Prevention, Management, Patients education

Reducing the risks

- not always possible to prevent macular degeneration
- linked to age(>50), family history, race ( white ), gender ( female )
- but you can reduced the risk of developing AMD or help prevent it getting worse
especially those with family members of patients with AMD
- smoking- stop smoking
- obesity- eating healthy balanced diet high in antioxidants,, low in saturated fat,
exercise
- Eat green leafy vegetables (eg, spinach, kale) daily.
- moderate consumption of alcohol **
- wearing UV absorbing glasses when outsides for long period **

Treatment for Dry AMD

- taking high dosage of specific antioxidants and zinc significantly reduces the risk of
advanced ARMD and it associated vision loss
- certain nutrients such as zinc, lutein, zeaxanthin and vitamin A, C and E helps to lower
the risk of developing ARMD or even to slow down the progression of the disease, also
shows benefit in preventing the conversion of dry AMD to wet AMD.
- Patient educations - Patients can be educated that while central visual loss is common,
peripheral (side) vision shouldn't be affected, total visual loss is extremely rare. Patients
with AMD can be reassured that there is no harm in using their eyes for normal visual
tasks.
- Follow ups - Patients with dry age-related macular degeneration (AMD or ARMD)
should be observed frequently. Their follow-up care should be determined by the extent
of disease and by the ophthalmologist's assessment of risk of conversion to wet AMD.
Daily Amsler grid evaluation is necessary, with immediate reports to the ophthalmologist
of any changes are noted.
- Patient can also be referred to low vision clinic to get support to do daily tasks and
minimise the effect on life. They may try magnifying lenses, large print books, screen
reading software on computer.

Treatment for Wet AMD

2 Main treatments
1. Anti-vascular endothelial growth factor (VEGF)
- to prevent growth of new blood vessels. In some cases, they can shrink the blood
vessels and restore some of the sight lost.
- injected into the eye using fine needles.
- 2 medications available are Ranibizumab and Aflibercept.
-Ranibizumb - monthly injection for 3 consecutive months and visual acuity will then be
monitored during a maintenance phase. If vision deteriorates during this phase, another
 injection can be given. Monitoring will then continue. The treatment will be stopped if no
sign of improvement or getting worse.
- Aflibercept - newer medication - month injection for 3 consecutive months. No need for
monitoring between injections. Depending on the outcome, you may have further
injections once every 2 months. After 12 months, the intervals between injections may
be extended depending on how well the medication is working.

2. Surgery
- Photodynamic therapy
It involves having a light-sensitive medicine called verteporfin injected into a vein in your
arm. The verteporfin attaches itself to the abnormal blood vessels in your macula. A low-
powered laser is then shone into your damaged eye over a circular area just larger than
the affected area in your eye. This usually takes around one minute. The light from the
laser is absorbed by the verteporfin and activates the drug. The activated verteporfin
destroys the abnormal vessels in your macula while reducing harm to other delicate
tissues in your eye.
Destroying the blood vessels stops them leaking blood or fluid, preventing damage and
therefore stopping the macular degeneration getting worse. You may need this treatment
every few months to ensure any new blood vessels that start growing are kept under
control.
PDT isn't suitable for everyone it will depend on where the blood vessels are growing
and how severely they've affected your macula. It may be suitable if your visual acuity is
6/60 or better

- Laser photocoagulation
this type of surgery is only suitable if the abnormal blood vessels aren't close to the fovea,
as performing surgery close to this part of the eye can cause permanent vision loss. A
powerful laser is used to burn sections of the retina. These sections harden, which
prevents the blood vessels moving up into the macula .One side effect of laser
photocoagulation is a permanent black or grey patch developing in your field of vision. This
loss of vision is usually but not always less severe than untreated wet AMD.
used in people who cannot be treated with anti-VEGF medication or PDT.

Newer types of surgery

In recent years, two new surgical techniques have been developed to treat wet AMD.
These are:
macular translocation where the macula is repositioned over a healthier section
of the eyeball not affected by abnormal blood vessels
lens implantation where the lens of the eye is removed and replaced with an
artificial lens designed to enhance central vision
Both approaches tend to achieve better results than laser surgery, but there are also
disadvantages, such as:
limited access to these treatments they may only be available in the context of a
clinical trial
uncertainty about whether these treatments are safe and effective in the long term
they carry a higher risk of serious complications than laser surgery
fig 2 illustration of current amd treatment with anti vegf which forms a complex with the
vegf protein molecule the formation of new blood vessel neovascularisation is inhibited

Differential diagnosis[3]
Painless loss of vision can be caused by:
Refractive errors.
Cataracts.
Some corneal diseases - eg, Fuch's endothelial dystrophy.
Posterior vitreous detachment or retinal detachment.
Retinal artery occlusion or retinal vein occlusion.
Central serous retinopathy.
Cerebrovascular disease including amaurosis fugax, transient ischaemic attack and
stroke.
Some drugs or chemicals including methanol, chloroquine, hydroxychloroquine,
isoniazid, thioridazine, isotretinoin, tetracycline or ethambutol.
Pituitary tumour, central nervous system tumour and papilloedema.
Macular hole.
Primary open-angle glaucoma (central visual loss occurs late).
Optic atrophy.