Understanding Macular Degeneration

Age-related macular degeneration (AMD), also simply called macular degeneration, is an eye condition that can result in severe loss of central vision while sparing the peripheral retina. It affects people over 50 years of age and prevents them from seeing fine details. AMD can lead to severe loss of central vision; however, AMD rarely causes complete blindness.

In early AMD, there may be no signs and symptoms, and the affected person may be unaware that they have an eye condition. In the advanced stages of AMD, affected individuals can lose the ability to drive, read small print, and see faces, which can affect their ability to function in daily life.

Importance of Central Vision

Macular degeneration occurs due to deterioration of the macula, which is the central portion of the retina. The retina is the back layer of the eye that records the images we see and sends them from the eye to the brain via the optic nerve.

The retina’s central portion, known as the macula, focuses central vision in the eye. Central vision is responsible for our ability to read, drive a car, recognize faces and colors, and see objects in fine detail. In people with age-related macular degeneration, cells in the macula slowly break down. This causes affected individuals to develop slow or sudden loss of central vision; however, they typically still have peripheral vision (side vision).

Demographic Impact: AMD Affects People Over 50

Macular degeneration is common in adults aged 50 and over, but there’s a chance that younger adults can develop this incurable eye disease.

According to the National Eye Institute, age-related macular degeneration (AMD) is the leading cause of vision loss (this is not the same as blindness), affecting over 10 million Americans—more than the number of people with cataracts and glaucoma combined.

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Types of Macular Degeneration

There are two different types of age-related macular degeneration (AMD) or maculopathy –“dry” (atrophic) and “wet” (exudative).

Dry Macular Degeneration

The dry form of age-related macular degeneration also called atrophic AMD, accounts for 85% to 95% of cases. There is degeneration of macular cells but no leakage of blood or serum in this type of AMD. Some people have only mild central vision loss, while in others it can be more severe. Geographic atrophy is an irreversible and advanced form of the condition when dry AMD progresses.

Wet Macular Degeneration

Wet age-related macular degeneration is also called neovascular age-related macular degeneration. Wet AMD is characterized by neovascularization or the formation of new blood vessels. These abnormal blood vessels leak fluid or blood into the macula, causing the affected person to lose central vision. The wet form of age-related macular degeneration typically starts off as dry, but symptoms usually appear suddenly and worsen rapidly. The symptoms may include visual distortions, reduced central vision, difficulty recognizing faces, increased blurriness of printed words, and difficulty adjusting to low light levels.

Note: Juvenile macular degeneration is a group of inherited genetic disorders passed from parents to their children. They include Stargardt disease, Best disease, and juvenile retinoschisis. In contrast to age-related macular degeneration, which occurs in older adults, juvenile macular degeneration affects young adults.

Learn about congenital glaucoma.

Stages of Macular Degeneration

Age-related macular degeneration (AMD) is classified into three stages, as follows:

Early AMD: Most people do not experience vision loss in the early stage of AMD. This is why regular eye exams are important, particularly if you have more than one risk factor. Early AMD is diagnosed by the presence of medium-sized drusen (yellow deposits beneath the retina).
Intermediate AMD: At this stage, there may be some vision loss, but there still may not be noticeable symptoms. A comprehensive eye exam with specific tests can identify larger drusen and/or pigment changes in the retina.
Late AMD: At this stage, vision loss becomes noticeable.

Underlying Causes and Risk Factors

The biggest risk factor for macular degeneration is age. As age increases, the risk for this disease increases, and it mostly affects people over the age of 55.

Other risk factors include:

Genetics (people with a family history of AMD are at higher risk).
Race (Caucasians are more likely to develop AMD than African-Americans or Hispanics/Latinos).
Smoking is another big risk factor—those who smoke increase their chances of developing AMD (macular degeneration) by nearly double.
Hypertension or high blood pressure can increase the risk of AMD.
Lifestyle and environmental factors such as a diet rich in saturated fats and lack of exercise.

Recognizing AMD Symptoms

Common Symptoms of AMD

Fuzzy or blurry vision
Distorted vision, such as straight lines appearing wavy
A blind spot (a dark or empty spot) in the central part of the visual field

Warning Signs to Watch For

Trouble driving
Problems with reading fine print
Difficulty recognizing familiar faces
Struggles with performing close-up work
Visual hallucinations or Charles Bonnet syndrome (seeing things that aren’t actually there, such as simple lines and shapes, flashes of light, or more complex objects, people, or animals)

Note: The warning signs and symptoms of age-related macular degeneration can be similar to other eye conditions. Only an eye professional can make a proper diagnosis.

Diagnosis of Macular Degeneration

Eye Exams and Testing Procedures

Age-related macular degeneration is diagnosed based on your symptoms, medical history, eye exam, and eye tests, including:

Visual acuity test: This is the common eye chart test that checks your vision at different distances.
Dilated eye exam: The pupil of the eye is dilated (widened) using eye drops to allow the eye doctor to get a closer look at the retina.
Fluorescein angiography: This test can detect wet AMD. A special dye is injected through a vein in the arm. Pictures of the retina are taken as the dye reaches the retina. This helps the eye doctor see if any of the blood vessels in the retina leak blood and if the leaking is treatable.
Optical coherence tomography (OCT): This is an imaging test that provides detailed images of the retina, the layer of light-sensitive cells in the back of the eye. It allows eye doctors to diagnose age-related macular degeneration in the early stages by showing changes in the retina, such as reduced blood flow, abnormal blood vessels that might leak, or degeneration in the retinal pigment epithelium.
Amsler grid: This is a checkerboard-like grid that you look at with one eye at a time. If the straight lines in the grid appear wavy, blurry, dark, or blank, it might indicate the wet form of age-related macular degeneration.

