A complete illustrated guide to age-related macular degeneration, it’s causes, treatments and prevention suggestions from Tampa Bay and Clearwater retina specialist, Dana Deupree, MD

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What is age-related macular degeneration?

Age-related macular degeneration (AMD) is a disease that blurs the sharp, central vision you need for “straight-ahead” activities such as reading, sewing, and driving. AMD affects the macula, the part of the eye that allows you to see fine detail. AMD causes no pain. Dr. Deupree manages and treats macular degeneration in Tampa Bay area, in Clearwater, Florida.

In some cases, AMD advances so slowly that people notice little change in their visual acuity. In others, the disease progresses faster and may lead to a loss of vision in both eyes. AMD is a leading cause of vision loss in Americans 60 years of age and older.

Where is the macula?

The macula is a small, highly sensitive area located in the center of the retina, the light-sensitive tissue at the back of the eye. The retina instantly converts light, or an image, into electrical impulses. The retina then sends these impulses, or nerve signals, to the brain where they are interpreted as an image. See Eye Anatomy.

Also see “Human Eye” animation

Are there different forms of AMD?

AMD occurs in two forms: wet and dry.

VIDEO: “The Difference Between Wet and Dry AMD”

What is wet AMD?

Wet AMD occurs when abnormal blood vessels behind the retina start to grow under the macula. These new blood vessels tend to be very fragile and often leak blood and fluid. The blood and fluid raise the macula from its normal place at the back of the eye. Damage to the macula occurs rapidly.

With wet AMD, loss of central vision can occur quickly. Wet AMD is considered to be advanced AMD and is more severe than the dry form.

An early symptom of wet AMD is that straight lines appear wavy. If you notice this condition or other changes to your vision, contact your eye care professional at once. You need a comprehensive dilated eye exam.

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What is dry AMD?

Dry AMD occurs when the light-sensitive cells in the macula slowly break down, gradually blurring central vision in the affected eye. As dry AMD gets worse, you may see a blurred spot in the center of your vision. Over time, as less of the macula functions, central vision in the affected eye can be lost gradually.

VIDEO: The Difference Between Wet and Dry Macular Degeneration

The most common symptom of dry AMD is slightly blurred vision. You may have difficulty recognizing faces. You may need more light for reading and other tasks. Dry AMD generally affects both eyes, but vision can be lost in one eye while the other eye seems unaffected.

One of the most common early signs of dry AMD is drusen. Drusen are yellow deposits under the retina. They often are found in people over age 60. Dr. Deupree can detect drusen during a comprehensive dilated eye exam. More about drusen.

Dry AMD has three stages, all of which may occur in one or both eyes:

• Early AMD. People with early AMD have either several small drusen or a few medium-sized drusen. At this stage, there are no symptoms and no vision loss.
• Intermediate AMD. People with intermediate AMD have either many medium-sized drusen or one or more large drusen. Some people see a blurred spot in the center of their vision. More light may be needed for reading and other tasks.
• Advanced Dry AMD. In addition to drusen, people with advanced dry AMD have a breakdown of light-sensitive cells and supporting tissue in the central retinal area. This breakdown can cause a blurred spot in the center of your vision. Over time, the blurred spot may get bigger and darker, taking more of your central vision. You may have difficulty reading or recognizing faces until they are very close to you.

If you have vision loss from dry AMD in one eye only, you may not notice any changes in your overall vision. With the other eye seeing clearly, you still can drive, read, and see fine details. You may notice changes in your vision only if AMD affects both eyes. If blurriness occurs in your vision, see an eye care professional for a comprehensive dilated eye exam.

Do drusen cause vision loss in advanced dry AMD?

Drusen alone do not usually cause vision loss. In fact, scientists are unclear about the connection between drusen and AMD. They do know that an increase in the size or number of drusen raises a person’s risk of developing either advanced dry AMD or wet AMD. These changes can cause serious vision loss.

