Macular Degeneration

In Macular Degeneration (AMD), the macula is disrupted by deposits called drusen, or other age-related changes. These changes, if severe enough, may cause vision to deteriorate. When the macula breaks down, you lose your central vision, but it does not affect your peripheral (side) vision. Associated with the aging process; the macula may lose effectiveness over time. Early AMD may be hardly noticeable, and may only occur in one eye. You may notice blurring of words on a page, difficulty recognizing people’s faces, dark or empty areas in the center of your vision, and/or distortion of straight lines.

There are two types of Macular Degeneration:

Dry macular degeneration and Exudative (“wet”) macular degeneration.

DRY AMD

Dry AMD is caused by abnormal aging changes called drusen and sometimes there is also thinning (atrophy) of macular tissues. It is the most common form of macular degeneration, affecting over 12 million Americans. Vision loss is usually gradual and less severe than in Wet AMD. While there is no current treatment for Dry AMD, AREDS2 vitamins and antioxidants help slow the progression, and good nutrition and a healthy lifestyle may also be helpful.

EXUDATIVE (WET) AMD

Exudative or Wet AMD is caused when abnormal blood vessels form underneath the retina. These vessels leak blood and or fluid and blur the central vision. Vision loss may be rapid and severe.

Treatment options for Wet AMD have made unprecedented advances in the last 3 years with the introduction of Anti-VEGF therapy (a drug treatment that works to slow down and reverse the abnormal blood vessel development). Macular degeneration treatment at East Florida Eye Institute includes the most advanced procedures available. See our treatment options for Macular Degeneration on our Advanced Treatments page.

Macular Degeneration Diagnosis

OUR STATE-OF-THE-ART DIAGNOSTIC CENTER OFFERS PATIENTS THE LATEST IN ADVANCED DIAGNOSTICS FOR MACULAR DISEASES.

Your Visual Acuity will be assessed using the Snellen eye chart which measures how well each eye can see. You will be given an Amsler Grid to look at in the office and also one to take home to test your vision daily. This looks like a checkerboard with a black dot in the middle. If the grid seems blurry or wavy, it may mean that you have AMD. Drops are put in your eye that help to widen (dilate) the pupils. Then, using a special magnifying lens, your eye doctor will look at your retina. Specialized imaging tests may be ordered to better assess the health of the macula.

CIRRUS HD-OCULAR COHERENCE TOMOGRAPHER (OCT)

We have the newest CIRRUS HD-Ocular Coherence Tomographer, (OCT) scans through your dilated pupil to assess the quality of the macula and surrounding retinal tissue, reflecting damaged areas and in the case of Wet Macular Degeneration – fluid.

Fluorescein Angiography (FA)
Fluorescein Angiography (FA)

In Fluorescein angiography (FA), a special dye is injected into your arm and as the dye passes through the blood vessels in your retina, pictures are taken of the back of your eye, allowing your eye doctor to see the blood vessels of the retina, which is critical to assessing your AMD. Since wet AMD is caused by abnormal blood vessels that grow under the center of your retina, this test is often very helpful.

INDOCYANINE GREEN (ICG) ANGIOGRAPHY

Indocyanine Green (ICG) Angiography, a procedure similar to Fluorescein angiography, uses Indocyanine green dye which can show more detail than Fluorescein angiography.

For information on treating Wet Macular degeneration see our page here, for information on treating Dry Macular degeneration see our page here.

WET MACULAR DEGENERATION TREATMENT OPTIONS

Treating Exudative Macular Degeneration (Wet AMD) has evolved over the years from a destructive treatment that damaged the area it was attempting to treat to a truly revolutionary therapy that for the first time allows ophthalmologists to halt the progression of the disease without damaging the cells of the macula that are responsible for seeing.

In years past, a thermal “hot” laser therapy destroyed abnormal blood vessels by “burning” it with a high-energy laser. Scar tissue formed where treatment occurred, creating a permanent blind spot that might be noticeable in your vision.

Photodynamic therapy (PDT) “cool” laser came along thereafter and involved the use of a combination of a medication injected into the arm and a lower-power “cool” laser. The laser activated the drug, which destroyed the abnormal blood vessels. While it was initially accepted as a better option than thermal laser, it still caused scar tissue.

East Florida Eye Institute currently offers the following to treat Wet AMD.

ANTI-VEGF : EYLEA, AVASTIN, & LUCENTIS
INTRAOCULAR INJECTIONS

In December 2004, the first in a new class of medications Anti-VEGF, became available for the treatment of wet AMD. The first drug was Macugen, followed by Avastin, Lucentis, and Eylea. These are the first non-destructive treatments for wet AMD. Rather than using a laser, these medications are injected directly into the eye.

In wet AMD, a protein called VEGF (vascular endothelial growth factor) causes growth of abnormal blood vessels in the eye, which lead to vision loss. VEGF is a signal protein. It’s normal function is to create new blood vessels. When it is overexpressed, it can contribute to disease. These drugs block VEGF, therefore halting the growth of abnormal blood vessels.

