Ask an Expert about Macular Degeneration
What is age-related macular degeneration (AMD)? [ 08/30/13 ]
AMD is a common eye disease associated with aging that gradually destroys sharp, central vision. The retina is the very thin tissue that lines the back of the eye and contains the light-sensing cells that send visual signals to the brain. Sharp, clear, 'straight ahead' vision is processed by the macula, which is the central part of the retina. When the macula is damaged, many daily activities such as driving, reading and recognizing faces become increasingly difficult.
What potential vision-related symptoms should I be aware of and mention to my eye doctor if they arise? [ 08/30/13 ]
- More light is needed for tasks such as reading
- A blurry spot appears in the center of the visual field
- A blurry spot becomes larger and darker
- Straight lines may appear wavy
- Straight-ahead vision becomes distorted or lost entirely in a short period of time
What is an Amsler grid? [ 08/30/13 ]
To discover any changes to your vision as early as possible, your eye care professional will probably have you test your own vision on a regular schedule using a small, hand-held Amsler grid. He or she may also do this at the office. At home, you will hold the chart at reading distance in good light, cover one eye, and focus on a black dot in the middle of the grid, then repeat with the other eye. If the lines of the grid appear dim, irregular, wavy, or fuzzy, you should schedule an eye exam immediately.
You can download an Amsler grid at www.brightfocus.org/amsler.
What resources are available to help people with age-related macular degeneration (AMD) and their caregivers? [ 08/30/13 ]
There are a great many resources available to people with low vision and their caregivers. For instance, every state has an agency on aging. You may find it in the phone book, online, or with the help of a librarian or friend. Professional low-vision therapists at eye clinics or other organizations can assist you. Let your eye doctor know what kind of limitations you are experiencing due to vision loss. He or she can then refer you to a vision rehabilitation center, where a low-vision therapist can work with you to help you adapt and resolve specific problems.
You can also modify your environment, use low-vision aids, develop your senses of hearing and touch, and practice using peripheral vision. Your doctor can prescribe optical devices such as magnifiers. Many non-prescription magnifying glasses and devices are also available to assist with reading and other close work, such as sewing or model-building. These devices range from the simple and inexpensive to more expensive high-tech products that can aid in using computers and watching television.
Many styles of magnifiers, including discreet ones, can be found at drug and medical supply stores, or may be ordered online or by phone through low-vision product catalogs. A hand-held magnifying glass can help with reading medicine bottle labels, mail, price tags in stores, and restaurant menus. Other magnifiers come in the form of eyeglasses or clip onto glasses to free your hands for other activities.
Commonly used household items with large numbers and letters, and others that “talk,” are also available. There are many sources for large-print books and audio materials, as well as services that read newspapers and magazines by phone or over the radio.
Electronic reading aids are proliferating, such as: computer programs that magnify the computer screen and/or read screen text out loud; special scanners to carry while shopping that read out prices, sizes, and colors; web browser plug-ins; and smartphone applications. One specialized device can take pictures of signs or menus and read the words in the pictures aloud.
Can diet prevent age-related macular degeneration (AMD)? [ 08/30/13 ]
Some limited studies appear to indicate that eating a diet high in carotenoids, and antioxidant vitamins (such C and E) may reduce the risk of developing age-related macular degeneration (AMD); however, more research is required before definitive statements can be made.
Carotenoids are compounds that are found in plants, which have been associated with protection not only from macular degeneration, but from cancer, heart disease, diabetes, and a number of other medical conditions. Dark green, yellow and orange fruits and vegetables, especially those high in the carotenoids known as lutein and zeaxanthin, may provide the best protection for AMD. Lutein and zeaxanthin are the primary pigments in the macula and are thought to protect the retina from ultraviolet light.
Lutein is found in spinach, collard greens, kale, broccoli, papaya, oranges, mango, green beans, peaches, sweet potatoes, lima beans, squash, red grapes, and green bell pepper. Yellow corn, squash, oranges, mango, kale, apricots, peaches, and orange bell pepper are good sources of zeaxanthin.
Foods abundant in vitamin C include green peppers, citrus fruits, tomatoes, broccoli, strawberries, yams, leafy greens, and cantaloupe.
Vitamin E is found in eggs, fortified cereals, fruit, wheat germ, green leafy vegetables, nuts/nut oils, vegetable oils, and whole grains.
How many people are estimated to have age-related macular degeneration (AMD)? [ 08/30/13 ]
Age-related macular degeneration (AMD) is a major cause of visual impairment in the U.S. Age-related macular degeneration (AMD) is a major cause of visual impairment in the United States. As many as 11 million Americans have some form of macular degeneration, including both early and later stages of the wet and dry forms. More than two million people, aged 50 and older, are living with the most advanced forms of the disease.
