What is Macular Degeneration?
Age-related macular degeneration (AMD) is an eye disease in which the specialized area of the retina responsible for sharp central vision and color discrimination (called the "macula") is damaged. Despite its small size (about that of a printed letter "O"), the macula is 100 times more sensitive to detail than the rest of your retina. As a result, AMD sufferers often can no longer distinguish faces, clocks, printed words, street signs, or other objects located straight ahead in the center of their field of vision.
Since images outside of the blurred area are often still visible, macular degeneration may result in legal (less than 20/200 vision), but not total blindness. Most patients are usually able to perform the majority of their daily activities and take care of themselves by using their remaining side (or "peripheral") vision.
Age-related macular degeneration is the leading cause of central vision impairment in people over age 50. At least 13 million Americans age 40 and older have some signs of AMD, and more than two million have the more advanced, vision-threatening stages of the disease. This "epidemic" is a major concern because, as our population ages, the number of people with AMD is expected to double by the year 2030.
Dry AMD - Yellowy spots are drusen
Wet AMD - Dark area is blood leakage
Types of AMD
AMD often starts with the appearance of drusen, fatty deposits beneath the light-sensing cells of the retina. Drusen are often found with aging (like age spots) and usually do not affect vision. However, if numerous drusen cluster in the center of the macula, they can lead to progressive deterioration, including the development of severe AMD.
The overwhelming majority of AMD cases (about 90 percent) are associated with the aging process and are called “dry” AMD. This more common form is caused by a breakdown or thinning of the tissues in the macula, which leads to a loss of vision cells. As a result, objects appear washed out or difficult to see. Fortunately, most “dry” cases progress slowly and are not associated with severe visual loss.
About 10 percent of AMD cases fall into a category called “wet” AMD. This more severe form is marked by the growth of new abnormal blood vessels under the macula, which can leak fluid and blood. This leakage may create scar tissue, resulting in a blind spot that causes a rapid and profound loss of sharp central vision. “Wet” AMD is less common than other forms but, of all patients legally blind from AMD, the majority have this type. The earlier it is detected, the better the chances for preserving vision.
Other Forms of Macular Degeneration
Less common reasons for damage to the macula include injury, infection, inflammation, marked nearsightedness, hereditary factors, and drug toxicity.
Researchers are not certain what causes the changes in the macula that lead to AMD. However, known risk factors include:
Aging (the number one risk factor, especially after age 65)
Smoking (increases risk 3-4 times)
Heredity (a family history of AMD)
Race (white ethnicity)
Gender (being female)
Circulatory problems, obesity and inactivity
Long-term sun/UV-light exposure
A diet high in fat and low in vitamins, minerals & antioxidants
AMD usually develops gradually and painlessly. If only one eye is affected, it may be difficult to detect in its early stages because vision in the "good" eye can often compensate for and thus mask problems in the "bad" eye. As the condition progresses, however, signs may become obvious.
Noticeable AMD symptoms include:
Difficulty reading or doing close-up tasks
Faces, clocks and printed words appear blurry
Distortion of vertical lines (for example, door frames, sides of buildings and streetlight posts may appear wavy)
Blind spots (dark/empty spaces) appear in the center of vision
A gradual "graying" or haziness of vision
The center of a scene appears smaller than the rest
The size of objects appears different for each eye
Colors are dim, hard to distinguish, or don't look the same for each eye
Detection & Monitoring
A comprehensive dilated eye exam is necessary to evaluate the presence, type and severity of AMD and whether or not treatment would help. At Eye Care Specialists, the following instruments and tests may be used.
Slit Lamp: A special microscope for seeing inside the eye to evaluate its overall health. The slit lamp can be used with a special lens to fully examine the macula.
Ophthalmoscope: This instrument is used to look through the pupil and light up the back of the eye to check the health of the optic nerve and retina for any abnormal conditions, such as AMD or retinal detachment.
Optical Coherence Tomography (OCT): During the fast, painless OCT procedure, patients simply focus on a light while a safe, invisible laser scans the inside of the eye to acquire an image in just seconds.
The OCT creates detailed computer printouts (similar to CT scans) that provide unparalleled accuracy in visualizing and measuring the severity and extent of AMD. This “optical ultrasound” of the anatomic layers of the retina and optic nerve enables us to determine how and when to treat wet AMD by mapping areas of fluid leakage and drying. Follow-up scans are then used to track and adjust each patient’s treatment plan.
Amsler Grid: This test (see next section) helps to detect subtle early changes in vision that may be caused by AMD.
