Age-Related Macular Degeneration
Age-related macular degeneration, often called AMD or ARMD, is the leading cause of vision loss and blindness among Americans who are age 65 and older. Because people in this group are an increasingly larger percentage of the general population, vision loss from macular degeneration is a growing problem.
AMD is degeneration of the macula, which is the part of the retina responsible for the sharp, central vision needed to read or drive. Because the macula primarily is affected in AMD, central vision loss may occur.
About 1.75 million U.S. residents currently have advanced age-related macular degeneration with associated vision loss, with that number expected to grow to almost 3 million by 2020.*
Wet and Dry Forms of Macular Degeneration
Macular degeneration is diagnosed as either dry (non-neovascular) or wet (neovascular). Neovascular refers to growth of new blood vessels in an area, such as the macula, where they are not supposed to be.
The dry form is more common than the wet form, with about 85 to 90 percent of AMD patients diagnosed with dry AMD. The wet form of the disease usually leads to more serious vision loss.
Dry Macular Degeneration (non-neovascular). Dry AMD is an early stage of the disease and may result from the aging and thinning of macular tissues, depositing of pigment in the macula or a combination of the two processes.
Dry macular degeneration is diagnosed when yellowish spots known as drusen begin to accumulate in and around the macula. It is believed these spots are deposits or debris from deteriorating tissue.
Gradual central vision loss may occur with dry macular degeneration but usually is not nearly as severe as wet AMD symptoms. However, dry AMD through a period of years slowly can progress to late-stage geographic atrophy (GA) gradual degradation of retinal cells that also can cause severe vision loss.
No FDA-approved treatments are available for dry macular degeneration, although a few now are in clinical trials.
Two large, five-year clinical trials the Age-Related Eye Disease Study (AREDS; 2001) and a follow-up study called AREDS2 (2013) have shown nutritional supplements containing antioxidant vitamins and multivitamins that also contain lutein and zeaxanthin can reduce the risk of dry AMD progressing to sight-threatening wet AMD.
But neither the AREDS nor the AREDS2 study demonstrated any preventive benefit of nutritional supplements against the development of dry AMD in healthy eyes.
Currently, it appears the best way to protect your eyes from developing early (dry) macular degeneration is to eat a healthy diet, exercise and wear sunglasses that protect your eyes from the sun's harmful UV rays and high-energy visible (HEV) radiation.
Wet Macular Degeneration (neovascular). In about 10 percent of cases, dry AMD progresses to the more advanced and damaging form of the eye disease. With wet macular degeneration, new blood vessels grow beneath the retina and leak blood and fluid. This leakage causes permanent damage to light-sensitive retinal cells, which die off and create blind spots in central vision.
Choroidal neovascularization (CNV), the underlying process causing wet AMD and abnormal blood vessel growth, is the body's misguided way of attempting to create a new network of blood vessels to supply more nutrients and oxygen to the eye's retina. Instead, the process creates scarring, leading to sometimes severe central vision loss.
Wet macular degeneration falls into two categories:
- Occult. New blood vessel growth beneath the retina is not as pronounced, and leakage is less evident in the occult CNV form of wet macular degeneration, which typically produces less severe vision loss.
- Classic. When blood vessel growth and scarring have very clear, delineated outlines observed beneath the retina, this type of wet AMD is known as classic CNV, usually producing more severe vision loss.
Age-Related Macular Degeneration Symptoms and Signs
Age-related macular degeneration usually produces a slow, painless loss of vision. In rare cases, however, vision loss can be sudden. Early signs of vision loss from AMD include shadowy areas in your central vision or unusually fuzzy or distorted vision.
An Amsler grid consists of straight lines, with a reference dot in the center. Someone with macular degeneration may see some of the lines as wavy or blurred, with some dark areas at the center.
(If you can't see the illustration above, you may need Flash Player.)
Viewing a chart of black lines arranged in a graph pattern (Amsler grid) is one way to tell if you are having these vision problems. See how an Amsler grid works by taking a macular degeneration test.
Eye care practitioners often detect early signs of macular degeneration before symptoms occur. Usually this is accomplished through a retinal exam. When macular degeneration is suspected, a brief test using an Amsler grid that measures your central vision may be performed.
