A Journey through the Eye

1. Macular Degeneration A Journey through the Eye Dr Dianne Sharp Ophthalmologist Retina Specialists, Auckland

2. What is the Macula? optic nerve retina macula Normal Retina

3. Progressive, chronic disease of central retina • Loss of central vision • Peripheral vision not affected • Not black blind What is Macular Degeneration (AMD)?

4. Leading cause of severe vision loss Macular Degeneration in New Zealand Other Macular Degeneration Cataract Glaucoma

5. Macular DegenerationFacts and Figures • Deloitte Access Economics 2011 and Macular Degeneration Foundation Australia www.mdfoundation.com.au

6. Macular Degeneration in NZAustralian pop 22 million: NZ pop 4.4million = approx. 1/5th • Macular Degeneration (MD) is a chronic disease with no cure1 • Cause of up to 50% of all blindness • Affects 1 in 7 people over 50 in some way:1 • 170,000 have early MD in NZ • 33,400 have late MD in NZ. 7,000 are legally blind. • 1 in 4 people over 80 have vision loss from MD1 • The number of people with MD will increase by 70% by 20301 ¹ Deloitte Access Economics

7. Prevalence of chronic diseasesAustralia 2010 – ref Deloitte

8. The Impact of Macular Degeneration* The impact of MD on quality of life is equivalent to cancer or coronary heart disease. • Access Economics & AMDAI 2010. 2x 4 to 8x Risk of hip fracture Risk of falls 3x 2x Rate of social dependence Risk of depression 3yr Employment Nursing home admission

9. Cost of vision loss from Macular Degeneration $AU2.55 billion in 2010 in Australia $NZ 0.64 billion in NZ (Adjusted for population and currency) Deloitte Access Economics & Macular Degeneration Foundation 2011,

10. Optimal integrated model of care for Macular Degeneration (AMD) • Primary prevention • Early detection & timely diagnosis • Early & regular treatment with on-going monitoring for wet AMD • Rehabilitation & emotional support

11. Macular Degeneration symptoms

12. How does MD Develop? Normal Retina Macula Retina RPE Choroid

13. Healthy retina RETINA RPE Bruch’s membrane CHOROID

14. Early AMD -“Drusen”

15. Early AMD Drusen Normal Retina

16. Early AMD Drusen

17. Early Stages of MD • Normally no symptoms but at risk of progression • Lipid deposits (drusen) • No treatment but progression slowed by diet and lifestyle modifications

18. Dry AMDDrusen Atrophy 7rs later

19. Dry AMD

20. Late Stages of AMD • Dry AMD: • Atrophy of retinal tissue. • Gradual loss of central vision over years • end stage has significant vision loss • Wet AMD: • Formation leaky blood vessels under retina • Rapid loss central vision

21. Wet AMD

22. Advanced Wet AMD

23. Wet AMD

24. Late Stages of MD • Dry MD: • Atrophy of retinal tissue. • Gradual loss of central vision over years • end stage has significant vision loss • Wet MD: • Formation leaky blood vessels under retina • Rapid loss central vision over weeks or months

25. Visual impairment by severity of vision loss

26. Optimal integrated model of care for Macular Degeneration (AMD) • Primary prevention • Early detection & timely diagnosis • Early & regular treatment with on-going monitoring for wet AMD • Rehabilitation & emotional support

27. Risk Factors for MD Age

28. Prevalence AMD (%) Blue Mountains Eye Study

29. % Prevalence AMD by age

30. Risk Factors for MD Genetics • 50 -70% cases have a genetic link • 50% risk of MD if a direct family history

31. AMD Principal genes CFH & ARMS2Rotterdam Eye Study • Early AMD 75% had one risk allele • Late AMD 93% had one risk allele • Risk of developing AMD by 85yrs increases with number of alleles

32. Genetics: Risk Alleles CFH • Mainly dry AMD • Inhibitory effect on complement pathway • ? Less effective inhibition of inflammatory pathway ARMS2 • Mainly wet MD • Gene located in mitochondria • ? Interferes with normal oxidation Rotterdam Eye Study

33. Modifying Genetic Risk Factors Smoking With 1 CFH allele Risk of AMD: Non smokers risk 12x Smokers risk 34x Diet 1 CFH &/or ARMS2 allele High dose Zn, omega 3, lutein rate close to no genetic risk

34. Risk Factors for MD Smoking • Smoking increases risk 3 to 4 times • Smokers get MD 10 years earlier, on average • BUT 20 years after quitting, a smoker’s risk is the same as a non-smoker

35. Reduce Your Risk of MD • Eye test every 2 years or earlier if any new symptoms • Recommend family members have eye test. • Protect eyes from sun • Healthy lifestyle: • Control weight • Exercise • Eat eye health foods • Consider a supplement

36. Eating for Eye Health Lutein Dark green and naturally yellow vegetables and fruit every day

37. Eating for Eye Health Omega 3 • Fish 2-3 times per week • (salmon, sardines, mackerel, anchovies, tuna)

38. Eating for Eye Health • Handful of nuts per week • (brazil nuts, almonds, walnuts, pine nuts) • Limit fat intake

39. Low Glycaemic Index foods Low GI Foods • Break down more slowly • Prolong energy release • Leave less waste products in the eye

40. What supplements? • 3 key supplements to consider: • AREDS formulation • Lutein • Omega 3 (fish oil)

41. AREDS Formula Age Related Eye Disease Study • Per day • Zinc 80mg • Vitamin C 500mg • Vitamin E 400IU • Copper 2mg • ß-carotene 15mg Macu-Vision Daily dose = 2 tablets People who smoke, suffer from lung cancer or asbestosis should not take a supplement with beta-carotene. This is the reason it is removed from most AREDS supplement products.

42. Diet supplements • AREDS Formulation: for intermediate or late AMD in one eye, reduces risk of progression by 20-25% • AREDS 2: trial in progress. Reducing Zn, removing beta-carotene, addition Lutein

43. Optimal integrated model of care for Macular Degeneration (AMD) • Primary prevention • Early detection & timely diagnosis • Early & regular treatment with on-going monitoring for wet AMD • Rehabilitation & emotional support

44. Symptoms of Macular Degeneration Early stages • Early MD may be asymptomatic. Eye tests are the key. Late stages • Difficulty distinguishing faces • Difficulty reading & fine vision • Distortion (straight lines appear wavy or bent) • Dark / blank patches in central vision

45. Use an Amsler grid (one eye at a time) Lines distorted Dark patches or empty spaces Normal

46. Treatments for AMD • Chronic disease • Dry AMD: diet and lifestyle important • Wet AMD: treatment available • diet and lifestyle also important

47. Treatment for Wet MD • Injection Lucentis or Avastin into the eye • Average every 4–6 weeks • Early treatment saves sight! Aim to stabilise vision and prevent further vision loss.

48. 0 AMD Treatment Trials (Anchor & Marina)Lucentis treatment: Mean gain in vision over 2yr ANCHOR +2 2 MARINA +1.5 1 0 2 4 6 8 10 12 14 16 18 20 22 24 Lines on vision chart -1 PDT -2 -2 sham -3 -3 Month ***p<0.0001 vs. sham

49. Current drug treatments • Lucentis or Avastin • Normally given as monthly injections • Highly effective. • CATT study: Comparing Lucentis and Avastin • Similar effect at 24 months • Still some unanswered questions re adverse events with Avastin

50. Optimal integrated model of care for Macular Degeneration (AMD) • Primary prevention • Early detection & timely diagnosis • Early & regular treatment with on-going monitoring for wet AMD • Rehabilitation & emotional support