The dry form has early and intermediate stages. Does the wet form have similar stages?

No. The wet form is considered advanced AMD.

Can advanced AMD be either the dry form or the wet form?

Yes. Both the wet form and the advanced dry form are considered advanced AMD. Vision loss occurs with either form. In most cases, only advanced AMD can cause vision loss.

People who have advanced AMD in one eye are at especially high risk of developing advanced AMD in the other eye.

Which is more common–the dry form or the wet form?

The dry form is much more common. More than 85 percent of all people with intermediate and advanced AMD combined have the dry form.

However, if only advanced AMD is considered, about two-thirds of patients have the wet form. Because almost all visual acuity loss comes from advanced AMD, the wet form leads to significantly more vision loss than the dry form.

Can the dry form turn into the wet form?

Yes. All people who have the wet form had the dry form first.

The dry form can advance and cause vision loss without turning into the wet form. The dry form also can suddenly turn into the wet form, even during early stage AMD. There is no way to tell if or when the dry form will turn into the wet form.

Who is at risk for AMD?

AMD can occur during middle age. The risk increases with aging. Other risk factors include:

• Smoking
• Obesity. Research studies suggest a link between obesity and the progression of early and intermediate stage AMD to advanced AMD.
• Race. Whites are much more likely to lose vision from AMD than African Americans.
• Family history. People with a family history of AMD are at higher risk of getting the disease.
• Gender. Women appear to be at greater risk than men.

How is AMD detected?

AMD is detected during a comprehensive eye exam that includes:

• Visual acuity test. This eye chart test measures how well you see at various distances.
• Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of AMD and other eye problems. After the exam, your close-up vision may remain blurred for several hours.

Your eye care professional also may do other tests to learn more about the structure and health of your eye.

During an eye exam, you may be asked to look at an Amsler grid. The pattern of the grid resembles a checkerboard. You will cover one eye and stare at a black dot in the center of the grid. While staring at the dot, you may notice that the straight lines in the pattern appear wavy. You may notice that some of the lines are missing. These may be signs of AMD. (See Amsler grid)

If your eye care professional believes you need treatment for wet AMD, he or she may suggest a fluorescein angiogram. In this test, a special dye is injected into your arm. Pictures are taken as the dye passes through the blood vessels in your retina. The test allows your eye care professional to identify any leaking blood vessels and recommend treatment.

How is dry AMD treated?

Once dry AMD reaches the advanced stage, no form of treatment can prevent vision loss. However, treatment can delay and possibly prevent intermediate AMD from progressing to the advanced stage, in which vision loss occurs. The National Eye Institute’s Age-Related Eye Disease Study (AREDS) found that taking a specific high-dose formulation of antioxidants and zinc significantly reduces the risk of advanced AMD and its associated vision loss. Slowing AMD’s progression from the intermediate stage to the advanced stage will save the vision of many people.

What is the dosage of the AREDS formulation?

The specific daily amounts of antioxidants and zinc used by the study researchers were 500 milligrams of vitamin C, 400 International Units of vitamin E, 15 milligrams of beta-carotene (often labeled as equivalent to 25,000 International Units of vitamin A), 80 milligrams of zinc as zinc oxide, and two milligrams of copper as cupric oxide. Copper was added to the AREDS formulation containing zinc to prevent copper deficiency anemia, a condition associated with high levels of zinc intake.

Who should take the AREDS formulation?

People who are at high risk for developing advanced AMD should consider taking the formulation. You are at high risk for developing advanced AMD if you have either:

1. Intermediate AMD in one or both eyes
2. Advanced AMD (dry or wet) in one eye but not the other eye.

Your eye care professional can tell you if you have AMD, its stage, and your risk for developing the advanced form.

The AREDS formulation is not a cure for AMD. It will not restore vision already lost from the disease. However, it may delay the onset of advanced AMD. It may help people who are at high risk for developing advanced AMD keep their vision.