EYLEA

The FDA approval of Eylea was based on two randomized, multi-center, double-masked, active-controlled studies. Ronald Frenkel, M.D. was a Principal Investigator for this particular study. A total of 2,412 subjects were treated and evaluated for efficacy. The primary efficacy endpoint was the proportion of subjects who maintained vision, defined as losing fewer than 15 letters of visual acuity at week 52 compared to baseline.

Eylea (aflibercept) is a recombinant fusion protein consisting of portions of human VEGF receptors 1 and 2 extracellular domains fused to the Fc portion of human IgG1 formulated as an iso-osmotic solution for intravitreal administration. Vascular endothelial growth factor-A (VEGF-A) is a member of the VEGF family of angiogenic factors that can act as mitogenic, chemotactic, and vascular permeability factors for endothelial cells. VEGF acts via two receptor tyrosine kinases, VEGFR-1 and VEGFR-2, present on the surface of endothelial cells. Activation of these receptors by VEGF-A can result in neovascularization and vascular permeability.

AVASTIN

Avastin is the first FDA approved therapy designed to inhibit angiogenesis, the process by which new blood vessels develop. Avastin was not initially developed to treat your eye condition. However, ophthalmologists are using Avastin to treat AMD and similar conditions since research indicates that VEGF is one of the causes for the growth of the abnormal vessels that cause these conditions. Some patients treated with Avastin had less fluid and more normal-appearing maculas, and their vision improved. Avastin is also used, therefore, to treat macular edema, or swelling of the macula.

LUCENTIS

Lucentis is a prescription medicine for the treatment of patients with Wet Age-Related Macular Degeneration (AMD) and Macular Edema following Retinal Vein Occlusion (RVO). In clinical trials, Lucentis has been shown to stop and, in many cases, reverse at least some vision loss in most people with advanced AMD.

OUR WET MACULAR DEGENERATION TREATMENT STRATEGIES

All treatment plans are individualized to each patient to give them the maximum quality of life.

Many factors are taken into account such as:
• How bad is your disease?
• How much difficulty are you having with your vision?
• Is there scar tissue in the center of the macula?
• How conservative or aggressive do you want your treatment to be?
• How difficult is it for you to get into the office?
• What other medical problems do you have? Have you ever had a stroke or heart attack? If so how recently? How long might you live? What is your quality of life?
• Did someone in your family have wet macular degeneration, and if so how did they do?
• Do you have 2,1, or 0 good eyes? It makes a difference in what we recommend for you. For example if one eye is very good and the other has scarring in the center of the macula and has had poor vision for a long time we tend to be less aggressive with the poor eye—but we will never deny you treatment.
• We rarely use laser as it destroys the retina and has a high rate of recurrence of disease
• Monthly treatments are required for certain patients and are more likely to be given if you only have one good eye.
• Treat and extend philosophy attempts to minimize the number of treatments you receive as long as we can keep your macula dry. We space out your treatments as long as possible.
• As needed philosophy treats you only when you are wet.

Dry Macular Degeneration Treatment Options

AREDS VITAMINS & DIET

There is no treatment for dry Age-Related Macular Degeneration (Dry AMD), but there are ways to slow the progression for some individuals. The Age-Related Eye Disease Study (AREDS) showed that people with intermediate stage dry AMD could reduce their risk of progressing to advanced AMD by about 25% by taking a special high-dose formula of supplements, sold without a prescription.

The specific formulation of vitamins known as the AREDS formula: (Zinc 80 mg, Vitamin C 500 mg, Vitamin E 400 IU, Beta-Carotene 15 mg, and Copper 2 mg) is readily available over-the-counter sold by many manufacturers.

Vitamin supplements are not cures for AMD, nor can they restore vision already lost from AMD. For dry AMD taking a multivitamin with LUTEIN, eating 3 servings of fruit a day, avoiding snack foods, smoking, and sunlight, and eating fish, spinach, and collard greens has been found helpful.

We strongly encourage you to talk to your doctor about the risks and benefits of these dietary supplements before taking them. High-dose vitamins, even when sold without a prescription, may present a risk for some people.

Smokers taking beta-carotene may increase their risk of lung cancer. High Dose Vitamin E (400 IU) has been linked to 5% higher death rates, bleeding, suppressing the body’s antioxidants and reducing the effect of cholesterol lowering medications.

WHAT IF AMD CANNOT BE TREATED?

People with wet or dry AMD who cannot be treated will not become totally blind—they will still have peripheral (side) vision. With special low-vision rehabilitation, devices and services, people can often learn how to “see” again with their remaining vision. Optical low-vision devices such as magnifying spectacles, hand magnifiers, stand magnifiers, video magnifiers and telescopes are available to help you make the most of what vision you do have.

If you have been diagnosed with AMD, you must monitor your vision every day with an Amsler Grid. By tracking changes in your vision at home, you are acting as a partner with your eye doctor alerting them to worsening of your condition as early as possible. Dry AMD can convert to Wet AMD, and treatment outcomes are much more favorable the earlier Wet AMD is detected and treated.

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