QuestionSBA
QuestionChoice
Thermal laser photocoagulation used to be the first-line treatment for wet AMD with extrafoveal choroidal neovascular membranes, although this has now largely been replaced by anti-VEGF treatment as treatment of subfoveal and juxtafoveal lesions often resulted in a dense scotoma with high recurrence rates
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e
Thermal laser photocoagulation
QuestionChoice
Anti-VEGF injections are the mainstay of management of wet AMD, reducing or eliminating macular oedema and reduce neovascularisation, which can reduce disease progression and reverse visual loss
33123
a
Intravitreal injection with vascular endothelial growth factor inhibitors (anti-VEGF)
QuestionChoice
This patient has progressed to advanced wet AMD with significant deterioration in vision. Wet AMD can be treated initially with anti-VEGF intravitreal injections and so this should be trialled first, providing there are no contraindications
33124
b
Observation
QuestionChoice
Photodynamic therapy (PDT) is frequently used in wet AMD, although only as an adjunct as second-line treatment with anti-VEGF after anti-VEGF has already been tried
33125
c
Photodynamic Therapy
QuestionChoice
Intravitreal corticosteroids can be given for macular oedema in diabetes, uveitis, and retinal vein occlusion. It is not currently recommended as a treatment for wet AMD
33126
d
Intravitreal corticosteroids
QuestionComment
is the patient male or female???
15763
User
subscriber
Chronic Haemophilus
QuestionComment
"She no has subretinal haemorrhages..." what does that mean? Please fix the vignette 
22710
User
subscriber
Rhinoplasty Recessive
QuestionComment
I thought anti-VEGF medications must be started within 3 months to be beneficial? 

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User
subscriber
Gitelmanz 
Concept
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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ARMD.jpeg
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1002
Age related macular degeneration
Topic
16
Ophthalmology
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Intravitreal anti-VEGF injections, such as ranibizumab, aflibercept, and bevacizumab, are the primary treatment for wet age-related macular degeneration as they work by inhibiting vascular endothelial growth factor (VEGF) to reduce abnormal blood vessel growth and fluid leakage in the retina, helping to preserve vision.
An 81-year-old male with wet age-related macular degeneration (AMD) is reviewed in clinic. Twelve months ago, she had early-stage disease, initially managed with risk factor modification, although her vision has now deteriorated from 6/24 to 6/60 vision in both eyes. On fundoscopy, she has subretinal haemorrhages, lipid exudates, and fibrovascular scarring - corresponding to advanced-stage disease.

Which of the following is the best next step in the management of this patient?
a