Can younger people get macular degeneration? [ 08/30/13 ]
Yes, there are several forms of juvenile macular degeneration (JMD), and all are inherited. The most common form of JMD is Stargardt's disease, also called fundus flavimaculatus or macular dystrophy, which normally develops in the childhood or teen years. Best disease or vitelliform macular degeneration is the second most common form of JMD; symptoms usually occur between birth and age 7. People in their thirties or forties can develop genetic forms of macular disease such as Sorsby's fundus dystrophy, Behr's dystrophy and Doyne's honeycomb retinal dystrophy. Finally, myopic macular degeneration can occur in people who are severely near-sighted due to extreme elongation of the eyeball. This condition can result in macula tears and bleeding beneath the retina.
Although there is no cure, are there treatments available for age-related macular degeneration? [ 08/30/13 ]
- Dry age-related macular degeneration
Once dry age-related macular degeneration reaches the advanced stage, there is no form of treatment at present to prevent further vision loss. However, there is an intervention measure that could delay and possibly prevent intermediate age-related macular degeneration from progressing to the advanced stage in which vision loss occurs.
The National Eye Institute’s Age-Related Eye Disease Study (AREDS) found that taking nutritional supplements with a specific high-dose formulation of antioxidants (vitamins C and E and beta-carotene), zinc, and copper delayed or prevented the progression of age-related macular degeneration from the intermediate to the advanced stage.
A follow-up trial, called AREDS2, was completed in May 2013. In that study, researchers found that the addition of omega-3 fatty acids to the supplements did not improve the formula’s success. The antioxidants lutein and zeaxanthin proved safer than beta-carotene, which increases the risk of lung cancer for smokers or ex-smokers. Thus, the AREDS2 recommendation for the supplement formula is 500 milligrams of vitamin C, 400 international units of vitamin E, 10 milligrams of lutein, 2 milligrams of zeaxanthin, 80 milligrams of zinc, and 2 milligrams of copper.
- Wet age-related macular degeneration
Wet AMD can be treated with injections of angiogenesis inhibitors into the eye, with photodynamic therapy, or with laser surgery. None of these treatments will cure wet AMD, but each may slow the rate of vision decline or stop further vision loss. However, the disease and loss of vision may also progress despite treatment. Options should be discussed with a doctor.
Angiogenesis Inhibitors: Angiogenesis inhibitors work by blocking the activity of vascular endothelial growth factor (VEGF), a protein that promotes blood vessel growth.
Three treatments for wet AMD using angiogenesis inhibitors—EYLEA®, Lucentis®, and Macugen®—were approved by the U.S. Food and Drug Administration (FDA) in 2011, 2006, and 2004, respectively. There is also a fourth drug, called Avastin®, approved by the FDA as a blood vessel growth inhibitor to treat colorectal and other cancers, that has been used off-label (i.e., for purposes other than the approved uses) by some doctors to treat AMD.
EYLEA®: After numbing the eye, the doctor injects EYLEA into the clear, jellylike substance (the vitreous) that fills the eye from the lens back to the retina and then monitors the patient's progress. After an initial three-month period of injections every four weeks, EYLEA can be administered every eight weeks.
In comparison, treatments with the other angiogenesis inhibitors are normally given every four weeks (Lucentis and Avastin) or every six weeks (Macugen). The actual number of injections needed is determined by the physician, taking the individual patient's disease status and response to treatment into consideration.
The most commonly reported side effects of EYLEA (affecting no more than fi ve percent of patients) include hemorrhage of the conjunctiva (the membrane that covers the white of the eye), eye pain, risk of cataract, vitreous detachment, vitreous floaters (specks or clouds moving in the field of vision), and increased eye pressure. There is a greater risk for endophthalmitis (severe inflammation of the eye interior) and retinal detachments, as can follow any injection into the vitreous.
Lucentis®: Lucentis is also injected into the vitreous portion of the eye after it has been numbed. Injections are given regularly over a period of time. The frequency and actual number of injections needed are determined by the physician and the individual patient's disease status and response to treatment. Findings from international studies announced in 2012 indicate that an injection every four weeks may be optimal.
The most commonly reported side effects of Lucentis include hemorrhage of the conjunctiva, floaters, eye pain, increased eye pressure, and inflammation of the eye. Rare but serious adverse events include endophthalmitis, retinal detachment, retinal tear, increased eye pressure, and traumatic cataract.
