Age Related Macular Degeneration. V Singh S Sivaprasad

Transcription

1 Age Related Macular Degeneration V Singh S Sivaprasad

2 Why ARMD leading cause of legal blindness in the elderly in the Western world and its financial impact (¼ of million in UK Blind due to ARMD) development of co morbidities such as depression Rapid changing diagnostic and treatment modalities (26000 pts with wet ARMD eligible for treatment each year)

3 Overview Anatomy & Physiology of the macula Histopathology of ARMD Epidemiology, Classification Progression, Treatment of AMD Advance topics Diagnostic techniques Latest Treatment options

4 Landmarks

5 Landmarks

6 Histopathology Drusen Deposition between RPE & Bruch membrane Failure to clear the debris With Age size and number

7 Drusen Hard Drusen Soft Drusen Coalescence Calcified

8 ARM Classification (Age Related Maculopathy International classification) Early ARMD Soft drusen Areas of pigment or hyperpigmentation with drusen Areas of depigmentation or hypopigmentation retinal pigment epithelium (RPE) Late ARMD Geographical atrophy Neovascular, Wet, Disciform or Exudative AMD

9 AREDS Classification (Age Related Eye Disease Study) No AMD None or few drusen Early multiple small, few intermediate drusen or RPE abn. Intermediate extensive drusen or geographical atrophy not centre Advance GA including fovea or features of neovascular Points from AREDS High dose multivitamins & antioxidant risk progression in high risk AMD pts High risk AMD Visual loss in fellow eye by AMD (Late AMD) Confluent soft drusen & pigmentary changes even with no visual loss

10 500mg Vit C 400IU Vit E 15mg Beta carotene 80mg Zn, 2mg Copper AERDS 2 Luetin& Zeaxanthin

11 Diagnosis & Progression Geographical Atrophy (Dry) atrophy of photoreceptors, RPE Presentation gradual loss of vision difficulty reading small prints Signs

12

13 Neovascular ARMD (Wet) Central visual blurring Distortion Subretinal or sub RPE neovascularisation Serous detachment of the neurosensory retina RPE detachment Haemorrhages subretinal pigment epithelial, subretinal, intraretinal or preretinal. Breakthrough bleeding into the vitreous may also occur Scar RAP

14

15

16 Atypical Neovascular AMD Idiopathic Polypoidal Choroidopathy Exudative lesion with Hemorrhagic PED Originally described in middle age black population Association with Hypertension and IHD Seen in > 1/3 elderly in asian 8 13% in caucasians Diagnosis FFA, ICG

17 Retinal Imaging & Updates Fundus Photograph Fundus Fluorescein angiography (FFA) Indocyanine green (ICG) angiography OCT Early OCT resolution 30 microns Then 10 to 15 microns Now 5 to 10 microns with scan /minute

18 OCT Drusen

19

20 OCT PED

21 OCT Neovascular AMD

22 Sick eyes may occur in sick bodies related to smoking, obesity Inadequate nutrient uptake and other unhealthy behaviour

23 Risk Factors Tobacco smoking 2 to 3 fold risk of AMD main modifiable risk for AMD Alcohol intake oxidative damage and damage to organs increased risk for Early AMD Diet & Nutrition antioxidant do reduce risk to late AMD Beta carotene risk of lung cancer Vit E risk of Heart failure Polyunsaturated fatty acids (Omega 3 fatty acid) reduces risk AERDS 2 evaluating Obesity association with AMD not consistent

24 Medical Risk factors Hypertension may increase the risk for AMD Coronary & Vascular Disease inconsistent association with AMD Genetic Factors Complement cascade Sunlight UVA & UVB

25 Therapies for acute neovascular AMD Laser photocoagulation Photodynamic therapy with Verteporfin Anti angiogenic therapy Pegaptanib sodium (Macugen) Binds and blocks VEGF A but only certain isoform Licensed in UK for AMD

26 Latest Therapies Ranibizumab (Lucentis) Humanised Fabfragment Blocks all isoforms of VEGF A intravitreal injection on a 4 weekly basis Licensed in USA, Europe & UK Bevacizumab (Avastin) Half life longer humanised full length antibody Binds all isoform but different affinity Head to Head UK (IVAN Study), USA (CATT Study).

27 Treatment Indications Active subfoveal neovascularisation Progression BCVA > 6/96 (LogMar1.2 or 24 ETDRS letters) There should be no significant permanent structural damage to the fovea disciform, fibrosis Further Management Low Visual Aid Hallucinations Charles Bonnet Syndrome (CBS).

28 AMD Pathway The Patient Self Referral GP Optician/Optometrist/ Eye Casualty Ideals to aim for: t = <1 week from optometrist to Fast Track Clinic t = <1 week from Fast Track Clinic to treatment

29 References 1 AGE RELATED MACULAR DEGENERATION Jack J Kanski, 6 th Edition 2 Age Related Macular Degeneration 2009 Guidelines for Management, Royal College of Ophthalmologists 3 Age Related Eye Disease Study Research Group. The Age Related Eye Disease Study system for classifying age related macular degeneration from stereoscopic color fundus photographs: the Age Related Eye Disease Study Report Number 6. Am J Ophthalmol Nov;132(5): The Natural History and Prognosis of Neovascular Age Related Macular Degeneration: A Systematic Review of the Literature and Meta analysis, Volume 115, Issue 1, Pages e1 (January 2008), Ophthalmology 5 Ferris FL, Davis MD, Clemons TE, Lee LY, Chew EY, Lindblad AS, Milton RC,Bressler SB, Klein R; Age Related Eye Disease Study (AREDS) Research Group. A simplified severity scale for age related macular degeneration: AREDS Report No. 18. Arch Ophthalmol Nov;123(11):