If your eye doctor detects some defect in your central vision, such as distortion or blurriness, he or she may order a fluorescein angiography to examine the retinal blood vessels surrounding the macula.
What Causes Macular Degeneration?
Though macular degeneration is associated with aging, research suggests there also is a genetic component to the disease. Duke University and other researchers have noted a strong association between development of AMD and presence of a variant of a gene known as complement factor H (CFH). This gene deficiency is associated with almost half of all potentially blinding cases of macular degeneration.
Columbia University Medical Center and other investigators found that variants of another gene, complement factor B, may be involved in development of AMD.
Specific variants of one or both of these genes, which play a role in the body's immune responses, have been found in 74 percent of AMD patients who were studied. Also, variants of complement factor C3 have been associated with increased risk of developing AMD.
Ophthalmology Clinics of North America reported in December 2003 that deteriorating, oxygen-starved cells within the retina likely help trigger neovascularization and accompanying damage in wet AMD. Neovascularization is activated by a protein called vascular endothelial growth factor (VEGF), targeted in macular degeneration treatments by anti-VEGF drugs.
Who Gets Age-Related Macular Degeneration?
Besides affecting older populations, AMD occurs in whites and females in particular. The disease also can result as a side effect of some drugs, and it seems to run in families.
New evidence strongly suggests smoking is high on the list of risk factors for macular degeneration. Other risk factors for macular degeneration include having a family member with AMD, high blood pressure, lighter eye color and obesity.
Some researchers believe that over-exposure to sunlight also may be a contributing factor in development of macular degeneration, but this theory has not been proven conclusively. High levels of dietary fat also may be a risk factor for developing AMD.
Commonly named risk factors for developing macular degeneration include:
Yellowish spots (drusen) that form in the back of the eye or retina are an early sign of "dry" macular degeneration.
"Wet" macular degeneration occurs with formation of abnormal blood vessels and leakage in the back of the eye (retina), affecting the macula where fine focusing occurs.
- Aging. Significant vision loss accompanying more advanced forms of AMD increases from fewer than 1 percent among people in their 60s to more than 15 percent among people in their 90s, according to the Canadian Medical Association Journal (February 2004).
- Obesity and inactivity. Overweight patients with macular degeneration had more than double the risk of developing advanced forms of macular degeneration compared with people of normal body weight, according to one study reported in Archives of Ophthalmology (June 2003). In the same study, those who performed vigorous activity at least three times weekly reduced their risk of developing advanced AMD, compared with inactive patients.
- Heredity. As stated above, recent studies have found that specific variants of different genes are present in most people who have macular degeneration. Studies of fraternal and identical twins may also demonstrate that heredity is a factor in who develops AMD and how severe it becomes.
- High blood pressure (hypertension). Investigative Ophthalmology and Vision Science reported the results of a European study demonstrating that high blood pressure may be associated with development of macular degeneration (September 2003).
- Smoking. Smoking is a major AMD risk factor and was found in one British study to be directly associated with about 25 percent of AMD cases causing severe vision loss. The British Journal of Ophthalmology in early 2006 also reported study findings showing that people living with a smoker double their risk of developing AMD.
- Lighter eye color. Because macular degeneration long has been thought to occur more often among Caucasian populations, particularly in people with light skin color and eye color, some researchers theorized that the extra pigment found in darker eyes was a protective factor against development of the eye disease during sun exposure. But no conclusive evidence as yet has linked excessive sun exposure to development of AMD.
A small study reported in the British Journal of Ophthalmology (January 2006) found no connection between the eye disease and sun exposure. In fact, the same study found no relation at all between lighter eye color, hair color and AMD. That finding is contradicted by several earlier studies indicating that lighter skin and eyes are associated with a greater prevalence of AMD.
- Drug side effects. Some cases of macular degeneration can be induced from side effects of toxic drugs such as Aralen (chloroquine, an anti-malarial drug) or phenothiazine. Phenothiazine is a class of anti-psychotic drugs, including brand names of Thorazine (chlorpromazine, which also is used to treat nausea, vomiting and persistent hiccups), Mellaril (thioridazine), Prolixin (fluphenazine), Trilafon (perphenazine) and Stelazine (trifluoperazine).
