Age-Related Macular Degeneration is the leading cause of permanent vision loss in people over age 60

Macular degeneration causes

Dry AMD

In dry AMD, the light-sensitive cells responsible for converting light into signals (the photoreceptors) that are then sent to the brain break down. Dry AMD tends to progress gradually, and usually affects both eyes.⁵VisionAware. 2021. The Difference Between Wet and Dry Age-Related Macular Degeneration – VisionAware. [online] Available at: <https://visionaware.org/your-eye-condition/age-related-macular-degeneration-amd/wet-and-dry-amd/#:~:text=There%20are%20two%20types%20of,same%20pace%20in%20both%20eyes.> [Accessed 24 June 2021].

Symptoms of dry AMD include:

• Need for increased light when reading or doing close work
• Difficulty adjusting to low light levels
• Increased blur when reading
• Reduced-intensity or brightness of colours
• Difficulty recognising faces⁶Mayo Clinic. 2021. Dry macular degeneration – Symptoms and causes. [online] Available at: <https://www.mayoclinic.org/diseases-conditions/dry-macular-degeneration/symptoms-causes/syc-20350375> [Accessed 24 June 2021].

Most people with early dry AMD will experience minimal or no loss of vision. However, dry AMD can potentially cause vision loss by either turning into wet AMD or by causing progressive and extensive destruction of the light-sensitive cells. Unfortunately, there is no way to tell if or when the dry form will turn into the wet form.

Wet AMD

In wet AMD, abnormal blood vessels start to grow under the macula. These new blood vessels are very fragile and leak blood and fluid. Unlike dry AMD, damage to the macula and loss of central vision will occur rapidly in wet AMD. Wet AMD is a treatable condition, but early detection is critical for stabilising vision.

Symptoms of wet AMD include:

• Distortion of printed words
• Distortion of straight lines (which often appear wavy), most clearly picked up with an Amsler grid
• Blurred central vision that may be associated with a grey patch in the centre of your vision⁷Fightforsight.org.uk. 2021. Age-related macular degeneration | Fight for Sight. [online] Available at: <https://www.fightforsight.org.uk/about-the-eye/a-z-eye-conditions/age-related-macular-degeneration/?gclid=CjwKCAjwt8uGBhBAEiwAayu_9VEOdM5Mqw5N8ZGxHtcsb0ZpJpYXeereHJz4wctlAi3zxAB-LaujjhoCBKwQAvD_BwE> [Accessed 24 June 2021].

If your doctor has indicated that you might be at risk of wet AMD, it is important to be aware that a new onset of blurred vision or distorted vision may be an early warning sign. Your vision may deteriorate unless you take urgent action.

Macular degeneration diagnosis and examination process

Eye examinations and regular screenings with your eye care practitioner will detect the early signs of AMD.

Testing may include:

• Visual acuity: a measurement of vision on a letter chart
• Amsler grid: assessment of central distortion such as faded, broken or wavy lines
• Retinal examination: an examination of the macula where we dilate your pupil
• In early dry AMD, there will often be small yellow spots at the macula (drusen), which represent the accumulation of metabolic waste products

Testing may also include:

• Optical coherence tomography (OCT), which can identify areas of macular thickening or thinning and the presence of abnormal blood and fluid under the macula.
• Fluorescein or OCT-angiography which can be used to visualise the blood vessels in the retina and can help with diagnosing or excluding wet AMD

Macular degeneration treatments

There is currently no treatment available for dry AMD. However, your eye care practitioner may recommend the use of formulated antioxidant and nutritional supplements. Extensive studies have shown that these can reduce the risk of developing wet AMD.⁸Khoo HE, Ng HS, Yap WS, Goh HJH, Yim HS. Nutrients for Prevention of Macular Degeneration and Eye-Related Diseases. Antioxidants (Basel). 2019;8(4):85. Published 2019 Apr 2. doi:10.3390/antiox8040085

Lifestyle and dietary changes may help prevent early dry AMD, including:

• • Eating a well-balanced diet, incorporating green leafy vegetables daily and fish two to three times a week
  • Maintaining a healthy weight and blood pressure
  • Exercising regularly
  • Quitting smoking⁹BrightFocus Foundation. 2021. Healthy Living. [online] Available at: <https://www.brightfocus.org/macular/diet-and-exercise> [Accessed 24 June 2021].