Can people with early stage AMD take the AREDS formulation to help prevent the disease from progressing to the intermediate stage?

There is no apparent need for those diagnosed with early stage AMD to take the AREDS formulation. The study did not find that the formulation provided a benefit to those with early stage AMD. If you have early stage AMD, a comprehensive dilated eye exam every year can help determine if the disease is progressing. If early stage AMD progresses to the intermediate stage, discuss taking the formulation with your doctor.

Can diet alone provide the same high levels of antioxidants and zinc as the AREDS formulation?

No. The high levels of vitamins and minerals are difficult to achieve from diet alone. However, previous studies have suggested that people who have diets rich in green leafy vegetables have a lower risk of developing AMD.

Can a daily multivitamin alone provide the same high levels of antioxidants and zinc as the AREDS formulation?

No. The formulation’s levels of antioxidants and zinc are considerably higher than the amounts in any daily multivitamin.

If you are already taking daily multivitamins and your doctor suggests you take the high-dose AREDS formulation, be sure to review all your vitamin supplements with your doctor before you begin. Because multivitamins contain many important vitamins not found in the AREDS formulation, you may want to take a multivitamin along with the AREDS formulation. For example, people with osteoporosis need to be particularly concerned about taking vitamin D, which is not in the AREDS formulation.

How is wet AMD treated?

Anti-VEGF Treatments, like LucentisTM , Avastin and Macugen, work by inhibiting the growth of the abnormal blood vessels that cause AMD.

Click here to watch an Avastin injection animation

They are also used to treat swelling of the macula due to AMD. The goal of treatment is to prevent further loss of vision. Although some patients have regained vision, the medication may not restore vision that has already been lost, and may not ultimately prevent further loss of vision caused by the disease.

Two other treatments for wet AMD are laser surgery and photodynamic therapy. Neither treatment is a cure for wet AMD. Each treatment may slow the rate of vision decline or stop further vision loss. The disease and loss of vision may progress despite treatment.

Click here to watch a Lucentis treatment animation

Laser surgery

This procedure uses a laser to destroy the fragile, leaky blood vessels. A high energy beam of light is aimed directly onto the new blood vessels and destroys them, preventing further loss of vision. However, laser treatment also may destroy some surrounding healthy tissue and some vision. Only a small percentage of people with wet AMD can be treated with laser surgery. Laser surgery is more effective if the leaky blood vessels have developed away from the fovea, the central part of the macula. (See illustration at the beginning of this document.) Laser surgery is performed in a doctor’s office or eye clinic.

The risk of new blood vessels developing after laser treatment is high. Repeated treatments may be necessary. In some cases, vision loss may progress despite repeated treatments.

Photodynamic therapy

A drug called verteporfin is injected into your arm. It travels throughout the body, including the new blood vessels in your eye. The drug tends to “stick” to the surface of new blood vessels. Next, a light is shined into your eye for about 90 seconds. The light activates the drug. The activated drug destroys the new blood vessels and leads to a slower rate of vision decline. Unlike laser surgery, this drug does not destroy surrounding healthy tissue. Because the drug is activated by light, you must avoid exposing your skin or eyes to direct sunlight or bright indoor light for five days after treatment. Photodynamic therapy is relatively painless. It takes about 20 minutes and can be performed in a doctor’s office.

Photodynamic therapy slows the rate of vision loss. It does not stop vision loss or restore vision in eyes already damaged by advanced AMD. Treatment results often are temporary. You may need to be treated again.  Read more about PDT >>

What can I do if I already have lost some vision from AMD?

If you have lost some sight from AMD, don’t be afraid to use your eyes for reading, watching TV, and other routine activities. Normal use of your eyes will not cause further damage to your vision.

If you have lost some sight from AMD, ask your eye care professional about low vision services and devices that may help you make the most of your remaining vision. Ask for a referral to a specialist in low vision. Many community organizations and agencies offer information about low vision counseling, training, and other special services for people with visual impairments. A nearby school of medicine or optometry may provide low vision services.

