eMedicine Specialties > Ophthalmology > Retina

ARMD, Nonexudative: Treatment & Medication

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

Updated: Sep 18, 2007

Treatment

Medical Care

Primary prevention

• Role of vitamins, antioxidants, risk of smoking, and hypertension: There is evidence that patients with early or moderate dry AMD should consume adequate quantities of antioxidants, including vitamin A, vitamin E, zinc, and lutein. Prevention is the best treatment in this case because no satisfactory method exists to treat dry AMD. Accumulated evidence suggests that AMD is a genetic disease. Therefore, children of patients who have lost vision to AMD are the best candidates for a primary prevention trial. Specific data that suggest the benefit of antioxidant supplementation are provided below:
  • The first AREDS study was recently concluded, and its results are illuminating. In this study, patients with very mild or moderate forms of dry AMD were given antioxidant supplementation (15 mg of beta-carotene, 500 mg of vitamin C, 400 IU of vitamin E, 80 mg of zinc, plus 2 mg of copper).  These patients had a small but definite decrease in their progression to advanced AMD. Interestingly, the data showed benefit in preventing the conversion of dry AMD to neovascular AMD.
  • The Rotterdam Study (1990–1993) investigated whether regular dietary intake of antioxidants was associated with a lower risk of incident AMD in over 4000 persons aged 55 years or older in The Netherlands. In this study, a high dietary intake of beta-carotene, vitamins C and E, and zinc was also associated with a substantially reduced risk of AMD in elderly persons.
  • Some evidence indicates that multivitamins with antioxidants and lutein may be of benefit. Clear evidence shows that smoking accelerates the disease process. It is recommended that patients who have a family history of AMD, and specifically those patients whose first-degree relative has lost vision due to AMD, should take a multivitamin with lutein each day. It is advised that patients stop smoking and consider supplemental oral antioxidants if they are unable to stop smoking.
  • Controversy exists over the exact vitamin combination that may be beneficial. Zinc and vitamin E are commonly touted as providing the best benefits. One study reports the beneficial effects of zinc, while another study shows a worse outcome with large doses of zinc. Therefore, it would be prudent to take a multivitamin containing a moderate dose of these vitamins.
  • To further refine the specific benefits of antioxidants, a randomized controlled clinical trial (AREDS 2) is currently underway. Its primary objective is to determine whether oral supplementation with macular xanthophylls (lutein at 10 mg/d plus zeaxanthin at 2 mg/d) or omega-3 long-chain polyunsaturated fatty acids (LCPUFAs; DHA plus eicosapentaenoic acid at a total of 1 g/d) will decrease the risk of progression to advanced AMD, as compared with placebo. 
• Early symptoms
  • Prolonged darkness (delayed dark adaptation) upon entering a restaurant from bright sunlight is one of the earliest symptoms, with patients noting this phenomenon prior to the presence of any significant atrophy. One effective suggestion for patients with this symptom is to use wrap-around shades. Some low-vision specialists suggest the use of orange-tinted, blue-blocker lenses.
  • Patients with dry AMD often have a visual function that is much poorer than suggested by their Snellen acuity. Presence of large areas of atrophy, usually in a perifoveal zone, results in large scotomas near the center of the visual field. These scotomas prevent patients from performing simple tasks (eg, recognizing faces, reading). Low-vision specialists often prescribe magnifiers with a line marker so that patients do not lose their place while reading.
• Epidemiologic studies using a computer database previously indicated that the use of statins was protective against the development of AMD. However, a recent study, using rigorous systems and graded macular photographs, confirmed that the use of statins was not correlated with AMD incidence or progression.⁵
• Family members of patients with AMD: While it would seem logical that the same vitamins used to treat patients with AMD would be of benefit prior to the development of AMD in family members, in the AREDS, supplements did not show any significant benefit with treatment over the 7-year follow-up when the disease was very mild.  Additionally, there are many risks in long-term treatment with zinc, vitamin A, or vitamin E.  Family members of patients with AMD are instead asked to do the following:
  • Avoid smoking or second-hand smoke
  • Protect eyes from direct sunlight using either dark glasses or a wide-brimmed hat.
  • Eat a well-balanced diet high in natural antioxidants
  • Eat fresh baked fish (1-2 servings) daily
  • Eat green leafy vegetables (eg, spinach, kale) daily

Surgical Care

It is possible that the drusen present in dry AMD can be ameliorated by the performance of a very light grid laser therapy. The Complications Of Age-Related Macular Degeneration Prevention Trial (CAPT), a National Eye Institute sponsored study examining the visual benefit from such treatment, recently concluded. Preliminary results indicated that focal laser therapy in a light grid pattern causes drusen resorption and improved visual acuity in the short term. However, the procedure was associated with a slightly higher risk of developing choroidal neovascularization in the short term compared to those who did not get treated.  Additionally, at the end of the study, there was no significant visual benefit to those who were treated compared to those who did not get any laser treatment.

More recently, a few patients obtained retinal translocation surgery where the retina is rotated.  Many of these patients developed accelerated dry macular degeneration with RPE atrophy at the site of the new macula.  The procedure's benefits are questionable at this time.

Consultations

Serial general ophthalmologic examination, on a nonemergent basis, is indicated for patients with dry AMD. If these patients have an acute loss of vision, retina consultation with fluorescein angiography is indicated in a timely manner to rule out the possibility of conversion to wet AMD.

Patients who have significant AMD changes, with or without vision loss, may wish to have their children evaluated by an ophthalmologist once the children reach age 50 years.

Diet

Recent evidence suggests that diet plays an important role in the prevention of dry AMD. Epidemiologic studies suggest that a diet containing green leafy vegetables is of benefit. Smoking cessation is of significant benefit.  Baked fresh fish are also beneficial due to the fatty acids provided; 1-2 servings a week are adequate.

Activity

No limitations exist. Each state has specific visual acuity criteria for driving with a private license. Commercial driving licenses typically require at least 20/40 in the worse eye and have other typical requirements for side vision.

Medication

Currently, no approved drug treatment of dry AMD is available. See Surgical Care  for the possible beneficial effects of laser therapy.

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