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A Patient's Guide to Macular Degeneration
A photo taken from inside of an eye of macular degenerationAge-related macular degeneration is the leading cause of vision loss in those who are age 50 or older. In fact, 11 million people in the U.S. have some type of age-related macular degeneration, according to the BrightFocus Foundation. That number is expected to double by 2050 as the population ages. By 2020, an estimated 196 million people will be living with age-related macular degeneration, according to the BrightFocus Foundation, a nonprofit that supports research and education about eye and brain diseases.

Our eyes have a retina, a thin tissue layer in the back of the eye that helps us sense light and send images of what we are seeing to our brain. One part of the retina is called the macula, and the macula gives us the crisp vision we need for common tasks like reading or driving.

Sometimes called ARMD or AMD (they are the same thing), age-related macular degeneration occurs when the macula doesn't work like it should. Although macular degeneration typically doesn't hurt, it can affect your ability to see well.

Age-related macular degeneration can lead to a loss of the central part of vision needed for important daily tasks or for seeing things like faces clearly, says Dr. Rahul Khurana, an American Academy of Ophthalmology spokesperson who practices at Northern California Retina Vitreous Associates in Daly City, California. Your peripheral vision remains.

A couple of decades ago, a diagnosis of age-related macular degeneration was a “one-way ticket to blindness,” Khurana explains. Nowadays, there are treatments available to help slow its progression, along with many other potential treatments in clinical trials.

According to the American Macular Degeneration Foundation, "There are two basic types of macular degeneration: dry and wet. Approximately 85% to 90% of the cases" are dry.

In addition, there are four stages of macular degeneration, ranging in severity from mild to severe. People in the advanced stages of the disease are considered legally blind.

  • Dry/early age-related macular degeneration. Dry age-related macular degeneration is the most common form of the disease, with nearly 90% of cases in this category. Most early cases of macular degeneration remain mild and don’t affect vision, says Dr. Carl Regillo, chief of retina service at Wills Eye Hospital, Thomas Jefferson University, in Philadelphia. However, it still requires regular monitoring as there’s a small chance that it will progress into another form of age-related macular degeneration.
  • Intermediate age-related macular degeneration. Intermediate age-related macular degeneration also is a dry form of the disease. It usually is associated with some vision loss. Before the wet stage occurs, there is always some form of dry age-related macular degeneration.
  • Geographic atrophy. Although geographic atrophy is still a dry form of age-related macular degeneration, it is associated with more vision loss than the early or intermediate stages. For this reason, it’s considered an advanced form of the disease. Geographic atrophy can turn into wet age-related macular degeneration.
  • Wet age-related macular degeneration. Wet age-related macular degeneration is also called advanced disease or neovascular age-related macular degeneration. It’s associated with the growth of abnormal blood vessels beneath the retina. These vessels may leak blood. Vision loss tends to be faster with wet age-related macular degeneration and is responsible for 90% of the vision loss from AMD, Khurana says. You can have both geographic atrophy and wet age-related macular degeneration in the same eye.

If wet age-related macular degeneration is caught early enough, you can usually preserve most of your vision.

The exact causes of age-related macular degeneration are not always clear, although it's associated with aging, starting at age 50 and onward. Genetics, smoking and being white all have a role as well. Here's more information on the causes of macular degeneration.

  • Aging – specifically, being age 50 or older. “Age is part of the name and diagnosis,” says Dr. Charles Wykoff of Retina Consultants Houston in Houston. The risk for age-related macular degeneration significantly grows with each passing decade starting in the 50s, Wykoff says.
  • Genetics, including a family history of age-related macular degeneration. There are dozens of genes associated with the disease, but genetic testing is not recommended by the AAO for the detection of age-related macular degeneration at this point because there is no perceived treatment benefit from the results, Khurana says.
  • Being white. In 2010, 89% of those who had age-related macular degeneration were white, according to the National Eye Institute.
  • Smoking. “Smoking doubles your risk, giving you another reason to quit,” Khurana says.
  • Heart disease. Having a stroke or heart attack can increase your risk of developing age-related macular degeneration. Estimates vary among studies, but researchers have frequently found a link between heart disease and the occurrence of macular degeneration.

