201820401011121 Pembimbing: dr. Fatin Hamamah, Sp.M Definition • ARMD is a degenerative disease of the central part of the retina— known as the macula—that results in a loss of central vision, which is essential for most daily activities • It is characterized by a loss of visual acuity caused by degeneration of the choriocapillaris, retinal pigment epithelium (RPE), and photoreceptors, usually beginning with drusen and pigmentary changes in Bruch's membrane Prevalency • The condition, which affects 30 million to 50 million people worldwide, is the leading cause of irreversible blindness in developed countries in people aged 50 years and older • The prevalence of ARMD increases exponentially every decade after age 50 Etiology • genetic, • environmental, • metabolic, and • functional factors; including aging, family history, smoking, high blood pressure, obesity, hypercholesterolemia, and arteriosclerosis, sun exposure, atherosclerosis, hypertension, diabetes, polypharmacy, alcohol, ethnicity, hypothyroidism, and C-reactive protein Patophysiology Stages of ARMD • Early stages of ARMD are characterized by a macula that has yellowish subretinal deposits (drusen) and/or increased pigment • Patients with early ARMD have stable visual acuity for many years, and loss of vision is gradual American Academy of Ophtalmology Retina/Vitreous Panel. Preferred Practice AREDS Classification of ARMD Pattern Guidelines. Age-Related Macular Degeneration. San Fransisco, CA: American Academy of Ophtalmology; 2014
Category Designation Description
No ARMDNo or few small drusen 1 (<63 μm in diameter) Multiple small drusen (<20), a few 2 Early intermediate drusen (63–124 μm in diameter), or RPE abnormalities Extensive intermediate drusen, ≥1 large drusen (125 μm in diameter), 3 Intermediate or geographic atrophy not involving center of fovea Geographic atrophy or neovascular 4 Advanced maculopathy AREDS: Age-Related Eye Disease Study; ARMD: age-related macular degeneration; RPE: retinal pigment epithelium. • Early AMD. Early AMD is diagnosed by the presence of medium-sized drusen, which are about the width of an average human hair. People with early AMD typically do not have vision loss. • Intermediate AMD. People with intermediate AMD typically have large drusen, pigment changes in the retina, or both. Again, these changes can only be detected during an eye exam. Intermediate AMD may cause some vision loss, but most people will not experience any symptoms. • Late AMD. In addition to drusen, people with late AMD have vision loss from damage to the macula. There are two types of late AMD: • In geographic atrophy (also called dry AMD), there is a gradual breakdown of the light-sensitive cells in the macula that convey visual information to the brain, and of the supporting tissue beneath the macula. These changes cause vision loss. • In neovascular AMD (also called wet AMD), abnormal blood vessels grow underneath the retina. (“Neovascular” literally means “new vessels.”) These vessels can leak fluid and blood, which may lead to swelling and damage of the macula. The damage may be rapid and severe, unlike the more gradual course of geographic atrophy. It is possible to have both geographic atrophy and neovascular AMD in the same eye, and either condition can appear first. 1. DRY ARMD • is also known as nonexudative, nonneovascular, or atrophic ARMD • more common form of ARMD, seen in about 90% of cases • Vision loss in dry ARMD is gradual and usually is associated with moderate visual impairment, as well as functional limitations including fluctuating vision, difficulty reading, and limited vision at night or under conditions of reduced illumination • Upon examination, the macula shows areas of depigmentation • Early to intermediate nonexudative AMD: Significant for the presence of multiple drusen for early AMD. For intermediate AMD, drusen may appear confluent with significant pigment changes and pigment accumulation in the posterior pole. In addition, the retinal pigment epithelium (RPE) often appears atrophic, with easier visualization of the underlying choroid vascular plexus • Difficulty with night vision and with changing light conditions (specifically, changes in Amsler grid self-evaluation and trouble with reading) • Visual fluctuation (ie, some days, vision is poor; other days, vision appears improved) • Difficulty with reading and making out faces • Metamorphopsia (distortion of visual images): Not a major patient complaint for dry AMD, but it may be present as the atrophy slowly progresses. Management dry AMD • Antioxidant vitamin and mineral supplements (vitamin A, vitamin E, zinc, and lutein) • Screening for impaired