Age Related Macular Degeneration (AMD)

What is AMD?

Age related macular degeneration (AMD) is a common eye condition and a leading cause of vision loss among people age 50 and older. It causes damage to the macula, a small spot near the center of the retina and the part of the eye needed for sharp, central vision, which lets us see objects that are straight ahead.

In some people, AMD advances so slowly that vision loss does not occur for a long time. In others, the disease progresses faster and may lead to a loss of vision in one or both eyes. As AMD progresses, a blurred area near the center of vision is a common symptom. Over time, the blurred area may grow larger or person may develop blank spots in the central vision. Objects also may not appear to be as bright as they used to be.

AMD by itself does not lead to complete blindness, with no ability to see. However, the loss of central vision in AMD can interfere with simple everyday activities, such as the ability to see faces, drive, read, write, or do close work, such as cooking or fixing things around the house.

The Macula

The macula is made up of millions of light-sensing cells that provide sharp, central vision. It is the most sensitive part of the retina, which is located at the back of the eye. The retina turns light into electrical signals and then sends these electrical signals through the optic nerve to the brain, where they are translated into the images we see. When the macula is damaged, the center of your field of view may appear blurry, distorted, or dark.

Who is at risk?

Age is a major risk factor for AMD. The disease is most likely to occur after age 60, but it can occur earlier. Other risk factors for AMD include:

• Smoking. Research shows that smoking doubles the risk of AMD.

• Race. AMD is more common among Caucasians than among African-Americans or Hispanics/Latinos.

• Family history. People with a family history of AMD are at higher risk.

Does lifestyle make a difference?

Researchers have found links between AMD and some lifestyle choices, such as smoking. You might be able to reduce your risk of AMD or slow its progression by making these healthy choices:

• Avoid smoking

• Exercise regularly

• Maintain normal blood pressure and cholesterol levels

• Eat a healthy diet rich in green, leafy vegetables and fish

• Protect eyes from harmful UV (ultraviolet) light with glasses or wide hat

How is AMD detected?

The early and intermediate stages of AMD usually start without symptoms. Only a comprehensive dilated eye exam can detect macular degeneration. The eye exam may include the following:

• Visual acuity test. This eye chart measures how well you see at distances.

• Dilated eye exam. Your eye care professional places drops in your eyes to widen or dilate the pupils. This provides a better view of the back of your eye. Using a special magnifying lens, he or she then looks at your retina and optic nerve for signs of AMD and other eye problems.

• Amsler grid. Your eye care professional also may ask you to look at an Amsler grid. Changes in your central vision may cause the lines in the grid to disappear or appear wavy, a sign of AMD.

• Fluorescein angiogram. In this test, which is performed by an ophthalmologist, a fluorescent dye is injected into your arm. Pictures are taken as the dye passes through the blood vessels in your eye. This makes it possible to see leaking blood vessels, which occur in a severe, rapidly progressive type of AMD (see below). In rare cases, complications to the injection can arise, from nausea to more severe allergic reactions.

• Optical coherence tomography. You have probably heard of ultrasound, which uses sound waves to capture images of living tissues. OCT is similar except that it uses light waves, and can achieve very high-resolution images of any tissues that can be penetrated by light—such as the eyes. After your eyes are dilated, you’ll be asked to place your head on a chin rest and hold still for several seconds while the images are obtained. The light beam is painless.

During the exam, your eye care professional will look for drusen, which are yellow deposits beneath the retina. Most people develop some very small drusen as a normal part of aging. The presence of medium-to-large drusen may indicate that you have AMD.

Another sign of AMD is the appearance of pigmentary changes under the retina. In addition to the pigmented cells in the iris (the colored part of the eye), there are pigmented cells beneath the retina. As these cells break down and release their pigment, your eye care professional may see dark clumps of released pigment and later, areas that are less pigmented.

What are the stages of AMD?

There are three stages of AMD defined in part by the size and number of drusen under the retina. It is possible to have AMD in one eye only, or to have one eye with a later stage of AMD than the other.

Early AMD - Early AMD is diagnosed by the presence of medium-sized drusen, which are about the width of an average human hair. People with early AMD typically do not have vision loss.

Intermediate AMD - People with intermediate AMD typically have large drusen, pigment changes in the retina, or both. Again, these changes can only be detected during an eye exam. Intermediate AMD may cause some vision loss, but most people will not experience any symptoms.

Late AMD - In addition to drusen, people with late AMD have vision loss from damage to the macula. There are two types of late AMD:

  •  In geographic atrophy (also called dry AMD), there is a gradual breakdown of the light-sensitive cells in the macula that convey visual information to the brain, and of the supporting tissue beneath the macula. These changes cause vision loss.

