OPHTHALMOLOGY MACULA DEGENERATION MBCh B 4 Prof P

OPHTHALMOLOGY MACULA DEGENERATION MBCh. B 4 Prof P Roux 2012

AGE-RELATED MACULAR DEGENERATION (AMD) 1. Drusen 2. Drusen and AMD 3. Atrophic AMD 4. Exudative AMD • Pigment epithelial detachment (PED) • Choroidal neovascularization (CNV)

Drusen Histopathology Hard • • Small well-defined spots Usually innocuous Soft • • • Larger, ill-defined spots May enlarge and coalesce Increased risk of AMD

FA of drusen `` Degree of hyperfluorescence depends on: • Extent of overlying RPE atrophy (window defect) • Amount of staining • Lipid content

Drusen and AMD - progression Atrophic AMD Exudative AMD

Atrophic AMD Progression Initially drusen and non-specific RPE changes Late RPE (geographic) atrophy

Atrophic AMD Fluorescein angiogram Management Hyperfluorescence from RPE window defect Low-vision aids if appropriate

Signs of Pigment epithelial detachment Circumscribed, dome-shaped elevation. Sub-RPE fluid may be clear or turbid

FA of pigment epithelial detachment Early, well-defined hyperfluorescence Progressive increase in hyperfluorescence No increase in size of lesion

ICG angiogram of pigment epithelial detachment Early, well-defined hypofluorescence Later, thin surrounding No increase in size of lesion hyperfluorescent ring

Possible subsequent course of PED Spontaneous resolution CNV Geographic atrophy RPE rip

Choroidal neovascularization (CNV) • • • Less common than atrophic AMD but more serious Metamorphopsia is initial symptom Most lesions are not visible clinically Suspicious clinical signs Pinkish-yellow subretinal lesion with fluid Subretinal blood or lipid

Angiographic classification of CNV Well-defined (classical) Extrafoveal > 200 m from centre of FAZ • Juxtafoveal < 200 m from centre of FAZ • Subfoveal - involving centre of FAZ • Occult • Poorly defined • Obscured by PED, blood or exudate

FA of classical CNV Very early ‘lacy’ filling pattern Leakage into subretinal space and around CNV Late staining

ICG angiogram in PED with occult CNV PED is hypofluorescent CNV is hyperfluorescent (hot spot)

Possible subsequent course of CNV Haemorrhagic sensory and. Subretinal (disciform) scarring RPE detachment Massive subretinal exudation Exudative retinal detachment

Potential indications for laser treatment of CNV • Classic extrafoveal CNV on FA • Occult extrafoveal CNV on ICG Pre-treatment FA of classic CNV

Technique of laser photocoagulation of CNV • Perimeter is treated with overlapping 200 m (0. 2 -0. 5 sec) burns • Entire area is covered with high energy burns Late staining around Lack of leakage following successful treatmentmargin is normal

Treatment • Anti VEGF intravitreal injection monthly x 3 – Avastin – Lucentis • Triamcinolone intravitreal injection every 3 -6 months

Amsler grid for follow up

Amsler grid

Prevention for patients with Drusen • Anti oxidants, vitamins and minerals • Ocuvite with Lutein • Eye Rx • Healthy diet of veggies and fruits • Stop smoking • Treat hypercholesterolemia

Prevention for general public • Healthy diet of veggies and fruits • Stop smoking • Treat hypercholesterolemia