Introduction

It is normal for our vision to gradually get worse with age. But some older people also have medical conditions that further affect their vision or may even lead to blindness. One common cause of worsening vision is known as age-related macular degeneration (AMD).

AMD is a chronic condition that usually affects both eyes and is caused by an underlying metabolic disorder. It develops in the macula – an area at the back of the eye that is especially important for seeing in focus. But vision loss usually only occurs in advanced AMD. There are two types of this disease:

• Dry AMD: This type of AMD tends to develop more slowly. There are currently no effective treatments for dry AMD.
• Wet AMD: This leads to faster vision loss, but there are effective treatments.

At a glance

• Age-related macular degeneration (AMD) is a chronic eye disease.
• It becomes increasingly common in older age.
• AMD causes gradual loss of vision in the part of the eye that allows us to see fine detail.
• There are two kinds of AMD, known as “dry” and “wet” AMD.
• Wet AMD leads to faster vision loss, but can be treated effectively.
• The treatment usually involves injecting medication into the eye.

Symptoms

Macular degeneration causes the gradual loss of vision in the part of the eye that allows us to see fine detail. This area is at the center of the retina lining the back of the eye. It takes its full Latin name from its yellowish color (“macula lutea,” meaning “yellow spot”). We need this “central vision” to do things like read, drive a car or recognize faces.

Central vision loss makes things appear blurry or distorted, particularly when you look at them directly. In advanced AMD, people can no longer see them at all. Although you can usually still see objects towards the edge of your field of vision, it's difficult to tell what they are.

Typical loss of vision caused by advanced AMD

Causes and risk factors

Age-related macular degeneration is caused by a metabolic disorder affecting the retina (the lining inside the eye). This leads to the release of waste products that are usually broken down by the body. But in some people, small deposits called drusen start to form. These deposits prevent enough oxygen and nutrients from reaching the retina.

In the dry form of AMD, this gradually causes the light-sensitive cells in the retina to die off. The pigments underneath the retina may also change. This is a sign of AMD that doctors can see when they examine your eye.

In wet macular degeneration, new blood vessels start growing underneath the retina as a reaction to the deposits. They grow into the retina and may lift it up. The new blood vessels may become “leaky,” allowing blood and fluid to seep into the retina, damaging the cells there.

Left: Structure of the eye, Right: Growth of new blood vessels

Your individual risk of developing AMD is somewhat greater if close relatives already have AMD. AMD is also more common in people who smoke, and they tend to get it at younger ages than non-smokers do.

Prevalence

In industrialized countries, macular degeneration is the most common cause of severe vision loss in older people.

It becomes increasingly common in older age: About 1 out of 100 people between the ages of 65 and 75 have age-related macular degeneration, and as many as 10 to 20 out of 100 people over the age of 85 are affected. Dry AMD is more common than wet AMD.

Outlook

The course of AMD is different in different people. There are three stages:

• Early-stage AMD: Medium-sized drusen deposits and no pigment changes, no loss of vision.
• Intermediate AMD: Large drusen and/or pigment changes. There may be mild vision loss, but most people don’t experience any problems.
• Late-stage AMD: Dry or wet macular degeneration that causes vision loss.

The time it takes for the disease to progress to late-stage AMD depends on various factors, including the size of the deposits in the retina:

• About 1 to 3 out of 100 people with small drusen experience vision problems within five years,
• compared to about 50 out of 100 people who have larger drusen.

Dry AMD generally worsens much more slowly than wet AMD does, and it is also less likely to lead to vision loss. Dry AMD can turn into wet AMD, though.

Most people with advanced AMD have the wet form of the condition. Wet AMD quickly worsens if left untreated, but can be stopped or slowed down by various treatments.

AMD doesn’t usually lead to complete blindness. Even at a very advanced stage of AMD in both eyes, it is usually still possible to find your way around. But the overall vision loss can be so severe that it meets the legal definition of “blindness,” for which the German health care system provides monthly disability benefits.

Diagnosis

The eye doctor will first ask about the symptoms and any other medical conditions. Then your eyes will be closely examined using a microscope with a light on it, called a slit lamp, to look at the front and middle sections of the inside of your eye. The fundus (the back of the inside of your eye) is also checked. Before the examination, eye drops are used to dilate (open) your pupils. Various types of tests can help to get an idea of how much your central vision has been affected.

Other tests can confirm the diagnosis and help to plan treatment. If the doctor thinks you have wet AMD, an examination called fluorescein angiography of the retina can be used to check whether that is true. This involves injecting a harmless dye solution into a vein in your arm. The solution is carried to the blood vessels in the retina. A special camera can then be used to detect changes in these vessels.

Another test that might be done is known as optical coherence tomography (OCT). OCT uses a laser to measure things like the thickness of the retina, as well as to detect any fluid-filled pockets. Doctors can use OCT to check on how the disease is changing over time and then adjust the treatment.

Prevention

People who don’t smoke are less likely to develop macular degeneration.

Some dietary supplements, e.g. containing beta-carotene, vitamins, zinc, omega-3 fatty acids or Ginkgo biloba, are marketed as treatments that can prevent AMD. But there is no evidence that they have a preventive effect.

Treatment

The following treatment options are available for wet AMD:

• Medications: This is the main treatment approach. The medications are injected into the eye to slow the growth of new blood vessels. They are called VEGF (vascular endothelial growth factor) inhibitors or anti-VEGF medications. Although this treatment can’t cure the disease, it can stop or at least slow down the progression. Sometimes vision even improves again during treatment.
• Photodynamic therapy: This involves treating the new blood vessels with a combination of medication and special laser light. Photodynamic therapy is less effective than anti-VEGF therapy, and it doesn't have any additional advantages. It is only rarely used nowadays.
• Laser therapy: This treatment involves heating and destroying abnormal blood vessels with laser beams. It is only rarely used for the treatment of wet AMD. It is less effective and has more side effects than anti-VEGF therapy.
• Surgery: In some exceptional cases – and if no other treatment has helped – abnormal blood vessels can be removed surgically.

Dietary supplements containing a combination of certain ingredients (vitamin C, vitamin E, zinc, copper, and lutein with zeaxanthin or beta-carotene) may be able to slow the progression of the disease in people who have large drusen deposits. These people are at greater risk of developing vision problems.

There is currently no effective treatment for dry macular degeneration.

Further information

When people are ill or need medical advice, they usually go to see their family doctor first. Information about health care in Germany can help you to navigate the German health care system and find a suitable doctor. You can use this list of questions to prepare for your appointment.

Sources

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