QuestionSBA
QuestionChoice
A cataract is an opacity in the lens. They are more common in the elderly, but they would not cause drusen on fundoscopy. Classic presenting symptoms include 'haloes around lights', and there will be a loss of the red reflex on examination
62182
e
Cataract
QuestionChoice
This patient has dry age related macular degeneration (ARMD). In wet ARMD, one would see neovascularisation, bleeding and fluid leakage on fundoscopy. This presents more rapidly and has a poorer prognosis than dry ARMD.
62179
b
Wet age related macular degeneration
QuestionChoice
Central retinal vein occlusion (CRVO) typically causes **sudden** painless visual loss, whilst this patient's presentation is far more insidious in onset. Fundoscopy in CRVO will show: haemorrhages, cotton wool spots, retunal oedema and tortuous retinal veins. None of these are present here.
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d
Central retinal vein occlusion
QuestionChoice
Correct! This patient has dry age related macular degeneration (ARMD). The 'yellow deposits' on fundoscopy are drusen which are seen in the condition. Dry ARMD accounts for the vast majority of cases. All patients with ARMD should be encouraged to stop smoking.
62178
a
Dry age related macular degeneration
QuestionChoice
Whilst this patient has known hypertension, this is well controlled (with normal BP on assessment) with one anti-hypertensive medication. Signs on fundoscopy of hypertensive retinopathy include: narrowing of the retinal arteries, retinal haemorrhages, hard exudates and cotton wool spots.
62180
c
Hypertensive retinopathy
QuestionComment
putting in a question is overrated anyways
25173
User
subscriber
Recessive Gallbladder
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Chapter
# Summary

Age-related macular degeneration (ARMD) is the most prevalent cause of blindness in the UK, characterized by the degeneration of photoreceptors in the central retina leading to drusen formation. There are two types: dry (most common, characterised by drusen deposition), and wet (exudative, caused by neovascularisation and carries worse prognosis). Key symptoms include subacute loss of and/or distortion of the central visual field, reduced visual acuity, night blindness, and photopsia. The primary investigation methods include slit-lamp biomicroscopy, colour fundus photography, fluorescein angiography, and ocular coherence tomography (OCT). Management generally involves smoking cessation, and depending on the type of ARMD, zinc and antioxidant supplements (dry ARMD) or anti-vascular endothelial growth factor (anti-VEGF) injections (wet ARMD).

# Definition

Age-related macular degeneration (ARMD) is the leading cause of blindness in the UK. Patients present with subacute loss of and/or distortion of the central visual field.

ARMD describes degeneration of photoreceptors in the central retina (macula) that leads to the formation of drusen, which are visible on slit-lamp biomicroscopy.

# Risk factors

- Age – the biggest risk factor for developing ARMD
- Male sex
- Smoking (doubles the likelihood of ARMD-related vision loss) – a smoking history should always be taken in patients with ARMD
- Family history 
- Cardiovascular risk factors: hypertension, diabetes mellitus, coagulopathy, dyslipidaemia

# Dry vs Wet ARMD

|      | Dry ARMD        | Wet ARMD  |
| ------------- |:-------------:| :-----:|
| **Prevalence**    | 85–90% of cases | 10–15% of cases|
| **Features**   |Drusen, macular thinning (geographic atrophy)     |   Neovascularisation, bleeding, leakage of fluid|
| **Prognosis**| Slow progression over decades  | Rapid progression over months, with poor prognosis |

# Signs and Symptoms

**Symptoms**:

* Reduced visual acuity, worse for near vision and central vision (patients may say they struggle seeing faces)
* Variability in visual disturbance from day to day is characteristic
* Poor vision at night
* Photopsia – perceived flickering of lights
* Glare

**Signs**:

* Visual distortion – particularly line perception when tested with Amsler grids. This is known as metamorphopsia.
* **Dr**usen in **dr**y ARMD – yellow pigmented spots on the retina that are collected around the macula
* Subretinal or intraretinal haemorrhages in wet ARMD – seen as red patches on the retina around the macula

[lightgallery]

# Differential Diagnosis


2. **Diabetic Macular Oedema (DME):**
   - **Diabetic Retinopathy:** Patients with diabetic retinopathy can experience macular oedema, which may lead to similar symptoms as neovascular AMD, such as visual distortion or blurred central vision.

3. **Retinal Vein Occlusion (RVO):**
   - **Central or Branch RVO:** A blockage of retinal veins can lead to macular oedema, haemorrhages, and vision changes similar to those in neovascular AMD.

4. **Central Serous Chorioretinopathy (CSC):**
   - **CSC:** This condition often presents with central serous retinal detachment, leading to vision disturbances. It can mimic wet AMD, but CSC is characterised by serous fluid accumulation rather than CNV.


A comprehensive eye examination, including optical coherence tomography (OCT), fluorescein angiography, and fundus photography, is often necessary to differentiate AMD from these conditions and guide appropriate management and treatment decisions.

# Investigations


| Technique | Notes |
|-----------|------|
| **Slit-lamp biomicroscopy**| Allows identification of exudative, pigmentary or haemorrhagic changes in the retina to allow diagnosis of ARMD |
| **Colour fundus photography** | Done at each assessment to monitor progression|
| **Fluorescein angiography** | Used to identify neovascular ARMD to guide anti-VEGF therapy |
| **Ocular coherence tomography (OCT)** | Allows assessment of all layers of the retina and identification of disease not visible by slit-lamp biomicroscopy |

# Management

Smoking cessation is important for all patients with ARMD.

## Dry ARMD

Zinc and antioxidant vitamin A, C and E supplements have been shown to reduce progression by up to 30%.

## Wet ARMD

Anti-vascular endothelial growth factor (anti-VEGF) injections limit progression and can even reverse vision loss – typically administered in monthly injections.

# NICE Guidelines

[Click here for NICE CKS on ARMD](https://cks.nice.org.uk/topics/macular-degeneration-age-related/)

# References

[Click here for more detailed Eye Wiki notes on ARMD](https://eyewiki.aao.org/Age-Related_Macular_Degeneration#Management)
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Drusen distributed at the macula in a patient with dry AMD.
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1002
Age related macular degeneration
Topic
16
Ophthalmology
12497
A 79-year-old presents with progressively worsening vision. He reports that he struggles to drive at night, but cannot pinpoint when this all began. He has a past medical history of hypertension and hypercholesterolaemia. He takes amlodipine and atorvastatin, and has no allergies. He smokes 10 cigarrettes per day and drinks 10 units of alcohol a week.

His observations are within normal limits. Fundoscopy identifies yellow deposits.
a