Initially, you may not notice any symptoms if you have age-related macular degeneration. Some people who live a long time with a mild form may never notice a change in vision.

Symptoms of age-related macular degeneration include:

  • Blurry vision.
  • Seeing black or dark areas in your central vision.
  • Vision that appears darker than before.
  • Trouble reading.
  • Difficulty seeing details in both close and far vision.

“Imagine you are looking at a clock with hands. With age-related macular degeneration, you might see the clock’s numbers but not the hands,” according to the AAO.

The symptoms of age-related macular degeneration may appear in one or both eyes. Sometimes, you could have age-related macular degeneration in one eye but not notice the symptoms because your other eye still sees well. It’s possible to have different stages of disease in each eye – or have disease in one eye but not in the other.

If you have these symptoms, you should see an eye doctor for a dilated eye exam. Although these are the typical symptoms associated with age-related macular degeneration, the disease may go undetected, especially if you have dry age-related macular degeneration, Khurana says.

It's important to get diagnosed early because you have a better chance of preserving vision.

The most common way that macular degeneration is diagnosed is with a dilated eye exam at a doctor’s office. A dilated eye exam is one of the most reliable ways that eye doctors can detect certain diseases, such as macular degeneration and glaucoma.

During a dilated eye exam, you’ll receive special drops that allow the doctor to see the back of the eye, including the retina, macula and optic nerve. These drops make your eyes appear wider. Your eye doctor also may use something called an Amsler grid that can help measure changes or loss of your central vision.

When checking for age-related macular degeneration, your doctor will look for signs of disease that are not visible to you, such as:

  • Yellow-colored deposits called drusen.
  • Blood vessel growth that is abnormal.
  • Blood vessels that leak fluid.
  • Deposits of pigment underneath the retina.

Although some drusen are normal with age, medium or large drusen can indicate that you have age-related macular degeneration, according to the NEI. As drusen become bigger, the risk of dry age-related macular degeneration becoming wet age-related macular degeneration grows.

The items that eye doctors are looking for, such as drusen and abnormal blood vessels, only can be seen with a dilated eye exam or with special technology. Eye doctors also use a kind of imaging called optical coherence tomography, or OCT, which uses light waves to get pictures of sections of the retina. OCT testing doesn't hurt; you just place your head on a chin rest while images of your eye are taken with OCT.

Another test used to diagnose AMD is a fluorescein angiogram. This consists of injecting a fluorescent dye in your arm and taking pictures as the colored dye passes through your eye’s blood vessels, according to the NEI. This helps eye doctors to see leaking blood vessels that are part of wet age-related macular degeneration.

Your eye doctor will combine the imaging results along with the exam findings to diagnose age-related macular degeneration, Wykoff says.

The treatment for age-related macular degeneration depends on the type that you have. However, early detection is always helpful in preserving your vision.

Dry Age-Related Macular Degeneration

There are no treatments for the dry forms of age-related macular degeneration. If you have dry age-related macular degeneration, your eye doctor will likely prescribe over-the-counter vitamins called AREDS2, short for Age-Related Eye Disease Study 2. The AREDS2 vitamins contain lutein, zeaxanthin, zinc, copper and vitamins C and E.

AREDS2 is a formula developed after AREDS1, which had a slightly different combination of vitamins. In clinical trials, the AREDS vitamins helped reduce the risk of developing wet macular degeneration by about 25%. The patients in the trials had intermediate macular degeneration or advanced macular degeneration in one eye only.

Your eye doctor can help you decide if taking the AREDS formula is right for you. It’s OK for most patients to take AREDS along with their multivitamin, Regillo says. However, always check with your doctor before using them.

Although some people will use AREDS vitamins if they have a family history of age-related macular degeneration and do not have the disease, the vitamins aren’t designed for this particular purpose. “There’s not data to support that this (works),” Wykoff says. However, if you have a mild form of the disease, it can help prevent it from becoming worse.