If you have dry AMD, we also recommend that you use an Amsler grid regularly for self-monitoring. New blur or distortion would warrant prompt investigation by your eye doctor.

In the majority of cases, we can successfully treat wet AMD with anti-VEGF medication, which stops the new abnormal blood vessels from growing and leaking.¹⁰Healthline. 2021. Anti-VEGF Injection: Success Rates for AMD. [online] Available at: <https://www.healthline.com/health/eye-health/anti-vegf-injection-success-rates-for-amd> [Accessed 24 June 2021].

We inject these anti-VEGF agents into the eye once we have anaesthetised the eye using local anaesthetic. The procedure involves minimal discomfort. An induction course of three monthly injections is initially required to stabilise wet AMD, with maintenance therapy typically needed every 4 to 12 weeks after that to maintain vision.

With treatment, there is a 90% likelihood of stabilising vision and preventing any further decline.¹¹Healthline. 2021. Anti-VEGF Injection: Success Rates for AMD. [online] Available at: <https://www.healthline.com/health/eye-health/anti-vegf-injection-success-rates-for-amd> [Accessed 24 June 2021].

The earlier this is initiated, the better the visual outcome is likely to be.

The majority of people suffering from early wet AMD can lead independent lives, with the ability to continue driving and reading.

Macular degeneration FAQs

What is age-related macular degeneration?

Age-related macular degeneration (AMD) is a disease that affects the macula and blurs the central vision. Medical professionals believe that damage from AMD is due to oxidative stress and the accumulation of waste products generated by metabolic processes within the retina.¹²Bellezza I. Oxidative Stress in Age-Related Macular Degeneration: Nrf2 as Therapeutic Target. Front Pharmacol. 2018;9:1280. Published 2018 Nov 5. doi:10.3389/fphar.2018.01280

AMD generally affects people aged 50 years and older, and it is the most common cause of irreversible vision loss in this age group. AMD does not cause total blindness, but it does interfere with many activities of daily living and can severely affect the quality of life.¹³Gehrs KM, Anderson DH, Johnson LV, Hageman GS. Age-related macular degeneration–emerging pathogenetic and therapeutic concepts. Ann Med. 2006;38(7):450-471. doi:10.1080/07853890600946724

There are two main types of age-related macular degeneration: dry AMD and wet AMD:

Dry age-related macular degeneration:

In dry AMD, the light-sensitive cells (photoreceptors) located at the macula gradually break down. Usually, both eyes are affected.

Symptoms of dry AMD include:

• Need for increased light when reading or doing close work
• Difficulty adjusting to low light levels
• Increased blur when reading
• Reduced-intensity or brightness of colours
• Difficulty recognising faces¹⁴Mayo Clinic. 2021. Dry macular degeneration – Symptoms and causes. [online] Available at: <https://www.mayoclinic.org/diseases-conditions/dry-macular-degeneration/symptoms-causes/syc-20350375> [Accessed 24 June 2021].

Wet age-related macular degeneration:

In wet AMD, abnormal blood vessels start to grow under the macula. These new blood vessels are very fragile and will leak blood and fluid. Unlike dry AMD, damage to the macula and loss of central vision will occur rapidly in wet AMD. Wet AMD is a treatable condition, but early detection is critical for stabilising vision.

Symptoms of wet AMD include:

• Distortion of printed words
• Distortion of straight lines (often will appear wavy), most clearly picked up with an Amsler grid¹⁵Mayo Clinic. 2021. Wet macular degeneration – Symptoms and causes. [online] Available at: <https://www.mayoclinic.org/diseases-conditions/wet-macular-degeneration/symptoms-causes/syc-20351107> [Accessed 24 June 2021].

If you notice any sudden distortion in your vision, contact your eye care practitioner immediately.

• Can dry AMD convert to wet AMD?

Yes. Dry AMD can potentially cause vision loss by either turning into wet AMD or by causing progressive and extensive destruction of the light-sensitive cells in the macula. There is no way to tell if or when the dry form will turn into the wet form.¹⁶Mayo Clinic. 2021. Dry macular degeneration – Symptoms and causes. [online] Available at: <https://www.mayoclinic.org/diseases-conditions/dry-macular-degeneration/symptoms-causes/syc-20350375> [Accessed 24 June 2021].

