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Classification

• Difference between dry and wet AMD
• Dry
  • early AMD: multiple small drusen <63um or some medium-sized drusen 63-125um
  • intermediate AMD: at least 1 large drusen >125um or ≥ 20 medium-sized drusen 63-125um.
  • Advanced AMD with geographic atrophy
• Wet
  • Advanced AMD with choroidal neovascularisation (CNV)

Symptoms

• Central visual loss, metamorphopsia, reading difficulties

Examination

• Visual acuity reduced, Amsler grid with metamorphopsia
• Fundoscopy
  • Dry: Drusen, pigmentary abnormalities, atrophy
  • Wet: retinal haemorrhages (sign of activity), macular edema, CNV membrane
• OCT
  • Dry: Drusen, retinal pigment epithelial detachments (PEDs), Atrophy
  • Wet: intra-/subretinal fluid, CNV membrane
• Fluorescence angiography: gold standard for the detection of wet AMD
  • Angio-OCT as an alternative / additional examination in case of unclear findings

Differential Diagnosis

• Central Serous Chorioretinopathy (CSCR)
• Myopic Choroidal Neovascularisation
• Polypoidal Choroidal Vasculopathy (PCV)

Treatment

• Dry AMD: smoking cessation, optimisation of cardiovascular risk factors, vitamin supplementation according to AREDS-2 (see below), low-vision counselling
• Wet AMD: intravitreal anti-VEGF injections (e.g. Lucentis, Eylea), usually according to a treat & extend regimen

Vitamin supplementation according to AREDS-2

• Original AREDS-2 Formula
  • Vitamin C 500 mg
  • Vitamin E 400 IU
  • Zinc 80 mg
  • Copper 2 mg
  • Lutein 10 mg
  • Zeaxanthin 2 mg
• Indication (in AREDS-2 study)
  • Patients aged 50 to 85 with bilateral intermediate AMD or advanced AMD in 1 eye
• Supplements with AREDS-2 Formula
  • e.g. Bausch & Lomb: PreserVision AREDS 2 or Protina Trophosan Visiobalance

Follow-up

• Dry AMD: 6-12 months with Amsler grid self-monitoring
• Wet AMD: initially monthly, extension of injection interval as soon as stable (various regimens possible)

Sources

• EyeWiki Age-related macular degeneration
• The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
• Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)
• The Age-Related Eye Disease Study 2 (AREDS2) Research Group*. Lutein + Zeaxanthin and Omega-3 Fatty Acids for Age-Related Macular Degeneration: The Age-Related Eye Disease Study 2 (AREDS2) Randomized Clinical Trial. JAMA. 2013;309(19):2005–2015. doi:10.1001/jama.2013.4997
• AREDS2 Research Group; Chew EY, Clemons T, SanGiovanni JP, Danis R, Domalpally A, McBee W, Sperduto R, Ferris FL. The Age-Related Eye Disease Study 2 (AREDS2): study design and baseline characteristics (AREDS2 report number 1). Ophthalmology. 2012 Nov;119(11):2282-9. doi: 10.1016/j.ophtha.2012.05.027. Epub 2012 Jul 26.