Macugen®: Macugen is also injected into the vitreous portion of the eye that has been numbed. It is usually administered every six weeks. The actual number of injections needed is determined by the physician, taking the individual patient's disease status and response to treatment into consideration. Macugen is still available for treatment of wet AMD, but is not used as often as other injectable angiogenesis inhibitors.
Common side effects of Macugen include inflammation of the eye, blurred vision, other changes in vision, cataracts, bleeding in the eye, swelling of the eye, eye discharge, irritation or discomfort of the eye, and "spots" in vision. Injection can also make the eye susceptible to infection for a period of time.
Avastin®: Avastin is an FDA-approved cancer therapy drug manufactured by the same company that makes Lucentis. Avastin has been used by doctors as an off-label treatment for AMD. Both drugs are similarly administered. However, Avastin is much less expensive, and many doctors believe these drugs are equally effective against macular degeneration. The National Eye Institute of the National Institutes of Health conducted clinical trials (Comparison of Treatments Trials, or CATT) to study the relative efficacy and safety of Avastin and Lucentis. In May 2011, they reported that Avastin and Lucentis were found to be nearly equally effective in treating AMD.
In April 2012, CATT findings showed that the best results for maintaining visual acuity are achieved with injections every four weeks, with comparable results for either Avastin or Lucentis injected monthly. The report showed that receiving doses of either drug "as needed" was less effective for maintaining visual acuity than monthly dosing. Although Avastin was associated with a greater number of serious adverse events than Lucentis, the researchers could not determine whether these differences were due to statistical chance or to real differences between the safety profiles of the two drugs.
Photodynamic Therapy: Photodynamic therapy (PDT) is most effective in a subtype of wet AMD called predominantly classic subfoveal choroidal neovascularization, in which blood vessel growth and leakage in the fovea—the small region in the center of the macula—are well defined. It should be noted that PDT is rarely used now that there are drugs (EYLEA, Lucentis, Macugen, and Avastin) that specifically block the vessel-promoting VEGF protein. During the PDT procedure, a drug called Visudyne® is injected into the arm. The drug courses through the body and is absorbed by the fragile, leaking blood vessels in the eye.
Drug Safety Issues
Avastin®, a drug approved for cancer treatment, must be divided into smaller doses for use as an eye treatment. This is done by licensed "compounding pharmacies." Although use of a compounding pharmacy is an accepted practice, currently the compounded medicines are not individually evaluated by the U.S. Food and Drug Administration.
The compounding procedure can also introduce the opportunity for bacterial contamination of a drug product. Although rare, there have been illnesses and even deaths due to poorly compounded drugs. Consult with your doctor about how your Avastin and other off-label drugs are prepared.
For the latest news on this and other drug safety issues, visit the news updates section of our website.
Because Visudyne is activated by light, the doctor directs a low-intensity laser at the retina for a little over a minute. This activates the Visudyne, allowing it to destroy the abnormal vessels. One treatment normally takes about twenty minutes and is relatively painless.
The most common side effects of PDT include headache, injection site reaction, and blurred or reduced vision. Because the drug is activated by light, it is important to avoid exposing eyes or any part of the skin to sunlight or bright indoor light for up to five days after treatment.
PDT may help to stabilize vision, but it will not restore lost vision.
Laser Surgery: Laser photocoagulation surgery was the first treatment used for wet AMD, but it is only an option for a small number of patients. During the outpatient procedure, the eye is numbed, and a high-energy laser heats, seals, and destroys abnormal leaky blood vessels. This can potentially prevent further vision loss, but it results in a permanent blind spot due to scarring.
Some patients experience mild pain during and/or shortly after the procedure. When successful, laser surgery is done once. However, if new blood vessels grow, surgery may have to be repeated.
Implantable Miniature Telescope: Approved by the FDA in 2010, the implantable miniature telescope (IMT) may help those with end-stage wet AMD gain back some vision.
The tiny telescope is inserted into one eye, which then provides central vision while the other eye provides peripheral vision. The telescope projects images over healthy areas of the retina. The IMT can usually be implanted by an eye surgeon during an outpatient surgical visit. After surgery, patients must participate in a structured vision rehabilitation program to learn how to perform daily activities using the device.
Disclaimer: The information provided here is a public service of the BrightFocus Foundation and should not in any way substitute for the advice of a qualified healthcare professional; it is not intended to constitute medical advice. Please consult your physician for personalized medical advice. BrightFocus Foundation does not endorse any medical product or therapy. All medications and supplements should only be taken under medical supervision. Also, although we make every effort to keep the medical information on our website updated, we cannot guarantee that the posted information reflects the most up-to-date research.
Some of the content in this section is adapted from other sources, which are clearly identified within each individual item of information.
Last Review: 04/29/13