• Aspirin and AMD–Is there a link?

Research in recent years examined the link between the use of aspirin and AMD. Medical professionals believe that aspirin does not affect early AMD. There may be a possible association between aspirin use and progression of moderate and high-risk AMD; however, the evidence behind this remains fairly limited.¹⁷Retinalphysician.com. 2021. [online] Available at: <https://www.retinalphysician.com/issues/2018/april-2018/aspirin-use-and-age-related-macular-degeneration> [Accessed 24 June 2021].

We recommend that AMD patients who are taking aspirin on the instruction of their general practitioner should continue to do so. Close monitoring of the maculae is advisable in cases of moderate and advanced AMD. Patients should always consult their general practitioner before starting aspirin use.

• What is the macula?

The macula is a small area (5mm in size) located in the very central part of the back of the eye (the retina). The macula contains a higher concentration of photoreceptors (cells that absorb light and transfer the information to the brain for visual interpretation) than the rest of the retina.

The macula is responsible for providing sharp central vision as well as recognition of colours. We use our macula for all “straight-ahead” tasks such as driving, reading and recognising faces. The rest of the retina is used in peripheral, or side, vision.

• Who is at risk of AMD?

Anyone can develop macular degeneration, but several factors place you at greater-than-average risk:

Controllable risk factors for AMD:

• Smoking: smokers have a 6x greater risk of developing AMD
• Nutrition: diets high in lutein and omega-3 fatty acids (fish) can reduce the risk of AMD
• Obesity: being severely overweight increases the chances of early AMD progressing to severe AMD
• Cardiovascular Disease/High Blood Pressure
• Sun Exposure: excessive UV exposure increases the risk of AMD¹⁸American Macular Degeneration Foundation. 2021. Risk Factors for Macular Degeneration – AMDF. [online] Available at: <https://www.macular.org/risk-factors#:~:text=While%20the%20causes%20of%20age,a%20person’s%20risk%20for%20AMD.> [Accessed 24 June 2021].

Uncontrollable risk factors for AMD:

• Age
• Genetics: specific genes have been associated with increased AMD risk. The risk of developing late-stage AMD is 4x higher for people with a family history of AMD.
• Gender: females are more at risk of AMD than males
• Light skin/eye colour: people with fair complexions are more at risk of AMD than those with darker-skinned individuals
• High long-sightedness¹⁹BrightFocus Foundation. 2021. Macular Degeneration: Prevention & Risk Factors. [online] Available at: <https://www.brightfocus.org/macular/prevention-and-risk-factors> [Accessed 24 June 2021].

• Living with AMD – What do I need to be aware of?

Driving

• Check with your doctor if driving is still safe and legal
• Abide by restrictions (e.g. you may be advised to avoid driving at night/in bad weather)
• Use public transportation, local area transport services or volunteer driving networks where possible
• Ask family members and friends to help with transport

Home and leisure

• Ensure your spectacles contain the best possible prescription
• Read large print books, magazines and newspapers; or use an e-reader such as a Kindle which can magnify and alter the contrast of print
• Ensure there is plenty of light when reading
• Magnify print on the computer
• Use specialised hand and stand magnifiers*
• Obtain specialised appliances with large numbers and displays (e.g. clock faces and telephone number pads)*
• Remove hazards at home that may cause falls or injuries*
  *see below for support networks who can offer/organise these services

Social support

• Ask family and friends for help and support
• Ask OKKO staff for help accessing and applying for services
• Take advantage of community and online networks that can offer support and resources for people with AMD
• Vision Australia: 37 Kent St, WOOLLOONGABBA QLD 4102
  Ph: 1300 847 46
  Site: www.visionaustralia.org.au
• LifeTec QLD: Level 1 Reading Newmarket, Newmarket Rd,
  NEWMARKET QLD 4051
  Ph: 1300 885 886
  Site: www.lifetec.org.au
• Macular Degeneration Foundation:
  Ph: 1800 111 709
  Site: www.mdfoundation.com.au

Macular degeneration treatment FAQs

What treatments are available for dry AMD?

