Age Related Macular Degeneration

Normal Vision	Vision with Macular Degeneration

Macular degeneration is a medical condition where the light sensing cells in the macula malfunction and over time cease to work. According to the American Academy of Ophthalmology, it is the leading cause of central vision loss (blindness) in the United States today for those over the age of fifty. There are two basic types of the disease: Standard Macular Degeneration (MD) and Age Related Macular Degeneration (ARMD), with ARMD being the most common form of the condition. Macular degeneration that is not age related is most commonly caused by an inherited condition. These forms are sometimes called Juvenile macular degeneration (JMD). In macular degeneration the final form results in missing or blurred vision in the central, reading part of vision. The outer, peripheral part of the vision remains intact.

Age related macular degeneration

ARMD is further divided into a "dry," or nonexudative, form and a "wet," or exudative, form. Eighty five to ninety percent of cases are categorized as "dry" macular degeneration where fatty tissue, known as drusen, will slowly build up behind the retina. Ten to fifteen percent of cases involve the growth of abnormal blood vessels under the retina. These cases are called "wet" macular degeneration due to the leakage of blood and other fluid from behind the retina into the eye. Wet macular degeneration usually begins as the dry form. If allowed to continue without treatment it will completely destroy the macula. Medical, photodynamic, laser photocoagulation and laser treatment of wet macular degeneration are available.

Risk factors

• Aging: Approximately 10% of patients 66 to 74 years of age will have findings of macular degeneration. The prevalence increases to 30% in patients 75 to 85 years of age.
• Smoking: The only environmental exposure clearly associated with macular degeneration is tobacco smoking.
• Family history: The lifetime risk of developing late-stage macular degeneration is 50% for people who have a relative with macular degeneration vs. 12% for people who do not have relatives with macular degeneration, i.e. a four fold higher risk.
• Macular Degeneration Gene: Complement factor H (CFH) gene has been determined to be strongly associated with a person's risk for developing macular degeneration.
• Exposure to sunlight especially blue light.
• Hypertension.
• Cardiovascular Risk Factors - high cholesterol, obesity.
• High fat intake is associated with an increased risk of macular degeneration in both women and men. Fat provides about 42 percent of the calories in the average American diet. A diet that derives closer to 20-25 percent of total calories from fat is probably healthier. Reducing fat intake to this level means cutting down greatly on consumption of red meats and dairy products such as milk, cheese, and butter. Eating more cold-water fish (at least twice weekly), rather than red meats and eating any type of nuts may help macular degeneration patients.(Reference: Macular degeneration Types and Risk Factors.
• Oxidative stress: It has been proposed that age related accumulation of low molecular weight, phototoxic, pro-oxidant melanin oligomers within lysosomes in the retinal pigment epithelium (RPE) may be partly responsible for decreasing the digestive rate of photoreceptor outer rod segments (POS) by the RPE. A decrease in the digestive rate of POS has been shown to be associated with lipofuscin formation - a classic symptom of macular degeneration. (Reference: Ophthalmic Research, 2005; volume 37: pages 136-141. "Melanin aggregation and polymerization: possible implications in age related macular degeneration")

Signs

• Visual acuity drastically decreasing (two levels or more) ex: 20/20 to 20/80.
• Holes visible in fundus photographs

Symptoms

Image courtesy AgingEye Times

• Blurred vision
• Distorted vision (i.e. metamorphopsia) - A grid of straight lines appears wavy and parts of the grid appear blank.
• Trouble discerning colors; specifically dark ones from dark ones and light ones from light ones.

The Amsler Grid Test is one of the simplest and most effective methods for patients to monitor the health of the macula. The Amsler Grid is essentially a pattern of intersecting lines (identical to graph paper) with a black dot in the middle. The central black dot is used for fixation (a place for the eye to stare at). With normal vision, all lines surrounding the black dot will look straight and evenly spaced with no missing or odd looking areas when fixating on the grid's central black dot. When there is disease affecting the macula, as in macular degeneration, the lines can look bent, distorted and/or missing.

The traditional Amsler grid test is a black and white pattern that may miss early defects (references at www.ixm.us). Since treatment and vision preservation in macular degeneration is facilitated by early detection of the disease, a more sensitive blue-on-yellow Amsler grid test pattern has recently been introduced (Home Amsler Color Test).

'Vision loss' or 'blindness' in macular degeneration refers to the loss of 'central vision' only. The peripheral vision is preserved. Blindness in macular degeneration does not mean 'inability to see light' and even with far advanced macular degeneration, the peripheral retina allows for useful vision.

The loss of central vision profoundly effects visual functioning. It is not possible, for example, to read without central vision. Pictures which attempt to depict the central visual loss of macular degeneration with a black spot do not really do justice to the devasting nature of the visual loss. This can be demonstrated by printing letters 6 inches high on a piece of paper and attempting to identify them while looking straight ahead and holding the paper slightly to the side. Most people find this surprisingly difficult to do.