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Age-Related Macular Degeneration

Age-Related Macular Degeneration. Tom Crawford, MD. ARMD is the most common cause of irreversible vision loss in people over 50 in the developed world. Incidence. The prevalence of ARMD is increasing rapidly After Age 75: 30% have early ARMD 7% have advanced ARMD. The Eye and Vision.

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Age-Related Macular Degeneration

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  1. Oregon Eye Specialists, PC

  2. Age-Related Macular Degeneration Tom Crawford, MD Oregon Eye Specialists, PC

  3. ARMD is the most common cause of irreversible vision loss in people over 50 in the developed world Oregon Eye Specialists, PC

  4. Incidence • The prevalence of ARMD is increasing rapidly • After Age 75: • 30% have early ARMD • 7% have advanced ARMD Oregon Eye Specialists, PC

  5. The Eye and Vision Oregon Eye Specialists, PC

  6. Retinal Anatomy Choroidal Vessels are Leaky Oregon Eye Specialists, PC

  7. Retinal Anatomy Oregon Eye Specialists, PC

  8. Your Fovea All Detail vision: • Reading • Driving • TV • Facial recognition • Much of color vision Oregon Eye Specialists, PC

  9. Your Fovea Oregon Eye Specialists, PC

  10. Pathophysiology - Drusen • Small drusen are normal after age 50 • Size Matters: large drusen increase risk Oregon Eye Specialists, PC

  11. Pathophysiology Drusen  RPE Damage and Chronic Inflammation  Geographic Atrophy and/or Vascular Endothelial Growth Factor (VEGF) Oregon Eye Specialists, PC

  12. Geographic Atrophy Oregon Eye Specialists, PC

  13. Subretinal Neovascularzation(SRN) Oregon Eye Specialists, PC

  14. Subretinal Neovascularzation • Choroidal neovascularization, plus • Breaks in Bruch’s Membrane • Fluid exudation • Subretinal hemorrhage • Lipid deposition • RPE detachments • Scarring Oregon Eye Specialists, PC

  15. Untreated SRNDisciform Scar Oregon Eye Specialists, PC

  16. Risk Factors - Genetic • Twin and Family studies indicate heritability • Complement Factor polymorphisms increase risk substantially (CFH,CFB,C2) • Also ARMS2 gene also strongly associated (function unknown) Oregon Eye Specialists, PC

  17. Risk Factors - Medical • Smoking or exposure to smokers increases risk; smoking by two-fold • CFH and ARMS2 anomalies reinforce smoking risk Oregon Eye Specialists, PC

  18. Risk Factors - Medical • Obesity • Hypertension • High Vegetable Fat Intake • Low dietary antioxidants and Zinc Oregon Eye Specialists, PC

  19. ARMD is a complex disorder resulting from a combination of genetic and environmental influences Oregon Eye Specialists, PC

  20. Evaluation - History • Usually: gradual vision loss • Can be subtle - ask family if present • Decreased dark-adaptation • Needs more light or magnifier to read • Prolonged after-images, scotomas • Family History Oregon Eye Specialists, PC

  21. Evaluation - History Development of Subretinal bleeding due to SRN can precipitate sudden vision loss Oregon Eye Specialists, PC

  22. Evaluation - History Metamorphopsia: rule out SRN Oregon Eye Specialists, PC

  23. Evaluation: Slit-lamp Fundus exam Oregon Eye Specialists, PC

  24. Evaluation - Testing Sudden vision loss, metamorphopsia or suspicious fundus  Fluorescein Angiography Oregon Eye Specialists, PC

  25. Evaluation OCT: Ocular Coherence Tomography Oregon Eye Specialists, PC

  26. Management - Lifestyle • Stop smoking • Weight Loss • Low fat diet • ? Omega 3 fatty acids Oregon Eye Specialists, PC

  27. Management - Vitamins • AREDS: Age-Related Eye Disease Study • 3640 patients, age 55-80 • Antioxidants reduced rate of progression from intermediate to advanced ARMD by 25% • 19% reduction of moderate vision loss Oregon Eye Specialists, PC

  28. Management - Vitamins • AREDS Formula: • Vitamin C 500mg • Vitamin E 400iu • Beta-Carotene 28000iu • Zinc Oxide 80mg • Copper 2mg Oregon Eye Specialists, PC

  29. Management - Vitamins • Beta Carotene should not be prescribed for smokers: increased risk of lung cancer Oregon Eye Specialists, PC

  30. Management - Low Vision Aids Oregon Eye Specialists, PC

  31. Management - Low Vision Aids Oregon Eye Specialists, PC

  32. Management - Intraocular Telescopes Oregon Eye Specialists, PC

  33. Management - Antiangiogenic • Current first-line therapy for SRN • Monoclonal antibody VEGF inhibitors • Injected intravitreally every 4-6 weeks • Visual loss stops in most patients and some improve Oregon Eye Specialists, PC

  34. Management - Antiangiogenic • Ranibizumab (Lucentis) best studied, but $1950 per dose • Bevacizumab (Avastin) used off-label probably as effective; $30 per dose • Do the Math! • Randomized comparative trial ongoing Oregon Eye Specialists, PC

  35. Management - Laser • Photodynamic therapy • Vertiporfin (Visudyne) IV with subsequent 689nm laser application damages rapidly growing vessels • On average patients experience some vision loss before stabilization Oregon Eye Specialists, PC

  36. Management - Monitoring High risk patients must be followed closely for signs of SRN and treated promptly when it develops. Suspicious Maculas SRN in Fellow Eye Oregon Eye Specialists, PC

  37. Management - Future • AREDS 2: lutein, zeaxanthin and n-3 long chain polyunsaturated fatty acids • Combination therapy with vertiporfin and VEGF inhibitors may be better • Intravitreal Steroids Oregon Eye Specialists, PC

  38. Management - Future • New anti-VEGF interventions: VEGF RNA silencer bevasiranib • VEGF Trap-Eye binds VEGF • Using genetic markers to direct treament • Electronically stimulated devices Oregon Eye Specialists, PC

  39. Management - Future Prevention Early Intervention Restoration of vision loss Oregon Eye Specialists, PC

  40. Oregon Eye Specialists, PC

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