eMedicine Specialties > Ophthalmology > Retina

ARMD, Nonexudative: Differential Diagnoses & Workup

Author: Raj K Maturi, MD, Clinical Associate Professor, Department of Ophthalmology, Indiana University School of Medicine
Contributor Information and Disclosures

Updated: Sep 18, 2007

Differential Diagnoses

Angioid Streaks
Best Disease
Chloroquine/Hydroxychloroquine Toxicity

Other Problems to Be Considered

Sorsby dystrophy
Malattia leventinese
Doyne honeycomb dystrophy
North Carolina macular dystrophy
Cuticular drusen
Serpiginous choroidopathy

Workup

Laboratory Studies

  • Fluorescein angiography is of value if the patient notes a recent onset or worsening of vision associated with metamorphopsia. Metamorphopsia may indicate the onset of choroidal neovascularization. Clinical evidence for neovascularization includes RPE elevation, subretinal hemorrhage, and/or presence of exudate.
  • Fluorescein angiography is performed by injecting 3 cc of 25% sodium fluorescein in a peripheral vein, followed by a rapid sequence of angiography images. Fluorescein is a vegetable-based dye that is activated by light at a particular wavelength and causes emission at a higher wavelength. Using the appropriate blocking and transmission filters, the photographer is able to capture an image of the dye in the blood vessels and, later as the dye leaks, images of the retina and the choroid.
  • Some complications of fluorescein angiography may occur. The dye is relatively safe. Occasionally (<5%), patients may have nausea or vomiting shortly after dye injection. Infrequently, patients may develop an allergic reaction to the dye and have hives, angioedema, venous dilation, and, very rarely, death (<1/250,000). No cross-reactivity occurs between this dye and iodine. The dye is cleared by renal excretion and is safe in patients on dialysis.

Imaging Studies

  • Dry AMD is followed best by accurate fundus photography.
  • Performing tests (eg, fluorescein angiography) on a routine basis is not necessary.
  • The physician is sometimes at a quandary when a patient describes loss of vision or new onset of metamorphopsia. The patient sometimes notes such changes as GA progresses; unfortunately, it is almost impossible to discern these symptoms from the symptoms that occur when neovascularization has occurred. Therefore, a patient with new onset of metamorphopsia or a sudden decrease in vision may require a fluorescein angiogram to distinguish exudative AMD versus the indeterminable progression of GA.

Other Tests

  • Recent reports have examined the thickness of the retina with optical coherence tomography (OCT). This study has shown decreased reflectance at the level of the rod-cone layer indicating that atrophy is present in this layer.
  • Multifocal electroretinography (MERG) may be performed on the retina to evaluate the functional response of rods and cones.
  • The above 2 tests are not required in the evaluation of AMD, but they have been performed by various authors to follow the progression of disease.

Procedures

  • Amsler grid evaluation, slit lamp biomicroscopy, and fluorescein angiography
    • The cornerstone of evaluation of dry AMD consists of visual acuity measurement and evaluation by Amsler grid. The biggest treatable risk of visual loss in dry AMD is the development of neovascularization. Studies have shown Amsler grid evaluations, if performed properly, are quite sensitive in detecting change. The specificity of this test is somewhat limited. Patients with dry AMD often note Amsler grid changes that are temporary, and good observers can detect progression of their dry AMD on the grid.
    • New metamorphopsia is a good indication for performing fluorescein angiography. This test is the most sensitive and specific way to evaluate for choroidal neovascularization.

Histologic Findings

The earliest morphologic features of dry AMD consist of the accumulation of 2 kinds of lesions (ie, basal laminar deposits, basal linear deposits) just beneath the RPE layer. The accumulation of these deposits is often uneven and associated with RPE hyperplasia and migration. This condition is clinically evident as pigment clumping. As these deposits slowly increase, they can be seen as soft drusen and/or localized RPE detachments.

As these drusen enlarge, they can cause either the development of new blood vessels (wet AMD) and/or the slow demise of the overlying photoreceptor cells. Photoreceptor cell loss can be accompanied by the thinning (atrophy) of RPE cells, as well as underlying choroidal circulation. The end stage of these changes is the presence of a very thin choroidal layer with the absence of small choroidal vessels underlying an area of atrophic RPE. The rod-cone layer overlying this zone is atrophied, and the middle retinal layers show signs of degeneration. This end stage gradually enlarges and is seen clinically as GA.

More on ARMD, Nonexudative

Overview: ARMD, Nonexudative
Differential Diagnoses & Workup: ARMD, Nonexudative
Treatment & Medication: ARMD, Nonexudative
Follow-up: ARMD, Nonexudative
Multimedia: ARMD, Nonexudative
References
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References

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Further Reading

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Keywords

nonexudative ARMD, nonexudative age-related macular degeneration, nonexudative AMD, age-related macular degeneration, AMD, dry macular degeneration, macular degeneration, senile macular degeneration, geographic atrophy, drusen, drusenoid changes, pigment epithelial degeneration, photodynamic therapy, PDT, transpupillary thermotherapy, TTT, IRIS medical laser, rheopheresis, complications of age-related macular degeneration prevention trial, CAPT, drusen ablation, laser to drusen

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Contributor Information and Disclosures

Author

Raj K Maturi, MD, Clinical Associate Professor, Department of Ophthalmology, Indiana University School of Medicine
Raj K Maturi, MD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Retina Specialists
Disclosure: QLT pharmaceuticals Honoraria Review panel membership

Medical Editor

Brian A Phillpotts, MD, Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine
Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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