Transcript Diapositiva 1

Age-Related Macular
Degeneration
(ARMD)
What is it
Age-related macular degeneration
(ARMD) is a disease of the
MACULA, the central part of the
retina, which causes severe visual
loss, particulary with regards to near
vision
CLASSIFICATION
• ARM ( Age-related maculopathy):
initial stage
• ARMD ( Age-related macular
degeneration ): non-exudative
(dry), exudative or neovascular
(wet)
How does ARMD appear?
• Loss of central vision
• Metamorphopsia ( distortion of perceived
images )
• Positive scotoma
• Blurring of central vision
This is an image seen by a patient with ARMD: in
this case it is, probably, a case of exudative
ARMD
Risk Factors
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Age
ARM
Race (prevalent in the Caucasian race)
Positive family history
Nuclear cataract
Biomarkers for cardiovascular disease
(smoking, obesity, hypertension)
Diagnosis
• Complete ophthalmic examination ( slitlamp biomicroscopy of the anterior
segment, visual acuity, tonometry, fundus
examination )
• Amsler test
• Fundus angiography : fluorescein
angiography (FA), indocyanine green
angiography (ICG)
• Optical Coherence Tomography (OCT)
Age related maculopathy
• Discrete yellow spots at the macula
(drusen)
• Hyperpigmentation or depigmentation of
the retinal pigment epithelium in
association with drusen.
Pigment epithelium defects
Hard drusen
Pigment epithelium defects
Pigment epithelium atrophy
Soft drusen
Fluorescein angiography
Pigment epithelium defects
Hard drusen
This image shows
areas with whitish
spots called HARD
DRUSEN associated
to small greyish areas
of tiny
hyperfluorescence
which correspond to
pigment epithelium
diseases
Fluorescein angiography
In this image
there are minute
whitish areas of
hyperfluorescence
called HARD
DRUSEN
Hard Drusen
Fluorescein angiography
Soft Drusen
Soft Drusen
Hard Drusen
This image shows
the presence of
Hard Drusen
associated to
whitish areas of
greater dimensions
(hyperfluorescence) called
SOFT DRUSEN
Fluorescein angiography
Soft Drusen
ARMD
• Geographic atrophy of the retinal pigment
epithelium (RPE) with visible underlying
choroidal vessels
• Pigment epithelium detachment (PED)
with or without neurosensory detachment
• Subretinal or sub-RPE choroidal
neovascularization
• Fibroglial scar tissue, haemorrage and
exudates.
Hemorrages
Sub-retinal fluid
Hemorrages
Sub-retinal fluid
Fluorescein angiography: exudative DMLE
with classic choroidal neovascolarization
This image shows
a whitish area with
vanished
boundaries: this is
neovascolarization
with new vessels
below the retina.
Also we can see,
at the edge of this
area, a grey zone
representing the
pigment epithelium
detachment
Pigment epithelium detachment
Neovascolarazion
Fluorescein angiography: exudative DML
with hidden choroidal neovascolarizaton
In this case there is
a large whitish area
with defined borders:
it’s a occult choroidal
neovascolarization.
Also there is a dark
zone: this is a small
little hemorrage on
the edge of the
defect
Hemorrage
Occult choroidal
neovascolarization with fibrous
tissue
Indocyanine green angiography
This image shows
two areas of
increasing
hyperfluorescence
called “Hot spots”
from underlying
choroidal
neovascularization
associated to areas
of hyperfluorescent
plaque
Hot spots with
hyperfluorescent plaque
Therapies
• Medical
• Laser
• Anti-angiogenic drugs
• Surgery
Medical Therapy
• Antioxidants and high dose multivitamins
are useful to reduce the risk of progression
of the disease
• Some scientific papers document, in 25%
of cases, a reduced risk of progression to
visual loss (within five years) if treatment
begins in the initial phase of the disease
Laser Therapy
• This therapy blocks the growth of new vessels
• Argon laser is an opportunity when the new vessels grow
far from the macula centre (fovea)
• Photodynamic therapy (PDT) is a good option when
new vessels grow under the fovea (subfoveal classic or
predominantly classic neovascularization)
• PDT is a combination laser-drug therapy: an intravenous
verteporfin injection, which is able to settle in the newly
formed vessels, followed by a treatment with laser. The
laser activates the drug (verteporfina) which arrests the
growth of new vessels
Intravitreal injections of anti VEGF
agents
• Anti VEGF drugs inhibit the growth of new
vessel and block the expansion of the exixting
ones
• Intravitreal iniection is an invasive technique: the
drug is injected in the eye
• At present two drugs are specific for exudative
DMLE: ranibizumb (“Lucentis”- Novartis) and
pegaptab sodicum (“Macugen”- Pfizer)
• New drugs are being tested in many
experimental studies
Surgery
• Only in specific cases
• Surgery techniques: submacular surgery,
macula translocation, pneumatic
displacement of submacular haemorrage
• These are invasive techniques with high
risks of complications.