Eye Care Specialist SC


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What is Macular Degeneration (AMD)?

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The function of your eye can be compared to the workings of a camera. Just as the camera focuses light rays onto film to register a picture, the lens of your eye focuses light onto your retina to form an image. The retina is a thin layer of tissue in the back of the eye. Specialized cells in the retina convert light into electrical impulses, which are then transmitted to the brain. If the film in your camera is defective, you will not get a perfect picture. Similarly, abnormalities of the retina will affect how well you can see.

Age-related macular degeneration (AMD) is an eye disease in which the specialized area of the retina responsible for sharp central vision and color discrimination (called the "macula") is damaged. Despite its small size (about that of a printed letter "O"), the macula is 100 times more sensitive to detail than the rest of your retina. As a result, macular degeneration sufferers often can no longer distinguish faces, clocks, printed words, street signs, or other objects located straight ahead in the center of their field of vision.

Since images outside of the blurred area are often still visible, macular degeneration may result in legal (less than 20/200 vision), but not total blindness. People are usually able to perform most of their daily activities and take care of themselves by using their remaining side (or "peripheral") vision.

More than 13 million Americans age 40 and older have some signs of age-related macular degeneration (AMD), and up to two million have the more advanced, vision-threatening stages of the disease. AMD is a leading cause of blindness in people over age 50. The greatest risk factor is age. AMD affects 11 percent of Caucasians ages 65 to 74, and 28 percent of Caucasians age 75 and older. This "epidemic" is a major concern because, as our population ages, the number of people with AMD is expected to double by the year 2030.

Types of AMD

Macular degeneration often starts with the appearance of drusen, yellowish-white deposits beneath the retina caused by the buildup of retinal waste products. The drusen themselves usually do not affect vision and are frequently found with aging (similar to age spots on the skin). However, if drusen are numerous and appear in the center of the macula, they can lead to progressive deterioration, including the development of severe macular degeneration. The main types of AMD are:

Dry Macular Degeneration

The overwhelming majority of AMD cases (about 90 percent) are associated with the aging process and are called “dry” AMD. This more common form is caused by a breakdown or thinning (atrophy) of the tissues in the macula, which leads to a loss of vision cells. As a result, objects appear washed out or difficult to see. Fortunately, most "dry" cases are not associated with severe visual loss.

Wet Macular Degeneration

About 10 percent of AMD falls into a category called "wet" AMD. This more severe form is marked by the growth of new abnormal blood vessels under the macula, which can leak fluid and blood. This leakage may create scar tissue, resulting in a blind spot that causes a rapid and profound loss of sharp central vision. "Wet" macular degeneration is less common than other forms but, of all patients legally blind from AMD, the majority have this type. The earlier it is detected, the better the chances for preserving vision.

Other Forms of Macular Degeneration

Less common reasons for damage to the macula include injury, infection, inflammation, marked nearsightedness, hereditary factors and drug toxicity.

Risk Factors for AMD

Researchers are not certain what causes the changes in the macula that lead to AMD. However, known risk factors include:

Symptoms Associated With AMD

Macular degeneration usually develops gradually and painlessly. It can cause different symptoms in different people. If only one eye is affected, AMD may be difficult to detect in its early stages. Good vision in one eye can often mask visual difficulty in the other eye. As the condition progresses, however, a number of symptoms may become more obvious, including:

If you suddenly notice any of these symptoms, you should see an eye care specialist as soon as possible. Do not assume you simply need a new pair of glasses and then wait to make an appointment for the future.

Macular degeneration normal vision Macular degeneration damaged vision

Self-Testing for Early Warning Signs

You can test for early warning signs of macular degeneration with a simple, inexpensive and effective screening tool called the Amsler Grid. A normal, healthy eye sees the grid pattern (shown below) in its entirety, without distortion. An eye with AMD, however, may see the lines as distorted or bowing, have a shadowy spot at the point of focus, or have entire areas that are missing. Patients diagnosed with AMD should do this test daily. This is especially important for prompt detection and treatment of cases where dry AMD changes into the more severe wet AMD.

People diagnosed with macular degeneration should do this test daily or at least several times a week. This is especially important for detecting and treating cases where the dry type of macular degeneration changes into the more severe wet type.

How to Use the Amsler Grid

Amsler grid
  1. View the grid from 12 to 16 inches away—either held at a comfortable reading distance or taped to a well-lit wall, refrigerator or cabinet door.
  2. If you normally wear glasses for reading, use them. If they are bifocals, look through the bottom (reading portion) of the lens.
  3. Cover your left eye (without pressing on it). Look at the center dot with your right eye. Do not move your gaze from the dot.
  4. While focusing on the center dot, note if all the lines are straight and squares the same size. Check for any distortion, blurriness, discoloration or other abnormalities.
  5. Repeat the test, covering your right eye and checking your left eye’s vision.

