OPHTHALMOLOGY MACULA DEGENERATION MBChB 4 Prof P Roux 2012

AGE-RELATED MACULAR DEGENERATION (AMD) 1. Drusen 2. Drusen and AMD 3. Atrophic AMD 4. Exudative AMD Pigment epithelial detachment (PED) Choroidal neovascularization (CNV)

Drusen Histopathology Small well-defined spots Usually innocuous Larger, ill-defined spots May enlarge and coalesce SoftHard Increased risk of AMD

FA of drusen Amount of staining Lipid content Degree of hyperfluorescence depends on: Extent of overlying RPE atrophy (window defect) ``

Drusen and AMD - progression Atrophic AMD Exudative AMD

Atrophic AMD Initially drusen and non-specific RPE changes Late RPE (geographic) atrophy Progression

Atrophic AMD Hyperfluorescence from RPE window defect Low-vision aids if appropriate ManagementFluorescein angiogram

Signs of Pigment epithelial detachment Sub-RPE fluid may be clear or turbid Circumscribed, dome-shaped elevation

FA of pigment epithelial detachment Early, well-defined hyperfluorescence Progressive increase in hyperfluorescence No increase in size of lesion

ICG angiogram of pigment epithelial detachment Later, thin surrounding hyperfluorescent ring No increase in size of lesion Early, well-defined hypofluorescence

Possible subsequent course of PED Spontaneous resolutionGeographic atrophy CNV RPE rip

Choroidal neovascularization (CNV) Metamorphopsia is initial symptom Most lesions are not visible clinically Suspicious clinical signs Pinkish-yellow subretinal lesion with fluid Subretinal blood or lipid Less common than atrophic AMD but more serious

Extrafoveal > 200  m from centre of FAZ Juxtafoveal < 200  m from centre of FAZ Angiographic classification of CNV Well-defined (classical) Subfoveal - involving centre of FAZ Poorly defined Obscured by PED, blood or exudate Occult

Late staining FA of classical CNV Leakage into subretinal space and around CNV Very early ‘lacy’ filling pattern

CNV is hyperfluorescent (hot spot) PED is hypofluorescent ICG angiogram in PED with occult CNV

Subretinal (disciform) scarring Massive subretinal exudation Possible subsequent course of CNV Haemorrhagic sensory and RPE detachment Exudative retinal detachment

Potential indications for laser treatment of CNV Classic extrafoveal CNV on FA Occult extrafoveal CNV on ICG Pre-treatment FA of classic CNV

Perimeter is treated with overlapping 200  m ( sec) burns Entire area is covered with high energy burns Technique of laser photocoagulation of CNV Lack of leakage following successful treatment Late staining around margin is normal

Treatment Anti VEGF intravitreal injection monthly x3 – Avastin – Lucentis Triamcinolone intravitreal injection every 3-6 months

Amsler grid for follow up

Amsler grid

Prevention for patients with Drusen Anti oxidants, vitamins and minerals Ocuvite with Lutein Eye Rx Healthy diet of veggies and fruits Stop smoking Treat hypercholesterolemia

Prevention for general public Healthy diet of veggies and fruits Stop smoking Treat hypercholesterolemia