There is currently no cure for dry AMD, and once vision has been lost it cannot be restored. Lifestyle and dietary changes may help prevent early dry AMD:

• Eating a well-balanced diet (incorporate green leafy vegetables daily and fish two to three times a week)
• Maintaining a healthy weight and blood pressure
• Exercising regularly
• Stop smoking²⁰BrightFocus Foundation. 2021. Healthy Living. [online] Available at: <https://www.brightfocus.org/macular/diet-and-exercise> [Accessed 24 June 2021].

For moderate and advanced dry AMD, treatment with antioxidant supplements can slow and/or prevent vision loss. The Age-Related Eye Disease Study (AREDS) found that specific high-dose formulations of antioxidant vitamins such as Macuvision significantly reduced the risk of AMD progression and vision loss in high-risk patients. Lutein supplements (e.g. Lutein Vision) also have protective effects on the macula. These tablets will not restore vision that has already been lost and does not benefit those with no or mild AMD.

Macutec is an AREDS formulation that also incorporates lutein, zinc and omega-3 fatty acids (fish oil). Taken three times a day, it contains:

• 500mg Vitamin C
• 400iu Vitamin E
• 50mg zinc oxide
• 10mg lutein
• 2mg zeaxanthin
• 1666mg omega-3

You should discuss taking antioxidant vitamins with your general practitioner before you start taking the tablets. This is particularly important if you take other medications or have other medical conditions. Side effects from AREDS supplements are uncommon but can occur, as with any medical treatment.

These include:

• A small risk of urinary conditions (primarily urinary obstruction related to prostate enlargement) – consult your general practitioner or urologist before starting treatment
• Nausea
• Indigestion
• Skin rash

AREDS vitamins are not known to increase the risk of serious conditions such as heart attack, stroke or cancer.

What treatments are available for wet AMD?

The current treatment for wet AMD is anti-VEGF therapy. VEGF is the chemical in the body responsible for the formation of abnormal leaky vessels in wet AMD. There are several anti-VEGF drugs currently available, including Eylea, Lucentis and Avastin.²¹Healthline. 2021. Anti-VEGF Injection: Success Rates for AMD. [online] Available at: <https://www.healthline.com/health/eye-health/anti-vegf-injection-success-rates-for-amd> [Accessed 24 June 2021].

Anti-VEGF agents are injected into the eye after it has been numbed with a local anaesthetic. Three injections are initially required to stabilise the wet AMD. After this, you will need 4 to 12 weeks of injections after that to maintain vision.

Anti-VEGF treatment can stabilise and prevent further vision decline in 90% of patients. It may even result in an improvement in vision in 40% of patients²²Clearkin L, Ramasamy B, Wason J, et alAnti-VEGF intervention in neovascular AMD: benefits and risks restated as natural frequenciesBMJ Open Ophthalmology 2019;4:e000257. doi: 10.1136/bmjophth-2018-000257

However, wet AMD may sometimes continue to progress despite treatment.

How is AMD detected?

An eye examination and regular macula screening with your eye care practitioner will allow early signs of AMD to be detected. Testing may include:

Visual acuity: a measurement of vision on a letter chart
Amsler grid: assessment of central distortion such as faded, broken or wavy lines
Retinal examination: We will usually dilate your pupils and examine your macula. There will often be small yellow spots at the macula (drusen) which represent the accumulation of metabolic waste products.

Optical Coherence Tomography (OCT)

Optical coherence tomography (OCT) allows non-invasive imaging of the macula in cross-section. It can identify areas of macular thickening or thinning, and detect the presence of abnormal blood and fluid under the macula, as seen in wet AMD. OCT is also helpful in monitoring the response of wet AMD to treatment.

Recent improvements to our OCT technology mean that we are now able to perform OCT Angiography. This allows visualisation of the blood vessels within the macula by tracking the movement of blood cells flowing through the vessels down to the capillary level. This allows for earlier identification of AMD. This technology is relatively new and further advancing the way we can diagnose retinal conditions.

In some instances, you may still need a traditional fluorescein angiography. In fluorescein angiography, we inject fluorescein dye into a vein in the arm or hand which then travels through the blood vessels to the back of the eye. A series of photographs are taken as the dye flows through these vessels within the retina. The abnormal leaky blood vessels that form in wet AMD will appear as a white patch. Fluorescein angiography can help with diagnosing or excluding wet AMD, and it will also detect subtle changes in macular pigment due to dry AMD changes.