In addition to undergoing examination and testing, it is important that you provide your doctor with an accurate medical history, including any vision symptoms or concerns, hereditary problems, and medication use.
Amsler Grid Self-Testing
The Amsler Grid is a simple, inexpensive and effective screening tool to test for early warning signs of AMD. A normal, healthy eye sees the grid pattern in its entirety, without distortion. An eye with AMD, however, may see lines as distorted or bowing, have a shadowy spot at the point of focus, or have entire areas that are missing. AMD patients should do this test daily, especially for prompt detection and treatment of cases where dry AMD changes into the more severe wet AMD. Your eye care specialist can provide you with an Amsler Grid and complete easy instructions for use.
Currently, treatment for this more common type of AMD primarily involves measures (see sections below) to prevent or slow its progression, including the intake of specific vitamins and the avoidance of risk factors (most importantly, not smoking). Because dry AMD usually does not result in rapid vision loss, many patients retain good sight throughout their lives. Some people, however, experience a significant loss of central vision over time. These patients usually benefit from magnifiers and other low vision aids.
For years, there were no treatment options for this less common, but more severe, form of AMD. Now, however, we are able to offer wet AMD patients (if their visual condition qualifies) revolutionary treatment involving injections of special medications, such as Avastin, Eylea or Lucentis.
Possible benefits of medication injection treatment
Although there are NO guarantees, we have seen remarkable results with injection treatment, including not only slowing or stopping the progression of wet AMD, but significantly reversing deterioration and improving vision. Clinical trials and our own results have demonstrated that, if wet AMD is treated promptly after its occurrence, 90 percent of patients experience stabilization of vision, and up to 30 percent gain improvement in vision. (Injection treatment is also successfully used to treat diabetes-related eye disease.)
How these medications work
They inhibit the growth of the abnormal blood vessels that cause wet AMD as well as treat swelling of the macula due to wet AMD.
The goal of injection treatment
The goal is to prevent further loss of vision. Most AMD patients treated with these medications have more normal-appearing maculas with less fluid and improvement in the quality of their vision. Although some patients regain some vision, there are no guarantees that medication injection treatment will restore lost vision or prevent further loss.
How the medications are given
After the eye is numbed with drops, the medication is painlessly injected into the vitreous (jelly-like substance inside the eye). The patient is then free to leave and resume activities.
How often you may need injections
To achieve the best possible benefit, injections must be administered every 4-12 weeks. Your eye care specialist will evaluate your response to determine the frequency and duration of your treatment.
Potential risks and side effects
As with any medication or procedure there are possible risks and side effects. Prior to treatment, these issues will be reviewed with your doctor and described in detail in an “Informed Consent” form.
At present, there are several FDA-approved treatments for wet (neovascular) AMD, including photodynamic therapy with the drug Visudyne and eye injections with Macugen. Although these treatment options have proven to slow the rate of visual loss, most people do not get back better vision. (In clinical studies, Avastin, Eylea and Lucentis have proven far more effective than other treatments in preserving and improving vision for patients with AMD.)
On the horizon. . .
Research continues in the areas of embryonic cell transplantation and implantation of tiny telescopes or bionic cameras. It is hoped that in 5-15 years, these or other treatments will effectively help all AMD patients.
Deciding when or whether to use injection treatment or vitamin supplements depends on careful evaluation of the type and severity of your AMD and your doctor’s opinion as to how well the condition may (or does) respond to treatment.
Nutritional Supplements to Reduce Vision Loss
In 2001, results were reported from the National Eye Institute Age-Related Eye Disease Study (AREDS), which found that high-dose antioxidant vitamins and minerals, taken orally, reduced the risk of progression to advanced AMD by 25 percent, and the risk of moderate vision loss by 19 percent. Although the AREDS vitamin did not improve vision or cure AMD, it provided definitive proof that nutritional supplements can protect and preserve vision for certain patients.
Due to the success of AREDS, a second nationwide clinical trial was launched. The AREDS2 study refined the original findings by adding lutein and zeaxanthin (plant-derived yellow pigments that accumulate in the macula, the small area of the retina responsible for central vision) and evaluated the effect of omega-3 fatty acids DHA and EPA (derived from fish oils). Results of the AREDS2 study showed that a specific combination of nutritional supplements (vitamins C & E, zinc, copper, lutein and zeaxanthin) successfully reduced the progression of significant dry AMD by 25 percent. In addition, this supplement was well-tolerated and safer than other formulations. As such, we strongly encourage the use of AREDS2 vitamins for our patients with significant AMD.