The American Academy of Ophthalmology notes that findings regarding AMD and risk factors have been contradictory, depending on the study. The only risk factors consistently found in studies to be associated with the eye disease are aging and smoking.
How Macular Degeneration Is Treated
There is as yet no outright cure for age-related macular degeneration, but some treatments may delay its progression or even improve vision.
Treatments for macular degeneration depend on whether the disease is in its early-stage, dry form or in the more advanced, wet form that can lead to serious vision loss. No FDA-approved treatments exist yet for dry macular degeneration, although nutritional intervention may help prevent its progression to the wet form.
For wet AMD, treatments aimed at stopping abnormal blood vessel growth include FDA-approved drugs called Lucentis, Eylea, Macugen and Visudyne used with Photodynamic Therapy or PDT. Lucentis has been shown to improve vision in a significant number of people with macular degeneration. [For more details, read our article about macular degeneration treatments.]
Nutrition and Macular Degeneration
It's obviously better to prevent the development of macular degeneration than to simply attempt to limit vision loss after the condition appears and worsens. It's very possible that future nutritional studies will provide additional clues about how to prevent AMD from occurring.
Though the AREDS and AREDS2 studies sponsored by the National Eye Institute were primarily designed to determine if nutritional supplements could limit the progression of AMD in individuals already affected by the condition, other research has provided evidence that good nutrition throughout a person's lifetime may have a preventive effect.
For example, some studies have suggested a diet that includes plenty of salmon and other coldwater fish, which contain high amounts of omega-3 fatty acids, may help prevent AMD or reduce the risk of its progression.
Other studies have shown that supplements containing lutein and zeaxanthin increase the density of pigments in the macula that are associated with protecting the eyes from AMD.
Testing and Low Vision Devices for
Age-Related Macular Degeneration Treatment
Although much progress has been made recently in macular degeneration treatment research, complete recovery of vision lost to AMD is unlikely.
Viewing the Amsler grid separately with each eye helps you monitor your vision loss. The Amsler grid is a very sensitive test and it may reveal central vision problems before your eye doctor sees AMD-related damage to the macula in a routine eye exam.
For those who have vision loss from macular degeneration, many low vision devices are available to help with mobility and specific visual tasks.
*The epidemiology of age-related macular degeneration. Archives of Ophthalmology, April 2004.
Age-related macular degeneration. Ophthalmology, 3rd ed. 2009.
Complement C3 variant and the risk of age-related macular degeneration. New England Journal of Medicine. August 2007.
Dietary fat and fish intake and age-related maculopathy. Archives of Ophthalmology. March 2000.
Oily fish consumption, dietary docosahexaenoic acid and eicosapentaenoic acid intakes, and associations with neovascular age-related macular degeneration. American Journal of Clinical Nutrition. August 2008.
Omega-3 long-chain polyunsaturated fatty acid intake and 12-year incidence of neovascular age-related macular degeneration and central geographic atrophy: AREDS report 30, a prospective cohort from the Age-Related Eye Disease Study. American Journal of Clinical Nutrition. December 2009.
Macular pigment response to a supplement containing meso-zeaxanthin, lutein and zeaxanthin. Nutrition & Metabolism. May 2007.
Lutein and zeaxanthin in the diet and serum and their relation to age-related maculopathy in the Third National Health and Nutrition Examination Survey. American Journal of Epidemiology. March 2001.
Associations between intermediate age-related macular degeneration and lutein and zeaxanthin in the Carotenoids in Age-Related Eye Disease Study (CAREDS). Archives of Ophthalmology. August 2006.
Macular pigment and risk for age-related macular degeneration in subjects from a Northern European population. Investigative Ophthalmology and Visual Science. February 2001.
Dietary carotenoids, vitamins C and E, and risk of cataract in women. Archives of Ophthalmology. January 2008.
Associations between age-related nuclear cataract and lutein and zeaxanthin in the diet and serum in the Carotenoids in the Age-Related Eye Disease Study (CAREDS), an ancillary study of the Women's Health Initiative. Archives of Ophthalmology. March 2008.
Healthy diets and the subsequent prevalence of nuclear cataract in women. Archives of Ophthalmology. June 2010.
Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: The Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA. Published online May 2013.
[Page updated August 23, 2013]
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