Age-Related Macular Degeneration

- is a degenerative process that affects the macula and its surrounding tissues,
resulting in central visual deficits.

Types:

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.

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.
 Signs & Symptoms

Dry AMD

• Need for more light when doing close-up work

• Blurring of print when trying to read
• Colors appear less bright
• Haziness of vision
• Blurred spot in the central field of vision, which may become larger and
darker

Wet AMD

• Straight lines that appear wavy

• Objects appearing further away or smaller than usual
• Loss of central vision
• Sudden blind spot

Predisposing Factors

• Aging
• 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, those who
performed vigorous activity at least three times weekly reduced their risk
of developing advanced AMD, compared with inactive patients.
• Heredity
• Hypertension
• Smoking
• 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 also is
used to treat nausea, vomiting and persistent hiccups), Mellaril
(thioridazine), Prolixin (fluphenazine), Trilafon (perphenazine) and
Stelazine (trifluoperazine).
 Medical Surgical Management

• An Amsler grid, a checkerboard pattern with a black dot at the center.

While staring at the dot with one eye, MD causes the straight lines to
appear wavy or disappear or some areas to appear blank.

• A dilated eye exam whereby drops are used to dilate the pupils and a
special magnifier called an ophthalmoscope shines a very bright light on
the back of the lens to examine the retina. Gross macular changes,
including scarring, thinning, or atrophy, may indicate MD. Numerous mid-
sized yellow bumps called drusen, or one or more large drusen, can
indicate intermediate-stage AMD. However, most people over age 42
have drusen in one or both eyes.
• Fluorescein or eye angiography, or retinal photography. An indicator dye
is injected and photographs are taken to detect dye leakage from retinal
blood vessels.
• Indocyanine green angiography examines choroid blood vessels that
cannot be seen with fluorescein.
• Optical coherence tomography. Light waves are used to obtain cross-
sectional views of eye tissue. This is easier and quicker than fluorescein
angiography.
• An electroretinogram, whereby a weak or missing electrical signal from an
illuminated point in the macula indicates MD.
• In a family history of MD suggesting hereditary juvenile macular
degeneration (JMD), molecular genetic screening can reveal the presence
of JMD-causing genes, facilitating early detection.

Nursing Management

Instruct/ Teach the client:

• the use of sunglasses with UV protection

• maintaining normal blood pressure
• avoiding the risk factors, including smoking and secondhand smoke
• the use of supplemental estrogen by postmenopausal women is
associated with a lower risk for AMD.
• Those with dry AMD should have a complete dilated eye examination at
least once a year and use an Amsler grid daily to check for signs of wet
AMD.
 • Foods containing omega-3 fats, such as nuts and fish, lower the risk of
progression to advanced MD.

Drug Therapies

For wet AMD, a type of medication called anti-vascular endothelial growth factor
(anti-VEGF) can be injected into your eye to stop new blood vessels from
growing. Two such drugs are approved to treat AMD:

• Pegaptanib (Macugen)
• Ranibizumab (Lucentis)

Complications:

Severe AMD can cause legal blindness. Low vision aids may help if you have
partial blindness. Sometimes blood vessels build up underneath the retina,
causing the retina to become detached or scarred. If this happens, the chances
of preserving your central vision are poor. This condition, called subretinal
neovascularization, occurs in about 20% of cases of AMD. It often recurs even
after laser treatment.