  •  In neovascular AMD (also called wet AMD), abnormal blood vessels grow underneath the retina. ("Neovascular" literally means "new vessels.") These vessels can leak fluid and blood, which may lead to swelling and damage of the macula. The damage may be rapid and severe, unlike the more gradual course of geographic atrophy. It is possible to have both geographic atrophy and neovascular AMD in the same eye, and either condition can appear first.

AMD has few symptoms in the early stages, so it is important to have your eyes examined regularly. If you are at risk for AMD because of age, family history, lifestyle, or some combination of these factors, you should not wait to experience changes in vision before getting checked for AMD.

Not everyone with early AMD will develop late AMD. For people who have early AMD in one eye and no signs of AMD in the other eye, about five percent will develop advanced AMD after 10 years. For people who have early AMD in both eyes, about 14 percent will develop late AMD in at least one eye after 10 years. With prompt detection of AMD, there are steps you can take to further reduce your risk of vision loss from late AMD.

If you have late AMD in one eye only, you may not notice any changes in your overall vision. With the other eye seeing clearly, you may still be able to drive, read, and see fine details. However, having late AMD in one eye means you are at increased risk for late AMD in your other eye. If you notice distortion or blurred vision, even if it doesn’t have much effect on your daily life, consult an eye care professional.

How is AMD treated?

Early AMD

Currently, no treatment exists for early AMD, these patients typically do not have any visual symptoms. Your eye care professional may recommend that you get a comprehensive dilated eye exam at least once a year. The exam will help determine if your condition is advancing.

As for prevention, AMD occurs less often in people who exercise, avoid smoking, and eat nutritious foods including green leafy vegetables and fish. If you already have AMD, adopting some of these habits may help you keep your vision longer.

Intermediate and late AMD

Age-Related Eye Disease Studies (AREDS and AREDS2) found that daily intake of certain high-dose vitamins and minerals can slow progression of the disease in people who have intermediate AMD, and those who have late AMD in one eye.

Here are the clinically effective daily doses based AREDS and AREDS2 studies:

500 milligrams (mg) of vitamin C

400 international units of vitamin E

80 mg zinc as zinc oxide (25 mg in AREDS2)

2 mg copper as cupric oxide

10 mg lutein

2 mg zeaxanthin

Persons that have intermediate or late AMD, might benefit from taking such supplements. But first, be sure to review and compare the labels. Many of the supplements have different ingredients, or different doses, from those tested in the AREDS trials. Also, consult your doctor or eye care professional about which supplement, if any, is right for you. For example, if you smoke regularly, or used to, your doctor may recommend that you avoid supplements containing beta-carotene.

Even if you take a daily multivitamin, you should consider taking an AREDS supplement if you are at risk for late AMD. The formulations tested in the AREDS trials contain much higher doses of vitamins and minerals than what is found in multivitamins. Tell your doctor or eye care professional about any multivitamins you are taking when you are discussing possible AREDS formulations.

Finally, remember that the AREDS formulation is not a cure. It will not restore vision already lost from AMD, but it may delay the onset of late AMD. It also may help slow vision loss in people who already have late AMD.

Advanced neovascular AMD

In the past neovascular AMD typically resulted in severe vision loss. In recent years great progress has been achieved in treatment of wet macular degeneration.  Your ophthalmologist may use different therapies to stop further vision loss and in some patients improve vision. Therapies for wet macular degeneration are not a cure. The condition may progress even with treatment.  Treatment is more successful if done early before wet macular degeneration had a chance to progress.  Thus if you have been diagnosed with macular degeneration checking Amsler grid as directed and seeking help at first sign of distortion or blurriness of vision is essential.

Injections. One option to slow the progression of neovascular AMD is to inject drugs into the eye. With neovascular AMD, abnormally high levels of vascular endothelial growth factor (VEGF) are produced in the eye. VEGF is a protein that promotes the growth of new abnormal blood vessels. Anti-VEGF injection with drugs such as Lucentis or EYLEA blocks this growth. Patients receiving this treatment may need multiple or monthly injections. Injections are very well tolerated, but be sure to discus specifics and risks with you ophthalmologist. Before each injection, eye is numbed (very well!) and cleaned with antiseptics. To further reduce the risk of infection antibiotic drops may be prescribed. A few different anti-VEGF drugs are available. They vary in cost and in how often they need to be injected, so you may wish to discuss these issues with your eye care professional.

Photodynamic therapy was a common treatment for wet AMD prior development of Lucentis and EYLEA; this treatment has become less common and is currently used only for specific types of neovascular AMD.

Laser surgery. Ophthalmologists treat certain cases of neovascular AMD with laser surgery, though this is less common than other treatments. This laser surgery may help prevent more severe vision loss from occurring later.

Loss of Vision

Coping with AMD and vision loss can be a traumatic experience. This is especially true if you have just begun to lose your vision or have low vision. However, help is available. You may or may not be able to restore your vision, but low vision services can help you make the most of what is remaining. You can continue enjoying friends, family, hobbies, and other interests just as you always have. Please ask your eye care provider about available services.