Geographic Atrophy

There are currently no treatments for geographic atrophy. People who have geographic atrophy can lose, on average, one line of vision each year. A line of vision refers to the lines on vision charts that are often at eye doctors' offices, which are used to help measure how well we see. Despite the lack of treatments for now, there are several potential treatments in development or in clinical trials, Wykoff notes, including special eye drops, gene therapy and cell transplantation.

Wet Age-Related Macular Degeneration

Since the early 2000s, eye doctors have had more reliable treatments to help those with wet age-related macular degeneration. These treatments don’t cure the disease, but they can lessen its effects. In some cases, they can bring back some of the lost vision. “Fortunately, we’ve had a revolution in how we care for [wet] age-related macular degeneration,” Khurana says.

For wet AMD, there are two Food and Drug Administration-approved treatments called ranibizumab (Lucentis) and aflibercept (Eylea). A third treatment called bevacizumab (Avastin) is also used in some patients, but is not approved by the FDA for macular degeneration. (It's approved to treat certain cancers.) It’s used off-label.

All of these medications are what are known as anti-vascular endothelial growth factor (VEGF) drugs. The treatments have specific engineered proteins that block the activity of proteins that help build blood vessels, Wykoff says. They can help decrease the number of abnormal blood vessels in the retina and stop these blood vessels from leaking.

The treatments for wet AMD are given through an injection in the vitreous cavity, which is a gel-filled area of the eye between the front of the eye and the retina. The injections are well tolerated by patients, Regillo says. If you receive one of these injections, your eye doctor will use an antiseptic drop as well as an anesthetic drop. You won’t feel the injection, but you may feel a little pressure in the eye. The injections are given at an eye doctor’s office.

Ninety percent of the time, the injections given prevent vision from getting worse. In fact, about a third of patients gain some of their vision back, Khurana says. Most of these vision gains happen when the injections first start. The earlier that macular degeneration is detected, the greater chance that treatments can slow disease progression or help bring back lost vision, Wykoff says.

Eye doctors will usually give these injections monthly until they see that signs of the disease have stopped appearing. Most people need to continue injections over their lifetime, Regillo adds. However, the frequency of injections are different for everyone. Some require the injections once a month, while other patients can wait up to six to eight weeks or more between injections. It depends on disease activity in each person.

Photodynamic therapy and laser surgery are older treatment options for age-related macular degeneration and are used much less frequently than anti-VEGF injections.

Assistive Devices

Many patients with age-related macular degeneration will use low-vision assistive devices, such as magnifiers, special reading glasses, large-print reading materials and other tools and technologies to help them see better. A vision rehabilitation specialist can help you learn how to use these types of devices, according to the AAO.

The best way to help prevent or slow age-related macular degeneration is with a dilated eye exam every year or every other year, starting at age 50. The AAO recommends getting a baseline dilated eye exam at age 40, Khurana says. This is to help detect other serious eye problems that are seen via a dilated exam. If you have dry age-related macular degeneration, your eye doctor may want you to have a dilated exam more frequently, he adds.

These regular eye exams can help monitor for age-related macular degeneration as well as other eye problems that come up as people age, including glaucoma and cataracts.

Regular dilated eye exams are especially important if you have certain diseases such as diabetes. That's because having diabetes can raise your risk for many types of eye problems, including age-related macular degeneration. Dilated eye checks can help monitor for other diseases, such as diabetic retinopathy.

If you smoke, use whatever resources available you have to quit. Smoking raises the risk for age-related macular degeneration.

A heart-healthy diet may play a role in decreasing the risk of age-related macular degeneration developing or progressing. Consuming more dark leafy greens, colorful vegetables and cold water fish might help, Regillo notes. Consuming seven ounces of vegetables a day, two servings of fruit and fish twice a week were associated with a lower risk of macular degeneration, according to a 2019 study in the American Journal of Ophthalmology.

Maintaining normal blood pressure and cholesterol numbers also may have a positive effect on keeping age-related macular degeneration away.

If you suspect you have age-related macular degeneration, it’s important to see an eye doctor. “It’s important to know if you have wet or dry AMD. Don’t assume that you know which one it is,” Wykoff says.

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