1. Age Related Macular Degeneration Bethan

2. Epidemiology Most common cause irreversible visual loss in >50yrs 10% > 65-74yrs 30% > 75yrs Prevalence increasing with ageing pop White ? women

3. Aetiology Age Smoking Pos fhx High BP ? Sunlight ? Alcohol ?obesity Healthy diet & exercise - protective

4. pathogenesis Deposition of colloid bodies (drusen) in macular area between retinal pigment epithelium (RPE) and underlying (bruch’s) membrane From age 45 Age related maculopathy Critical size/ number – ARMD Early ARMD – vision preserved (small, apigmentary) Late ARMD – vision affected (large, pigmented) Two subtypes

5. Dry Atrophic, dry, non exudative, geographic 90% of cases Atrophy of neuroretina – RPE Photoreceptors (over rpe) Choriocapillaris (below rpe)

6. Wet Wet, exudative, neovascular 10% of patients Drusen lift retinal pigment epithelium from blood supply Choroidal vessal growth – sub retinal neo vasc, (SRNV), retinal angiomatous proliferation serous fluid accumulation, vessels leak, scars formed

7. Differential diagnosis Refractive errors. Refractive errors Cataracts. Cataracts Some corneal diseases. Posterior vitreous detachment or retinal detachment.vitreous detachmentretinal detachment Retinal artery occlusion or retinal vein occlusion. Retinal artery occlusionretinal vein occlusion Central serous retinopathy. Central serous retinopathy Cerebrovascular disease. Pituitary and other neurological tumours. Some drugs or chemicals including methanol, chloroquine, hydroxychloroquine,chloroquine hydroxychloroquine Rule out diabetes (diabetic maculopathy).diabetesdiabetic maculopathy Type 2 membranoproliferative glomerulonephritis.membranoproliferative glomerulonephritis Various rare ophthalmic conditions to be ruled out by ophthalmology team.

8. Clinical features Bilateral 1 > loss Deterioration/distortion of central vision – scotoma – lines, micro/macropsia Dark patch “shadowy figure” on waking Visual hallucinations with severe v loss Incidental at optometrist Affected adl’s – driving, reading, recognition Night glare, photopsia, Sudden deterioration (bleed) +/- floaters

9. Investigations Visual acuity Fundus – yellow deposits Slit lamp exam Optical coherence tomography (OCT) Fluorescein angiography

10. Referral Ref ophthalmology –within one week Or optometrist

11. Management - support No effective treatment for dry ARMD Register blind - ophthalmologist Social support Visual rehab – refract to optomise vision, magnify/ telescope, large print books, house aids Counselling – reassure re peripheral vision, advise about DVLA Txt of choroidal neovascularisation - criteria

12. Management –wet ARMD Laser photocoagulation – away from fovea Verteporfin – iv injection activated by argon laser beam – stabilises condition Anti VEGF’s – prevent endothelial cell proliferation – intraocular PDT & anti VEGF Surgical options rarely used Immunomodulation is being explored

13. ranibizumab Monoclonal antibody to vascular growth factor Injected into eye 1/12 x3 NICE & RCO criteria –minority ok 80% slows visual loss Aims to preserve central vision Complications - Retinal detachment, haemorrhage, infection, hypersensitivity

14. Advice See GP if worsening or other eye affected Stop smoking ? Prevention... Healthy diet with antioxidants & carotenoids High dose vitamin & mineral supplements

15. Questions