• 06 May

    Macular Degeneration

    Age-related macular degeneration (AMD) is an aging change in the area of the retina that provides central vision. AMD results from damage to the photoreceptors within the macula, a tiny area at the center of the retina in the back of the eye (see diagram). People with AMD may develop deterioration of their central vision but usually retain their peripheral sight. Its cause is not well understood and no treatment has been uniformly effective. It is the leading cause of severe visual loss in people over 65.

    Macular degeneration may result in a decrease in central vision, such as difficulty identifying faces or reading road signs. Additionally there may be a distortion of images where straight lines appear bent:

    Normal Distorted

     

    “Dry” and “Wet” Forms of Macular Degeneration

    The “dry” type of AMD occurs when retinal aging limits visual performance. This type accounts for 90% of the disease and does not cause a total loss of central vision. The “wet” form, by contrast, involves abnormal blood vessel development that damages the macula. This type is often more visually threatening, and occurs in only 10% of AMD patients but causes 90% of the disease’s severe visual loss.

    Prevention of Dry and Wet Macular Degeneration

    Sunglasses: Protect the retinal from potentially damaging ultraviolet light.

    Nutrition: The Age Related Eye Disease Study (AREDS) demonstrated that dietary supplementation of antioxidants and zinc reduces the progression from intermediate to advanced dry AMD by 25%, and the chance of further visual loss by 19%. A review of these results is available at http://www.nei.nih.gov/amd.

    The specific total daily amounts of antioxidants and zinc are:

    » 500 milligrams of vitamin C
    » 400 International Units of vitamin E
    » 15 milligrams of beta-carotene (equivalent to 25,000 International Units of vitamin A)
    » 80 milligrams of zinc as zinc oxide
    » 2 milligrams of copper (as cupric oxide)

    Studies are underway to determine the role of lutein and zeaxanthin to protect against developing or worsening AMD. The following may be used as a guide to such potentially beneficial foods:

    Kale 21,900
    Collard greens 16,300
    Spinach (cooked, drained) 12,600
    Spinach (raw) 10,200
    Parsley (not dried) 10,200
    Mustard greens 9,900
    Dill (not dried) 6,700
    Celery 3,600
    Scallions (raw) 2,100
    Leeks (raw) 1,900
    Broccoli (raw) 1,900
    Broccoli (cooked) 1,800
    Leaf lettuce 1,800
    Green peas 1,700
    Pumpkin 1500
    Brussels sprouts 1,300
    Summer squash 1,200
    Corn (yellow) 790
    Yellow pepper (raw) 770
    Green beans 740
    Green pepper 700
    Cucumber pickle 510
    Green olives 510

     

    Treatment for Dry Macular Degeneration

    No specific treatment has been shown to reduce dry AMD, though sunglasses and dietary supplementation may delay its progression.

    Research in Dry Macular Degeneration: Two large multicenter trials, the Complications of Macular Degeneration Prevention Trial (CAPT) and the Prophylactic Treatment of Macular Degeneration (PTAMD), are underway to determine if low-intensity laser treatment of retinal aging deposits (drusen) reduces the development or advancement of AMD. These trials are also evaluating whether visual function could be improved with such laser treatment.

    Treatment for Wet Macular Degeneration

    Therapeutic options for specific cases of wet AMD include antiangiogenic drugs and laser treatment.

    Antiangiogenic drugs: Antiangiogenic drugs have recently been used in wet AMD to stop the formation of new blood vessels that can result in scarring and eventual loss of central vision. These medications block Vascular Endothelial Growth Factor (VEGF), a substance responsible for the growth of new blood vessels. In most cases these drugs are injected into or around the eye.

    Macugen was FDA-approved in December 2004. Studies have demonstrated that Macugen stabilized or improved vision in 33% of the patients in clinical trials, while the same results occurred in 23% of a control group not given Macugen. 71% of the patients given Macugen lost less than three lines of vision during the year, compared with 55% of the control group. Macugen treatment often involves injection into the eye every six weeks.

    Lucentis was FDA-approved in June 2006, and is an antibody fragment to VEGF. 95% of patients maintained or improved vision (defined as a loss of less than 15 letters in visual acuity) at one year when treated with Lucentis injections, compared to approximately 62% of those treated in the control arm. Lucentis treatment often involves injection into the eye every month.

    Avastin is an investigational antiangiogenic cancer medication that has been used off-label for wet AMD. Avastin is manufactured by the same company, Genentech, that produces Lucentis, and treatment involves injection into the eye.

    Conventional Laser Therapy for Wet AMD: Involves a strong beam of light directed to the areas of abnormal blood vessel growth. Since the laser energy damages the areas of treatment, only specific types of wet AMD are candidates, and visual function afterward does not improve.

    New Laser Treatments for Wet AMD: The specific new blood vessels of wet AMD may be selectively targeted during laser treatment following intravenous injection (typically into the arm) of the dye Visudyne. Such laser treatment is termed Photodynamic Therapy, and typically involves many exams and treatment sessions. During each treatment, dye is injected and then the eye is exposed to red laser light which specifically treats the abnormal new blood vessels absorbing the dye. There is relatively little effect on the surrounding normal eye tissue. Visual improvement only occurs in about 15 to 20% of cases, but further visual loss is prevented in another 50 to 60%.

    Transpupillary Thermal Therapy: Photodynamic therapy has not been shown to be effective when abnormal blood vessels grow in to the center of the eye in a diffuse pattern. Transpupillary Thermal Therapy may be useful for such patients. Instead of a hot laser, this technique uses a cooler laser to heat the abnormal blood vessels more gently. This type of treatment typically stabilizes wet AMD in 50 to 70% of patients.

    Research in Wet Macular Degeneration: Drugs, such as thalidomide, Retaane, and other anti-VEGF therapies, are being investigated in terms of their potential to inhibit new vessel growth of wet AMD. Additionally, new surgical strategies being evaluated include Macular Translocation Surgery, during which the retina is detached and the macula is relocated away from blood vessel growth, and Radiation Therapy, directly applied to the abnormal new blood vessels. These areas of AMD research are being watched with great interest so that patients can be offered the most effective proven strategy depending on their risk factors and stage of retinal health.