visual acuity • Wraparound shades (eg, orange-tinted, blue blocker lenses): Effective solution for delayed dark adaptation and to protect eyes from direct sunlight • Avoidance/cessation of tobacco use • Frequent follow-up for risk assessment of conversion to exudative AMD 2. WET ARMD • also referred to as exudative or neovascular ARMD, accounts for about 10% of cases • its presence usually indicates a more advanced disease state, and it is associated with rapid distortion and a sudden loss of central vision over a period of weeks to months • he eyes have two times the expected prevalence of vitreomacular adhesion and are less likely to have a posterior vitreous detachment. • Fluid and exudate may accumulate underneath the retina in patients with neovascular ARMD, resulting in severe macular edema Diagnosis WET AMD After a thorough dilated examination of the fundus with slit lamp biomicroscopy, the following imaging studies are frequently performed on many patients with signs and symptoms of exudative AMD: • Color photography of the fundus • Fluorescein angiography (FA) - Helps to identify and confirm the source of CNV • Optical coherence tomography (OCT) - Can identify soft drusen, RPE detachments, subretinal and intraretinal fluid, CNV, and cystoid macular edema; can accurately measure foveal and macular thickness; and can demonstrate the integrity of the photoreceptor and RPE layers Management WET AMD 1. Antiangiogenic agents Animal and clinical studies have established vascular endothelial growth factor (VEGF) as a key mediator in ocular angiogenesis.Therefore, particular attention has been focused on the development of pharmaceutical agents to block or neutralize VEGF expression. The following agents, delivered via intravitreal injection, have been proven effective in clinical trials: • Pegaptanib sodium • Ranibizumab • Bevacizumab • Aflibercept 2. Laser treatments • Laser treatments include the following: • Thermal laser photocoagulation - Until the advent of anti-VEGF agents, ophthalmologists traditionally used thermal laser destruction of CNV as the primary treatment of exudative AMD. • Photodynamic therapy with verteporfin (PDT) - To avoid creating a central, blinding scotoma when treating subfoveal CNV with thermal lasers, clinicians turned to PDT; effective in some forms of CNV, although its use is sometimes limited by cost. • If left untreated, the neovascular membrane forms a big scar in the macular area, resulting in a sudden decrease in central vision • Choroidal neovascularization (CNV) is an advanced stage of wet ARMD that can lead to the development of polypoidal choroidal vasculopathy • he condition progresses from drusen to the development of CNV, whereby the choriocapillaries cross Bruch's membrane and spread laterally within the planes of these lesions Drusen • Drusen are focal deposits of extracellular debris that typically form between the basal lamina of the RPE and the inner collagenous layer of Bruch's membrane • generally round and yellowish in color • These lesions, which are considered the hallmark of ARMD and are characteristic of the aging eye and age-related maculopathy, can be detected through various assays • Drusen are classified as hard or soft, depending upon their borders and the level of risk they confer on progression of ARMD • Soft drusen are more commonly found in the macula and pose a higher risk of ARMD development • They are slightly larger than hard drusen and do not have well- defined margins • Hard drusen tend to be smaller and well defined. The distinct features of the druse may give an indication of the stage of ARMD • Drusen are known to contain lipids, carbohydrates, zinc, and at least 129 different proteins, including extracellular matrix • The molecules trapped in drusen have varying roles, including the processing of extracellular enzymes, the stigmata of formative processes (e.g., extrusion or secretion of cellular materials), and cellular invasion • Charles Bonnet syndrome is a common side effect of vision loss in people with AMD. However, it often goes away a year to 18 months after it begins. In the meantime, there are things you can do to reduce hallucinations. Many people find the hallucinations occur more frequently in evening or dim light. Turning on a light or television may help. It may also help to blink, close your eyes, or focus on a real object for a few moments Prognosis • Prognosis dari degenerasi makula dengan tipe eksudat lebih buruk di banding dengan degenerasi makula tipe non eksudat. Prognosis dapat didasarkan pada terapi, tetapi belum ada terapi yang bernilai efektif sehingga kemungkinan untuk sembuh total sangat kecil