DRY AGE RELATED MACULAR DEGENERATION

Geographic atrophy occurs when the photoreceptors (seeing part of the retina) no longer works and the patient develops a blind spot or spot of poor vision in the macula (see photo). Geographic atrophy is usually a sharply delineated round or oval area of hypopigmentation, or apparent absence of the retinal pigment epithelium (RPE), in which choroidal vessels are more visible than in surrounding areas The most common sequence of events leading to GA is the progression of a large drusen to hyperpigmentation, followed by regression of the drusen, hypopigmentation and ultimately RPE cell death, with development of an atrophic area of retina and underlying choriocapillaris, sometimes preceded by the appearance of refractile deposits.

Geographic atrophy is a type of advanced dry age-related macular degeneration that can lead to irreversible vision loss. The progression of geographic atrophy is gradual and typically occurs over a period of years. At the onset of geographic atrophy, patients may not notice any significant changes in their vision. However, as the disease progresses, patients may experience a gradual loss of their central vision, resulting in difficulty recognizing faces, reading, and performing other daily activities. The size of the atrophic area usually increases over time, and new areas of atrophy usually develop, leading to further vision loss. In some cases, the disease may progress to the point where the entire macula becomes atrophic, resulting in complete and permanent vision loss in the affected eye.

Geographic atrophy can progress and lead to vision loss. When people with dry AMD lose vision, it is almost always from geographic atrophy. The animated image with this text shows growing geographic atrophy over 3 years in an 86 year old patient. This person is fortunate to have good vision because the dark areas of geographic atrophy are not yet affecting the central vision. Given the progression, the central vision will likely be affected within about 3 years. The images are fundus autofluorescent images that are useful for following geographic atrophy because the atrophy shows up as well delineated dark spots.

In 2023, the first treatment for Geographic Atrophy, Syfovre, was approved by the FDA. It is available in all of our offices. Syfovre is an intravitreal injection that reduces the rate of progression of geographic atrophy. It is given every month or two as ongoing treatment.

Pattern dystrophy is a type of dry age-related macular degeneration that involves mostly the very center of the macula. There are several types of pattern dystrophy. The image with this text is of a patient with adult vitelliform macular dystrophy. The image shows the buildup of abnormal deposits under the retina in the center of the macula. Unlike typical dry macular degeneration where the buildup of material is below the retinal pigment epithelium, in pattern dystrophy, the buildup of material is above the pigment epithelium and directly beneath the retina (see asterisks on image). Pattern dysrophy is autosomal dominant, usually presents at a younger age than typical dry AMD, and usually does not progress to wet AMD.

Patients who consume fruits and vegetables have the lowest rates of macular degeneration development. Lutein, a carotenoid pigment found exclusively in fruit and vegetables, serves as the primary protector of the eye. Lutein accumulates in the macula and likely blocks the damage caused by sunlight, one proposed cause of AMD. Fruits and vegetables are also high in antioxidant vitamins such as Beta- carotene, Vitamin E, and Vitamin C. Green leafy vegetables and other colorful foods like kiwi, squash, red grapes, and corn are good sources of Lutein. Other dietary habits have been shown to increase the risk of AMD. Individuals with a higher percentage of vegetable, monounsaturated, and polyunsaturated fats in their diet have higher rates of Wet AMD development. Diets rich in Omega 3 fatty acids reduce the risk of vision loss. These are found naturally in cold-water fish such as salmon and tuna, and in flaxseeds and flaxseed oil. Two servings of fish per week are adequate.

The Age-Related Eye Disease Study 2 showed that among people at high risk for developing late-stage, or wet, macular degeneration (such as those who have large amounts of drusen or who have significant vision loss in at least one eye), taking a dietary supplement of vitamin C, vitamin E, lutein and zeaxanthin, along with zinc, lowered the risk of macular degeneration progressing to advanced stages by at least 25 percent. The supplements did not appear to provide a benefit for people with minimal macular degeneration or people without evidence of the disease during the course of the study. These vitamins contain a mixture of Vitamins C and E, Lutein, Zeaxanthin, Zing and Copper. Another large study in women showed a benefit from taking folic acid and vitamins B6 and B12. It is very important to remember that vitamin supplements are not a cure for macular degeneration, nor will they give you back vision that you may have already lost from the disease. However, these supplements do play a key role in helping some people at high risk for developing advanced (wet) AMD to maintain their vision, or slow down the progression of the disease.

DR. PAUTLER’S BLOG

• Dr. Pautler’s Blog on AMD
  All about AMD

AMERICAN ACADEMY OF OPHTHALMOLOGY

• What Is ARMD?
  The basics about AMD

MEDLINEPLUS

• Macular Degeneration
  Extensive list of links from excellent sources

NATIONAL INSTITUTES OF HEALTH

• ARMD
  NIH’s SeniorHealth website covers the topic of Age-Related Macular Degeneration

NATIONAL EYE INSTITUTE

• ARMD Resource Guide
  Answers questions about causes and symptoms, and discusses diagnosis and types of treatment.
• ARMD What You Should Know
  Booklet covering the same topic as provided in the NEI website, in printable PDF format.
• AREDS Information
  Age-Related Eye Disease Study
• AMD Video
  Video illustration of changes in the eye associated with AMD.

AMERICAN FOUNDATION FOR THE BLIND – SENIOR SITE

• Macular Degeneration
  Basic information about AMD and low vision; includes a self-test using an Amsler Grid

JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION (JAMA)

• Macular Degeneration
  Patient page providing the basics of AMD

WEBMD

• Macular Degeneration
  Detailed article covering all aspects of AMD.

LIGHTHOUSE INTERNATIONAL

• Macular Degeneration
  Provides a general overview of the basics of AMD, and a simulation showing a scene as it might be viewed by a person with AMD

PREVENT BLINDNESS AMERICA

• AMD Learning Center
  AMD basics and links to relevant news stories