Should I take these nutrients?
While repeated studies have shown a benefit for people with significant AMD, there has not been good evidence to support nutrient supplementation in healthy people with minimal or no AMD. Therefore, it is important to seek the advice of a qualified eye care specialist before purchasing these (not inexpensive) products. Upon careful dilated examination, your doctor can determine if you have AMD, how advanced your condition is, and whether or not you will benefit from using a supplement.
Where can I find these supplements?
AREDS2 eye vitamins are sold over-the-counter as tablets and soft gels at pharmacies and retail stores (Walgreens, Target, Walmart, etc.).
What if I already take a multivitamin?
Multivitamins and/or diet alone can’t achieve the high levels of nutrients used in the AREDS2 studies. Most AREDS participants safely took both a multi-vitamin and the supplement.
What are the potential side effects?
The thousands of AREDS participants aged 55-80 reported few, if any, side effects. Typically, stomach upset (which went away upon stopping the supplement) was the most common problem.
Should I be cautious about using these nutrients and doses?
Yes. Many people, especially older adults, use a variety of prescription medications, over-the-counter drugs, dietary supplements and herbal medicines. High-dose vitamins and minerals like the AREDS2 formulation can interfere with these medications or decrease the absorption of other nutrients in the body—ultimately affecting a person's health and nutritional status.
Because of the vitamin E in the AREDS2 formula, people taking blood thinners should be cautious about using these supplements. Generally, the high doses of vitamins and minerals in the AREDS2 formula may not be recommended for people with liver and/or kidney disease.
If you plan to take eye-related nutrients, discuss your ideas (and whatever else you take) with your eye care specialist, doctor, and/or pharmacist.
Tips to Protect Vision
The following measures may help you to “see” life to the fullest:
Schedule regular dilated eye exams (every 2 years over the age of 50; every year if you have early AMD).
Use the Amsler Grid self-test (daily if you already have AMD).
Eat a balanced diet high in healthy Omega 3, vitamins, minerals and antioxidants and low in fat and sugar. Some studies show that lutein and zeaxanthin (found in eggs, corn and spinach) may help protect your retina.
Wear sunglasses and hats with brims (UV-light exposure has been linked to the development of AMD and cataracts).
Control other diseases, like high blood pressure and circulatory problems.
Don’t smoke. It’s your single greatest controllable risk factor. Smoking raises your risk 2-4 times for developing AMD.
If you notice a problem with your vision (especially straight lines appearing wavy or blind spots) don’t ignore it.
Resources for AMD Patients
Losing sight to AMD does not have to mean losing quality of life. Most patients are able to use their remaining side vision, along with a variety of coping techniques and tools, to lead independent, productive lives. The key is to reach out and take advantage of the many resources that are available, including the support of friends and family.
We strongly urge you to contact the organizations listed below for needs assessment; counseling; low vision aids; and help with obtaining Social Security/veterans benefits, income tax exemptions, and handicapped parking designations or transportation services. This list also includes reputable local suppliers of adaptive devices, including special lamps, big button phones and TV remotes, keyboards, large-print publications, reading machines, and magnifiers that can project items (like recipes, books, magazines, prescription bottles, etc.) onto a video screen. Some organizations even offer in-home visits to show you ways to make tasks easier and safer.
The most satisfied patients are those who are educated, active partners in their own care. As such, we encourage you to ask questions and stay abreast of new developments that may improve or protect your vision. And, we remind you that scheduling regular eye appointments is essential to ensuring that you have every opportunity to see life to the fullest.
Local help is just a call away
ATR—Adaptive Technology Resources
1350 14th Ave., Suite 3
Grafton, WI 53024
Prevent Blindness—Wisconsin Chapter
759 N. Milwaukee St.
Milwaukee, WI 53202
State of Wisconsin—Office for the Blind & Visually Impaired
Vision Forward Association
912 N. Hawley Rd.
Milwaukee, WI 53213
Wisconsin Talking Book & Braille Library
American Foundation for the Blind
American Macular Degeneration Foundation
The National Eye Institute
For more information or a comprehensive examination . . .
Since 1985, Eye Care Specialists has provided comprehensive medical, surgical and laser care for virtually every eye condition to more than 185,000 people. If you would like our free educational booklet on the eye concern reviewed above, please complete this form or call our Communications & Education Department at 414-321-7035. To schedule a comprehensive eye examination or a second opinion evaluation, call any of our three convenient Milwaukee-area locations directly.