Defining Age-Related Macular Degeneration

Karl Csaky, MD, PhD: Hello, and welcome to this HCPLive® Peer Exchange titled, “Advances in the Management of Age-Related Macular Degeneration.” My name is Dr Karl Csaky, and I am the executive and medical director of the Retina Foundation of the Southwest in Dallas, Texas.

Joining me today in this discussion are my colleagues and good friends, Dr Nancy Holekamp, who is the director of the Retina Service at the Pepose Vision Institute in St. Louis, Missouri;

Dr Jenny Lim, who is the Marion H. Schenk Chair and director of the Retina Service and vice chair of Ophthalmology at the University of Illinois at Chicago, in Chicago, Illinois;

Dr Carl Regillo, director of the Retina Service at the Wills Eye Hospital, as well as professor of Ophthalmology at the Thomas Jefferson University in Philadelphia, Pennsylvania;

and Dr Lloyd Clark, physician at the Palmetto Retina Center in West Columbia, South Carolina. Today we’re going to discuss a number of topics pertaining to age-related macular degeneration and diabetic eye diseases, including the diagnosis and clinical manifestations, traditional treatment options, and the potential for new agents on the horizon. Welcome, everybody, and let’s get started.

Nancy, let’s start with some basics. Can you tell us how we define age-related macular degeneration, what our thinking is about the pathophysiology and the prevalence?

Nancy M. Holekamp, MD: Yes, Karl, happy to start things off. Age-related macular degeneration is an age-related degeneration of the center part of the retina that’s called the macula. It happens to be the leading cause of legal blindness for people over the age of 65 in the United States, and I like to think of it as a gene pool disease. It’s a complex inherited disease. It’s where many different DNA variations, not necessarily mutations, come together in the right combination to create this risk for age-related macular degeneration, that shows up later in life. It’s very uncommon to have that diagnosis under the age of 50, and its prevalence increases with age.

Importantly, there are 2 forms of age-related macular degeneration that we commonly describe. One is called dry macular degeneration, and the very first manifestation of that clinically is drusen. Drusen are some yellow spots that we see on the macula when we do a dilated retinal exam. These drusen, may or may not affect vision, but they do warrant the diagnosis of age-related macular degeneration. Then with age, the drusen accumulate, they go from early-stage drusen to intermediate-stage drusen, there becomes some changes in the coloration of the retina such as some pigment modeling, and then you can progress to the advanced forms. That’s where people lose their vision; they lose vision to the point of legal blindness. Then, 2 advanced forms, [one] is a form called geographic atrophy, where the outer most layers of the retina, the RPE [retinal pigment epithelial] and the choriocapillaris atrophy, or die, and if that involves the fovea, people become legally blind, and another advanced form is called wet macular degeneration. There’s been a lot of publicity about wet macular degeneration because we have a treatment for it. Fortunately, with treatment, we can prevent legal blindness from this wet form of macular degeneration if people get diagnosed early and get treated consistently. We’re going to talk more about those treatments later today. That’s my introduction to macular degeneration, and I’m happy to have anybody else add some more info if they’d like.

Karl Csaky, MD, PhD: That’s fantastic, Nancy. Jennifer, could you talk to us a bit about patients who might be watching this or other health care providers. What should they be looking for in terms of initial symptoms, 1 eye, both eyes, we talked about age of onset, anything that patients and health care providers should be looking for in terms of symptoms?

Jennifer I. Lim, MD: Yes, happy to do that, Karl. As you know, most of the patients who present with age-related macular degeneration are in their 50s to 60s, and as Nancy alluded to, there are 2 forms of the disease, the dry form, and the wet form. Typically, early on, patients may not have many symptoms at all. They may have a nonspecific visual blur, if they have early macular degeneration causing loss of tissue or geographic atrophy, or they can have wavy vision, or we say metamorphopsia in that case, when there’s abnormal blood vessels or the wet form of macular degeneration in their retina. When the patients have more advanced disease, they can present with scotoma formation, that is complaining of missing parts of their vision, because that severe form of the dry macular degeneration can rob them of the photoreceptors that capture the light and give them an image on their retina and cause a blind spot in their vision. Also, choroidal neovascularization, or the wet form, can also cause severe loss of vision, and untreated can also cause loss of vision centrally.

As you know, we try to get these patients very early on, when they’re very mildly symptomatic. I would say for those patients who are listening today, if you have any change in your vision, a slight blur, a slight waviness in vision when you look at straight lines, it doesn’t look quite right, you should really come in and see your eye care professional. Sometimes patients just complain of trouble reading, and not infrequently, as we all know and we’ve all seen, patients sometimes cover one eye, and they discover they can’t see out of the other eye. They may not have known that they were legally blind in that eye or that they had a blind spot in the eye or wavy vision in that eye. It’s very important to check your vision every day and to see an eye care professional at least once a year, and if you have any symptoms of blurry vision, wavy vision, loss of vision, blank spot in your vision.

Karl Csaky, MD, PhD: That’s great.

This transcript has been edited for clarity.