If you notice any problems or changes, contact your eye care specialist immediately.

Diagnosis of AMD

A complete eye examination is necessary to evaluate the presence, type and severity of AMD and to determine whether treatment would be beneficial. At Eye Care Specialists, the following instruments and tests may be used.

Dr. Freeman eye examination Ophthalmoscope:  This instrument is used to look through the pupil and light up the back of the eye to check the health of your optic nerve and retina for any abnormal conditions, such as AMD or retinal detachment.

Slit Lamp:  With this special microscope, we can see inside your eye to evaluate its overall health. By using a special lens with the slit lamp, we are able to conduct a detailed examination of the macula.

Amsler Grid test:  This self-test (see above) helps to detect subtle and early changes in your vision that may be caused by AMD.

OCT Scan:  A fast, non-invasive and painless scanning test (similar in concept to a CT scan of the inside of the eye) that enables us to determine how and when to treat wet AMD by mapping areas of fluid shrinkage and drying.

Treatment of AMD

Dry Macular Degeneration

Currently, treatment for this more common type of AMD primarily involves measures (see below) to prevent or slow its progression, including the intake of specific vitamins and the avoidance of certain risk factors (most importantly, not smoking). Because dry AMD usually does not result in rapid vision loss, many patients retain good sight throughout their lives. Some people, however, experience a significant loss of central vision over time. These patients usually benefit from magnifiers and other low vision aids.

Wet Macular Degeneration

For years, there were no treatment options for this less common, but more severe, form of AMD. Now, however, we are able to offer wet AMD patients (if their visual condition qualifies) revolutionary treatment involving injections of special medications, such as Avastin, Eylea or Lucentis.

What are the possible benefits of medication injection treatment?
Although there are NO guarantees, we have seen remarkable results with injection treatment, including not only slowing or stopping the progression of wet AMD, but significantly reversing deterioration and improving vision. Clinical trials and our own results have demonstrated that, if wet AMD is treated promptly after its occurrence, 90 percent of patients experience stabilization of vision, and up to 30 percent gain improvement in vision. (Injection treatment is also successfully used to treat diabetes-related eye disease.)

How do these medications work?
They inhibit the growth of the abnormal blood vessels that cause wet AMD as well as treat swelling of the macula due to wet AMD.

What is the goal of injection treatment?
The goal is to prevent further loss of vision. Most AMD patients treated with these medications have more normal-appearing maculas with less fluid and improvement in the quality of their vision. Although some patients regain some vision, there are no guarantees that medication injection treatment will restore lost vision or prevent further loss.

How are the medications given?
After the eye is numbed with drops, the medication is painlessly injected into the vitreous (jelly-like substance inside the eye). The patient is then free to leave and resume activities.

How often do you need injections?
To achieve the best possible benefit, injections must be administered every 4-12 weeks. Your eye care specialist will evaluate your response to determine the frequency and duration of your treatment.

Are there any risks or side effects?
As with any medication or procedure there are possible risks and side effects. Prior to treatment, these issues will be reviewed with your doctor and described in detail in an “Informed Consent” form.

Are there any alternative treatments?
At present, there are several FDA-approved treatments for wet (neovascular) AMD, including photodynamic therapy with the drug Visudyne and eye injections with Macugen. Although these treatment options have proven to slow the rate of visual loss, most people do not get back better vision. (In clinical studies, Avastin, Eylea and Lucentis have proven far more effective than other treatments in preserving and improving vision for patients with AMD.)

On the horizon. . .

Research continues in the areas of embryonic cell transplantation and implantation of tiny telescopes or bionic cameras. It is hoped that in 5-15 years, these or other treatments will effectively help all AMD patients.

Reducing Vision Loss with Vitamins & Supplements

In 2001, results were reported from the National Eye Institute Age-Related Eye Disease Study (AREDS), which found that high-dose antioxidant vitamins and minerals, taken orally, reduced the risk of progression to advanced AMD by 25 percent, and the risk of moderate vision loss by 19 percent. Although the AREDS vitamin did not improve vision or cure AMD, it provided definitive proof that nutritional supplements can protect and preserve vision for certain patients.

