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Nonexudative ARMD Follow-up

  • Author: Raj K Maturi, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Apr 24, 2014
 

Further Outpatient Care

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  • Patients with dry age-related macular degeneration (ARMD) should be observed frequently. Their follow-up care should be determined by the extent of disease and by the ophthalmologist's assessment of risk of conversion to wet ARMD.
  • Daily Amsler grid evaluation is necessary, with immediate reports to the ophthalmologist of any changes are noted.
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Inpatient & Outpatient Medications

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  • No approved medications for the treatment of dry age-related macular degeneration (ARMD) are available.
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Complications

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  • The major complication of dry age-related macular degeneration (ARMD) is the conversion to wet (or exudative/neovascular) ARMD.
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Prognosis

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  • Prognosis for this disease is significantly better than the prognosis for wet age-related macular degeneration (ARMD). Patients likely will have steadily but slowly deteriorating visual acuity. It also is common to have other visual dysfunction (eg, loss of ability to quickly adapt to changing lighting conditions, loss of contrast sensitivity). Variability of vision from day-to-day is common.
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Patient Education

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  • Patients with geographic atrophy (GA) may have a variety of visual dysfunction. The location of atrophy often suggests the type of visual dysfunction that will be experienced by the patient. Many patients with age-related macular degeneration (ARMD) report difficulty in adjusting to changing light conditions; specifically, they take a significantly longer time to adjust to indoor lighting after being outside in bright sunlight. Wrap-around outdoor sunglasses that have an orange tint work for some patients.
  • Patients who primarily have central atrophy often note trouble with reading and performing fine motor tasks. Magnification and increased contrast (via a monitor or increased illumination) are the best solutions for such visual dysfunction.
  • In contrast, other patients have GA that spares the foveal center but affects the entire perifoveal region. These patients often can see 20/20, but they are unable to navigate due to the small area of good visual acuity. Some of these patients have to scan the screen to be able to see the 20/400 character. In these patients, excess magnification would be detrimental, because it would effectively decrease their limited visual field. Increased contrast and minification, by way of increased illumination and reverse telescopes respectively, may be beneficial for these patients.
  • Referral to comprehensive vision rehabilitation is indicated early in the disease process. The American Academy of Ophthalmology (AAO) recommends referral for vision rehabilitation when acuity is less than 20/40 or when a loss of contrast sensitivity, scotoma, or field loss is noted. The aim of early referral is to prevent the many negative consequences of vision loss. For example, when acuity is reduced to 20/50 or worse, patients have twice the risk of falling, 3 times the risk of depression, and 4 or greater times the risk of hip fracture. Rehabilitation aims to maximize patients’ use of their partial vision and to provide practical adaptation to reduce disability. Comprehensive rehabilitation addresses the “whole person,” as outlined in the AAO’s booklet of Vision Rehabilitation for Adults. Barriers to low-vision therapy access include poor insurance coverage and transportation.[22]
  • For patient education resources, see the Eye and Vision Center, as well as Macular Degeneration.
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Contributor Information and Disclosures
Author

Raj K Maturi, MD Private Practice in Vitreoretinal Diseases, Surgery, and Uveitis; Volunteer 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, American Society of Retina Specialists, Society of Heed Fellows, Indianapolis Ophthalmological Society, Indiana Academy of Ophthalmology

Disclosure: Received grant/research funds from Allergan for consulting; Received consulting fee from DRCR/National Eye Institute, NIH for consulting; Received grant/research funds from LUX, Inc for consulting; Received grant/research funds from DRCR/JAEB for none; Received consulting fee from ALIMERA for consulting; Received consulting fee from ALCON for consulting; Received consulting fee from GLAXOSMITHKLINE for consulting; Received consulting fee from QUARK PHARMACEUTICALS for consulting; Received consul.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

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, Retina Society, Club Jules Gonin

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Brian A Phillpotts, MD, MD 

Brian A Phillpotts, MD, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, National Medical Association

Disclosure: Nothing to disclose.

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A normal-appearing macula of the left eye. Note the even pigmentation of the retinal pigment epithelium and the absence of any yellow excrescences (drusen) in the fovea. The optic nerve has unrelated changes.
In angiography, fluorescein dye is passed through a peripheral vein and transmits through the vascular system. The dye fluoresces in the vasculature, as seen here. No vascular prominences are seen in the macula or in any areas of dye pooling or staining. The abnormal vessels in the optic nerve, however, do show dye leakage.
Moderate nonexudative age-related macular degeneration is shown with the presence of drusen (yellow deposits) in the macular region.
Staining of drusen. Drusen absorb dye and, in the late frames of the angiogram, show hyperfluorescence. This staining is distinguished from the leakage that occurs when the dye spreads outside the boundary of the lesion.
A more advanced case of nonexudative age-related macular degeneration (ARMD). This image shows drusen that are larger, more confluent, and soft. Soft drusen are defined as drusen that have indistinct borders. Such drusen are more likely to convert to wet ARMD. A few areas of atrophy are noted, where the retinal pigment epithelium (RPE) has lost pigmentation. The retinal cells overlying atrophic RPE are generally nonfunctional and result in a scotoma.
The atrophic retinal pigment epithelium (RPE) demonstrates staining of the underlying choroidal vasculature. Normally, the intact RPE masks the presence of choroidal fluorescence. However, when the RPE atrophies, the underlying dye appears as an area of hyperfluorescence in the early stages of angiography. In the late stages, the drusen lose fluorescence in concert with (or with a small time lag) the rest of the retinal layers.
A more advanced case of dry age-related macular degeneration. Several areas of atrophy are present, as are areas of significant pigment mottling in the macula. The large drusen inferior to fixation are poorly distinguished from each other.
The atrophic areas are easily distinguished by the hyperfluorescence of the retinal pigment epithelium (RPE) in the mid phase of the angiogram. Hypofluorescence of dye, due to masking caused by the increased pigmentation, is seen. No areas of frank dye leakage or exudative age-related macular degeneration (ARMD) are apparent. A "hot cross bun" pattern of dry ARMD-related pigment changes is evident near the fovea.
High-definition optical coherence tomography scan of a 67-year-old woman showing retinal pigment epithelium mottling and pigment epithelial detachments temporal to fixation consistent with dry macular degeneration.
Fundus photo showing drusen in a 67-year-old woman with dry age-related macular degeneration.
Fluorescein angiogram 4 minutes after injection of dye on 67-year-old woman showing pigment epithelial detachments.
A later frame of the angiogram demonstrating the absence of dye leakage outside the lesion, with staining of the areas of atrophy (window defects) in the macular region.
High definition optical coherence tomography right eye demonstrating retinal pigment epithelium atrophy and changes in the deeper layers of retina. The absence of intraretinal cysts, subretinal fluid, or sub-retinal pigment epithelium fluid indicates the absence of wet age-related macular degeneration.
 
 
 
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