Age Related Macular Degeneration

Age-related macular degeneration (AMD) is a degenerative disease of the retina that causes central vision loss, and it is the leading cause of blindness in the developed world. Age is a strong nonmodifiable risk factor for AMD. Patients may have genetic susceptibility to AMD from mutations in genes such as CFH and AMRS2-HTRA1. Smoking, poor diet, and lack of physical activity are modifiable risk factors for AMD. Early stages of AMD are usually asymptomatic, but as the disease progresses, patients may experience distorted vision or central vision loss. Non-neovascular AMD, also known as "dry" AMD or nonexudative AMD, is the most predominant form of the disease (80-85% of all cases) and carries a better visual prognosis. Accumulation of extracellular deposits called drusen is a hallmark finding of non-neovascular AMD. These patients may develop progressive loss of RPE cells, photoreceptor cells, and choroidal capillaries in the macular region. In addition to drusen, fundus examination may reveal pigment mottling or areas of geographic atrophy in the retina. Neovascular AMD, also known as "wet" AMD or exudative AMD, usually causes rapid vision loss and carries a worse visual prognosis. Pathologic development of new, abnormal vessels can cause the formation of a choroidal neovascular membrane, macular edema, hard exudates, hemorrhage, or a disciform scar in neovascular AMD. Though early AMD can be asymptomatic, worsening of central vision or metamorphopsia from patient history can be early clues for diagnosis. Evaluation including best-corrected visual acuity, funduscopic examination, optical coherence tomography (OCT), fluorescein angiography, and Amsler grid testing can aid in the diagnosis and management of AMD. OCT imaging may show an irregular contour of the macula due to drusen deposits as well as areas of hyper- and hypo- reflectance. Patients with wet AMD may also have intra- or sub- retinal fluid, pigmentary epithelial detachments, and subretinal hyperreflective material. Nonexudative AMD is managed with AREDS2 oral supplementation. Other therapies to slow the progression of geographic atrophy include intravitreal drugs such as pegcetacoplan and avacincaptad pegol. Intravitreal anti-VEGF therapy (bevacizumab, aflibercept, faricimab-svoa) is at the core of treatment for neovascular AMD. Other options to consider include submacular surgery to remove choroidal neovascular membranes or gene therapy. Collaboration with retinal specialists can be greatly beneficial to the care and management of patients with AMD.