Due to the success of AREDS, a second nationwide clinical trial was launched. The AREDS2 study refined the original findings by adding lutein and zeaxanthin (plant-derived yellow pigments that accumulate in the macula, the small area of the retina responsible for central vision) and evaluated the effect of omega-3 fatty acids DHA and EPA (derived from fish oils). Results of the AREDS2 study showed that a specific combination of nutritional supplements (vitamins C & E, zinc, copper, Lutein and zeaxanthin) successfully reduced the progression of significant dry AMD by 25 percent. In addition, this supplement was well-tolerated and safer than other formulations. As such, we strongly encourage the use of AREDS2 vitamins for our patients with significant AMD.

Should I take these nutrients?
While repeated studies have shown a benefit for people with significant AMD, there has not been good evidence to support nutrient supplementation in healthy people with minimal or no AMD. Therefore, it is important to seek the advice of a qualified eye care specialist before purchasing these (not inexpensive) products. Upon careful dilated examination, your doctor can determine if you have AMD, how advanced your condition is, and whether or not you will benefit from using a supplement.

Where can I find these supplements?
AREDS2 eye vitamins are sold over-the-counter as tablets and soft gels at pharmacies and retail stores (Walgreens, Target, Walmart, etc.).

What if I already take a multivitamin?
Multivitamins and/or diet alone can't achieve the high levels of nutrients in the studies.
Most AREDS participants took both a multivitamin and the supplement.

What are the potential side effects?
The thousands of AREDS participants aged 55-80 reported few, if any, side effects. Typically, stomach upset (which went away upon stopping the supplement) was the most common problem.

Should I be cautious about using these nutrients and doses?
Yes. Many people, especially older adults, use a variety of prescription medications, over-the-counter drugs, dietary supplements and herbal medicines. High-dose vitamins and minerals like the AREDS2 formulation can interfere with these medications or decrease the absorption of other nutrients in the body—ultimately affecting a person's health and nutritional status.

Because of the vitamin E in the AREDS2 formula, people taking blood thinners should be cautious about using these supplements. Generally, the high doses of vitamins and minerals in the AREDS2 formula may not be recommended for people with liver and/or kidney disease.

If you plan to take eye-related nutrients, discuss your ideas (and whatever else you take) with your doctor, eye care specialist and/or pharmacist to determine which formulation and dosages are best for you.

Tips for Protecting Your Vision

The following measures may help you to "see" life to the fullest:

Resources for Leading a Relatively Normal Life

Losing sight to AMD does not inevitably mean losing your way of life. By using their remaining side vision, along with a variety of coping techniques and tools, most people are able to lead independent, productive lives pursuing their goals and interests. The key is to reach out and take advantage of the many resources that are available, including the support of friends and family.

Our office can suggest where to obtain special lamps, magnifiers, eyeglasses, large-print publications and other aids. We also have access to a new, lighted magnifying device that can plug into your TV to enlarge words on a medicine bottle, magazine pages, or anything else you wish to show on your screen.

We also strongly urge you to contact the following organizations for counseling; needs assessment; low vision aids; and help with obtaining Social Security/veterans benefits, income tax exemptions, and handicapped parking designations or transportation services. Some groups even offer in-home visits to show you ways to make tasks easier and safer.

The most satisfied patients are those who are educated, active partners in their own care. As such, we encourage you to ask questions and stay abreast of new developments that may improve or protect your vision. And, we remind you that keeping your eye appointments is essential to ensuring that you have every opportunity to see life to the fullest.

Help is just a call or click away at:

Vision Forward Association
912 N. Hawley Rd.
Milwaukee, WI 53213
(Offers information, products, local resources, etc.)

Adaptive Technology Resources (ATR)
1350 14th Ave., Suite 3
Grafton, WI 53024
(Offers in-home evaluation/consultation for products)

Prevent Blindness--Wisconsin Chapter
759 N. Milwaukee St.
Milwaukee, WI 53202
(Offers information, event listings, program and service listings, etc.)

State of Wisconsin Office for the Blind & Visually Impaired
414-302-2763 (if you live north of I-94)
262-859-0100 (if you live south of I-94)
(In addition to making home visits, this organization sets up local support groups)

American Foundation for the Blind
(Offers information, adaptation tips, books and guides)

American Macular Degeneration Foundation (AMDF)
888-MACULAR (888-622-8527)
(Offers information, research updates, books, videos, etc.)

The National Eye Institute
(Offers information, AREDS nutrition study Q&As, research news, etc.)

For more information or a comprehensive examination . . .

Since 1985, Eye Care Specialists has provided comprehensive medical, surgical and laser care for virtually every eye condition to more than 130,000 people in southeastern Wisconsin. If you would like detailed booklets/handouts on the information contained in this section or other eye-related topics, please contact our Communications & Education Department at 414-321-7035. To schedule a comprehensive eye evaluation, call one of our three convenient Milwaukee-area locations directly.