What research is being done?

The National Eye Institute is conducting and supporting a number of studies to learn more about AMD.

For example, scientists are:

• Studying the possibility of transplanting healthy cells into a diseased retina.
• Evaluating families with a history of AMD to understand genetic and hereditary factors that may cause the disease.
• Looking at certain anti-inflammatory treatments for the wet form of AMD.
• This research should provide better ways to detect, treat, and prevent vision loss in people with AMD.

What can I do to protect my vision?

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Dry AMD

If you have dry AMD, you should have a comprehensive dilated eye exam at least once a year. Your eye care professional can monitor your condition and check for other eye diseases. Also, if you have intermediate AMD in one or both eyes, or advanced AMD in one eye only, your doctor may suggest that you take the AREDS formulation containing the high levels of antioxidants and zinc.

Because dry AMD can turn into wet AMD at any time, you should get an Amsler grid from your eye care professional. Use the grid every day to evaluate your vision for signs of wet AMD. This quick test works best for people who still have good central vision. Check each eye separately. Cover one eye and look at the grid. Then cover your other eye and look at the grid. If you detect any changes in the appearance of this grid or in your everyday vision while reading the newspaper or watching television, get a comprehensive dilated eye exam.

Wet AMD

If you have wet AMD and your doctor advises treatment, do not wait. After laser surgery or photodynamic therapy, you will need frequent eye exams to detect any recurrence of leaking blood vessels. Studies show that people who smoke have a greater risk of recurrence than those who don’t. In addition, check your vision at home with the Amsler grid.

Click here to watch a Macugen animation

If you detect any changes, schedule an eye exam immediately.

Can my lifestyle make a difference?

Your lifestyle can play a role in reducing your risk of developing AMD.

• Eat a healthy diet high in green leafy vegetables and fish
• Don’t smoke
• Maintain normal blood pressure
• Watch your weight
• Exercise

What should I ask my eye care professional?

You can protect yourself against vision loss by working in partnership with your eye care professional. Ask questions and get the information you need to take care of yourself.

What are some questions to ask?

About my eye disease or disorder…

1. What is my diagnosis?
2. What caused my condition?
3. Can my condition be treated?
4. How will this condition affect my vision now and in the future?
5. Should I watch for any particular symptoms and notify you if they occur?
6. Should I make any lifestyle changes?

About my treatment…

1. What is the treatment for my condition?
2. When will the treatment start and how long will it last?
3. What are the benefits of this treatment and how successful is it?
4. What are the risks and side effects associated with this treatment?
5. Are there foods, drugs, or activities I should avoid while I’m on this treatment?
6. If my treatment includes taking medicine, what should I do if I miss a dose?
7. Are other treatments available?

About my tests…

1. What kinds of tests will I have?
2. What can I expect to find out from these tests?
3. When will I know the results?
4. Do I have to do anything special to prepare for any of the tests?
5. Do these tests have any side effects or risks?
6. Will I need more tests later?

Other suggestions

If you don’t understand your eye care professional’s responses, ask questions until you do understand.

Take notes or get a friend or family member to take notes for you. Or, bring a tape recorder to help you remember the discussion.

Ask your eye care professional to write down his or her instructions to you.

Ask your eye care professional for printed material about your condition.

If you still have trouble understanding your eye care professional’s answers, ask where you can go for more information.

Other members of your health care team, such as nurses and pharmacists, can be good sources of information. Talk to them, too.

Today, patients take an active role in their health care. Be an active patient about your eye care.

The National Eye Institute (NEI), part of the National Institutes of Health (NIH), is the Federal government’s principal agency for conducting and supporting vision research. Inclusion of an item in this publication does not imply the endorsement by the NEI or the NIH or The Macula Center.

Click here to watch an Avastin injection animation

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Some information courtesy of the National Eye Institute