SEEING PROGRESS
(continued from page 21)
macular degeneration should be encouraged to stop smoking.
There are two types of macular degeneration: dry/nonexudative
and wet/exudative. Patients may have a different type in each eye.
The nonexudative or dry form accounts for 85-90% of cases of
macular degeneration. The dry form tends to be slowly progressive
and is currently treated with AREDS-2 formula vitamins to delay the
progression. The Age Related Eye Disease Study concluded in 2001
that treatment of high-risk patients with AREDS formula vitamins
decreased the risk of progressing to advanced AMD by 25%. In
addition, the risk of moderate or severe vision loss was decreased by
19% over five years in those patients who were treated. Multivitamins
are not a substitute for AREDS-2 formula vitamins; however, they
may be taken in addition to AREDS-2 formula vitamins.
acting medications. Treatments for dry macular degeneration will
be focused on slowing the development of atrophy, recovering lost
tissue or growing new tissue.
Figure 2: A typical intravitreal injection of anti-VEGF medication
under topical anesthesia.
Figure 1: A simulation of the vision of a patient with advanced macu-
lar degeneration. Note that the peripheral vision is largly intact.
Vision loss from the dry form is caused by progressive atrophy of
the tissue under the retina, called the retinal pigmented epithelium,
and the retina itself. The dry form occasionally progresses to the wet,
or exudative form, in which new blood vessels grow underneath
the retina, also called neovascularization. The blood vessels are
abnormal and cause leakage, edema, bleeding and scarring. The wet
type of macular degeneration may be treated with regular injections
of anti-VEGF (vascular endothelial growth factor) agents into the
vitreous cavity of the eye under topical anesthesia, which are well
tolerated by most patients. These injections can often stabilize, or
even improve, the vision in these patients. Figure 2 shows a typical
intravitreal injection through the pars plana of the eye utilizing a
sterile eyelid speculum.
Treatment for macular degeneration is expensive, because of
the chronic nature of the disease, the frequent need for monthly
or every other month injections, and the cost of the intravitreal
medications (ranging from $75 to $1,800 per dose). However, the
societal costs of central vision impairment are likely greater than
the cost of providing treatment. Despite the positive treatment
results, frequent office visits are burdensome for patients and their
families. It is also becoming increasingly difficult for physicians to
treat the large numbers of patients with ARMD in a timely fashion.
Future treatments for wet macular degeneration will likely
include alternate medication administration strategies in order to
decrease treatment burden, such as slow-release devices or longer
22
LOUISVILLE MEDICINE
The increasing difficulty in reading as the disease progresses
is one of the most significant challenges faced by patients with
macular degeneration. It becomes difficult to read the mail, sign
checks, use the stove, or even see the numbers on a cell phone
screen. For those patients who have lost central vision due to
macular degeneration or another ocular disease, there are visual
aids available such as hand-held magnifiers or strong magnifying
lenses placed in the patients glasses on the inexpensive end of
the spectrum, up to electronic readers and digital magnification
computer screens, on the more expensive end of the spectrum, to
assist patients in remaining independent at home. Focused lighting,
such as that provided by lighted magnifiers and reading lamps, can
improve contrast sensitivity and reading ability, as compared to
diffused overhead lighting. For patients who enjoy reading but have
significant difficulty with the task, audio books are readily available
at libraries and book stores.
If a patient is 60 years or older, it is recommended they have
their eyes dilated by an ophthalmologist at least yearly to detect
early signs of macular degeneration, even if they are not currently
experiencing symptoms. It is also important to remember that if one
is diagnosed with macular degeneration, it does not guarantee vision
loss. There are many patients with the disease who lead fulfilling
lives and continue to enjoy their favorite activities.
It is important for non-ophthalmologists to understand the
major impact macular degeneration can have on the quality of life
and degree of independence experienced by their patients, and to
encourage them to seek the care of a retinal specialist. The ability to
enjoy life does not end with a diagnosis of macular degeneration.
Dr. Harper practices vitreoretinal surgery and diseases with Ophthalmology
Associates, PSC.