Applied Evidence

Age-related macular degeneration: Options for earlier detection and improved treatment

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References

Conventional thermal laser therapy directly coagulates the neovascular area. The Macular Photocoagulation Study showed that thermal laser therapy reduced the likelihood of losing 3 to 6 lines of vision (for example, going from 20/20 to 20/70) after 2 years of follow-up (SOR: A; LOE: 1, RCT).18 Conventional laser therapy requires retreatment less often than photodynamic therapy. However, it is applicable only to certain subtypes of wet ARMD and may immediately cause vision loss if used too close to the center of the macula.

Surgery usually not recommended

Surgical removal of neovascular tissue in wet ARMD has succeeded anatomically but has not yielded consistent results in protecting vision. Using microsurgical instruments, the surgeon can separate the macula from the retinal pigment epithelium and remove the neovascular tissue through a small incision in the retina. Though the Submacular Surgery Trials did find a subset of patients who benefited from this procedure, overall results did not support the use of this surgery (SOR: A; LOE: 1, RCT).19

Pegaptanib injections show promise

The newest treatment for wet ARMD is pegaptanib (Macugen). Pegaptanib is a macromolecule designed specifically to bind to VEGF165 isoform, thus blocking its angiogenic and permeability enhancing activity. It is injected directly into the vitreous cavity of patients with wet ARMD. Study results have encouragingly shown a significant reduction in moderate and severe visual loss at 12 months of follow-up (SOR: A; LOE: 1, RCT).20

Measures for wet and dry macular degeneration

Smoking cessation most important lifestyle change

Of all the treatment options for patients with wet or dry ARMD, the most effective means of preserving vision is smoking cessation. As mentioned, controlling blood pressure is also an important modifiable risk factor. Lowering cholesterol or decreasing body mass index may help prevent vision loss, but the literature does not consistently support these claims.

Counseling

Instruct patients with ARMD of either type on how to use the Amsler grid at home. They should understand that any changes on the grid should prompt a call to their ophthalmologist.

Patients with dry ARMD should understand that while the disease is progressive, it does so very slowly.

Patients with wet ARMD and those with end-stage dry ARMD should be counseled that, unless another ocular disease is present, they will not go blind. They can maintain normal peripheral vision. If their central vision is 20/200 or worse in the better eye with glasses, they are considered “legally blind” (in most states) and may qualify for certain disability help.

Low-vision aids

Even in the most advanced cases of ARMD, patients must never be told that nothing more can be done. Low-vision devices are available to aid and restore the functional needs of patients. These range from simple handheld magnifiers to closed-circuit television scanners. Inquire of your local ophthalmologist if he or she incorporates low-vision aid training into his practice. If not, it may be necessary to refer to a low-vision clinic at a larger institution.

Acknowledgments

This work was supported in part by unrestricted grants from Research to Prevent Blindness and the Pat & Willard Walker Eye Research Center.

CORRESPONDENCE
Michael N. Wiggins, MD, Jones Eye Institute, University of Arkansas for Medical Sciences, 4301 West Markham St. Slot 523, Little Rock, AR 72205-7199. E-mail: wigginsmichael@uams.edu

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