend on whether the disease is in its early-stage, dry form or in the more advanced, wet form that can lead to serious vision loss. No FDA-approved treatments exist yet for dry macular degeneration, although nutritional intervention may help prevent its progression to the wet form.

For wet AMD, treatments aimed at stopping abnormal blood vessel growth include FDA-approved drugs of Lucentis, Macugen and Visudyne used with Photodynamic Therapy or PDT. Lucentis has been shown to improve vision in a significant number of people with macular degeneration. Nutrition and Macular Degeneration

Recent Studies

Recent studies have revealed that people with a diet high in fruits and vegetables (especially leafy, dark green vegetables) are less likely to suffer from macular degeneration. Studies have also shown that taking supplements such as vitamins C and E, beta-carotene (not to be used by actively smoking patients), and zinc may lower the chances that macular degeneration will get worse in some patients.Therefore, we suggest that patients with this condition consider taking antioxidant and zinc supplements. However, more research needs to be done on this subject and supplements are not recommended for all patients. Many researchers and eye care practitioners believe that certain nutrients – zinc, lutein, zeaxanthin and vitamins A, C and E – help lower the risk for AMD or slow down the progression of dry macular degeneration. Benefits of high levels of antioxidants and zinc for halting or slowing development of macular degeneration have been widely reported based on results released in 2001 from the Age-Related Eye Disease Study (AREDS) conducted by the National Eye Institute.

Phase two of the AREDS study began in late 2005 to evaluate whether similar protective effects against AMD might be associated with other nutrients such as omega-3 fatty acids or “good fats,” and lutein and zeaxanthin found in green, leafy vegetables.

Archives of Ophthalmology reported findings in August 2001 that consumption of omega-3 fatty acids, which are particularly prevalent in cold-water fish, also had a protective effect against advanced macular degeneration. Meanwhile, consumption of omega-6 fatty acids, prevalent in vegetable oils, was associated with an increased risk of developing AMD.

Testing and Low Vision Devices for Age-Related Macular Degeneration Treatment

Although much progress has been made recently in macular degeneration treatment research, complete recovery of vision lost to AMD is unlikely. Your eye doctor may ask you to check your vision regularly with the Amsler grid described above. Viewing the Amsler grid separately with each eye helps you monitor your vision loss. The Amsler grid is a very sensitive test and it may reveal central vision problems before your eye doctor sees AMD-related damage to the macula in a routine eye exam.

For those who have vision loss from macular degeneration, many low vision devices are available to help with mobility and specific visual tasks.

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