AMD Management

Patients in early-stage AMD are usually asymptomatic. When visual changes do occur, the patient most likely has intermediate to advanced disease. Early detection and referral to an ophthalmologist is critical to preserve vision because prompt treatment is associated with more successful outcomes in patients with wet AMD.1,2

The American Academy of Ophthalmology (AAO) recommends the following frequency for comprehensive eye examinations in adults with no risk factors for AMD or signs of disease:1,3,4

  • Under age 40 years: every 5 to 10 years
  • Ages 40 to 54 years: every 2 to 4 years
  • Ages 55 to 64 years: every 1 to 3 years
  • Age 65 and older: every 1 to 2 years

Patients should have a comprehensive medical eye evaluation with an ophthalmologist at age 40 years if they have not previously had one.1,3

Occasionally patients with monocular visual loss are unaware of any deficits in their vision when sight in the contralateral eye is still good.1,2 Therefore, the proper administration of the Snellen examination may give evidence of any monocular vision loss. Symptomatic patients or those in whom risk factors have been identified should have closer follow up, and decisions on the frequency of their visits should be made on an individual basis.1,3 Findings of macular drusen may be an incidental funduscopic finding that should prompt providers to refer patients with significant risk factors to an ophthalmologist.1

Patients with symptomatic dry AMD initially present with complaints of gradual onset of blurred vision in one or both eyes. They will describe having difficulties with activities that require fine visual acuity such as driving or reading. They may even talk about the need to use brighter lights or possibly need to use a magnifying lens for specific tasks. Patients also may describe the appearance of new scotomas in their vision.1

Patients with wet AMD may present with complaints of an acute onset of visual distortion in one eye or complete loss of unilateral central vision, which occurs with a sudden subretinal hemorrhage. Disease usually already exists in both eyes, but most frequently only presents in one. Straight lines will appear wavy and distorted, a symptom referred to as metamorphopsia. Patients also may complain that the edges of windows or doors appear curved.1

Clinicians should obtain a thorough history for symptomatic patients to assess the onset of visual symptoms, whether one or both eyes are affected, and if the vision loss involves far vision, near vision, or both. The physical examination should include visual acuity, visual fields by confrontation, external eye and lid assessment, pupillary function, extraocular movement, and a funduscopic evaluation. All patients with visual loss should be referred to an ophthalmologist and timing of that referral is determined by the time frame in which symptoms have presented. Any sudden loss of vision (days up to a week) should be evaluated within 48 hours; visual changes occurring over weeks to months should be assessed nonurgently at the next available appointment.1,2

Current and emerging treatments for AMD are discussed in the next section; however, insights concerning nutrients broadly associated with retinal and choroidal health from studying the Age-related Eye Disease Study (AREDS) model and experience, have been, and continue to be, explored. These nutrients include glutathione/selenium and vitamin D3 status, the family of vitamin E molecules known as tocotrienols/tocopherols, polyphenols, the calcium/magnesium ratio, omega-3 fatty acids, zeaxanthin, and activities that enhance endothelial nitric oxide production.5 (see Table below)

DHA, docosahexaenoic acid; GSH, glutathione stimulating hormone; RV, resveratrol; Se, selenium.
Table: Nutrients for retinal health based on the AREDS experience and other research5

Clinicians should be aware of the potential effects of the nutrients to be able to have informed conversations with patients about if, and/or when, any should be incorporated into lifestyle and treatment plans.

References

  1. Cunningham J. Recognizing age-related macular degeneration in primary care. JAAPA. 2017;30(3):18-22.
  2. Marra KV, Wagley S, Kuperwaser MC, et al. Care of older adults: role of primary care physicians in the treatment of cataracts and macular degeneration. J Am Geriatr Soc. 2016;64(2):369-377.
  3. American Academy of Ophthalmology. Comprehensive Adult Medical Eye Evaluation—2015. https://www.aao.org/preferred-practice-pattern/comprehensive-adult-medical-eye-evaluation-2015. Accessed April 3, 2020.
  4. American Academy of Ophthalmology. Age-Related Macular Degeneration PPP—2019. https://www.aao.org/preferred-practice-pattern/age-related-macular-degeneration-ppp. Accessed April 3, 2020.
  5. Richer S, Ulanski L, Natalia A, Popenko NA, et al. Age-related macular degeneration beyond the Age-related Eye Disease Study II. Adv Ophthalmol Optometry. 2016;1(1):335-369.

Clinician Scientific & Educational Resources

The RELIEF Clinical Toolkit is an online tool that aims to provide clinicians with up-to-date information on the presentation, prognosis, pathophysiology, and treatment strategies for age-related macular degeneration (AMD). Click on one of the options below to learn more about AMD.

This activity is provided by Med Learning Group. This activity is co-provided by Ultimate Medical Academy/Complete Conference Management (CCM). This activity is supported by an independent medical education grant from Regeneron Pharmaceuticals, Inc.

Copyright © 2019 | AMD Relief | All Rights Reserved | Website by Divigner

Scientific Council

Neil M. Bressler, MD

James P. Gills Professor of Ophthalmology
Professor of Ophthalmology, Johns Hopkins University School of Medicine
Wilmer Eye Institute, Johns Hopkins Medicine
Baltimore, MD

A. Paul Chous, MA, OD, FAAO

Specializing in Diabetes Eye Care & Education, Chous Eye Care Associates
Adjunct Professor of Optometry, Western University of Health Sciences
AOA Representative, National Diabetes Education Program
Tacoma, WA

Steven Ferrucci, OD, FAAO

Chief of Optometry, Sepulveda VA Medical Center
Professor, Southern California College of Optometry at Marshall B. Ketchum University
Sepulveda, CA

Julia A. Haller, MD

Ophthalmologist-in-Chief
Wills Eye Hospital
Philadelphia, PA

Allen C. Ho, MD, FACS

Director, Retina Research
Wills Eye Hospital
Professor and Chair of the Department of Ophthalmology
Thomas Jefferson University Hospitals
Philadelphia, PA

Charles C. Wykoff, MD, PhD

Director of Research, Retina Consultants of Houston
Associate Professor of Clinical Ophthalmology
Blanton Eye Institute & Houston Methodist Hospital
Houston, TX