Note: The presence of tiny yellow deposits in the retina called drusen on eye exam is the most common early sign of age-related macular degeneration. The presence of drusen indicates that the eye is at risk of developing a more severe form of age-related macular degeneration.

Role of Regular Eye Exams in AMD Diagnosis

Many eye conditions, including age-related macular degeneration, cataracts and glaucoma, develop gradually and without causing any noticeable symptoms in the early stages. Regular eye exams can detect the disease process early on and allow timely treatment. This can potentially prevent vision loss related to advanced AMD.

It’s important to get regular eye exams, especially if you’re over the age of 55 and experiencing symptoms such as changes in central vision and/or your ability to see color and fine details.

Treatment Options for AMD

There is currently no cure for AMD, but there are ways to decrease your risk of developing AMD and to slow the progression once you’ve been diagnosed with AMD.

Wet AMD Treatment

Anti-VEGF Drugs

Based on the results of clinical trials, the first line of therapy to treat wet AMD is a group of injectable medications called anti-VEGF (anti-vascular endothelial growth factor) agents. Vascular endothelial growth factor is a protein that signals the body to produce new blood vessels. Anti-VEGF agents block VEGF and slow disease progression. They can help to stabilize or even improve vision in people with wet AMD.

Anti-VEGF drugs are administered by intravitreal injection (directly injected into the affected eye with a very fine needle after the use of anesthetic eye drops). Multiple injections are needed over time for the treatment to be effective.

Examples of anti-VEGF drugs include ranibizumab (Lucentis), aflibercept (Eylea), brolucizumab (Beovu), and pegaptanib (Macugen). In addition, bevacizumab (Avastin) may be used off-label for treating wet AMD. The U.S. Food and Drug Administration (FDA) has also approved faricimab, an angiopoietin-2 and VEGF inhibitor.

Laser Therapy

Eye doctors may recommend laser treatment to some patients who develop AMD. Laser therapy photocoagulation is an option for wet AMD, where the abnormal blood vessels are tightly grouped together and in people with rapid vision loss. However, laser treatment is less helpful if the abnormal blood vessels are scattered or located in the central portion of the macula.

Photodynamic Therapy

Photodynamic therapy is a type of laser therapy in which an eye doctor injects a light-sensitive medicine called verteporfin (Visudyne) through a vein in the arm. Verteporfin collects in the abnormal blood vessels in the macula. A special contact lens is then used to shine a laser beam into the eye. (An anesthetic eye drop is used to keep you comfortable.) The laser activates the medicine, which causes blood clotting in the abnormal blood vessels, thereby sealing them off and preventing more vision loss.

Dry AMD Treatment

Pegcetacoplan (Syfovre) and avacincaptad pegol intravitreal solution (Izervay) are complement inhibitors. These are relatively new FDA-approved medications for treating dry AMD. They are prescribed to people with geographic atrophy, a late stage of dry AMD (non-neovascular age-related macular degeneration).

Nutritional Supplements

People with wet and dry age-related macular degeneration can benefit from taking nutritional supplements called AREDS 2 that contain high doses of vitamins, minerals, and antioxidants such as vitamin C, vitamin E, copper, zinc, lutein, and zeaxanthin. Systematic review of clinical trials suggests that AREDS 2 can slow the progression from early AMD to intermediate AMD and help in retaining remaining vision.

An older form of the supplement called AREDS also contained beta carotene; however, beta carotene was found to increase the risk of lung cancer in smokers, and therefore the newer form, AREDS 2, is recommended for smokers.

Lifestyle Changes and Adaptive Devices

Your healthcare provider may prescribe vision rehabilitation programs and low-vision devices (lenses, lighting aids, magnification devices) to allow you to perform routine activities if you are living with age-related macular degeneration.

Lifestyle changes such as eating a healthy diet with foods rich in omega-3 and omega-6 fatty acids, exercising, avoiding smoking, and protecting your eyes from ultraviolet light can help prevent and slow vision loss.

Emerging Therapies and Research

Scientists are exploring new treatments for age-related macular degeneration such as stem cell therapy, where stem cells are used to replace some of the degenerated macular cells in advanced dry AMD. However, it may take a decade or even longer for these experimental treatments to be considered safe and effective and prescribed routinely.

Lifestyle Adjustments and Support

What Should You Avoid If You Have Macular Degeneration?

You should avoid smoking, eating a diet high in saturated fat, and a lack of exercise if you have macular degeneration. These are all modifiable risk factors for this eye condition.

Can You Be Treated For Macular Degeneration?

Yes, you can be treated for macular degeneration with:

Drugs called anti-VEGF agents, laser treatment, and photodynamic therapy for wet macular degeneration
Drugs called complement inhibitors for dry macular degeneration

In addition, your healthcare provider can prescribe vision rehabilitation programs and low-vision devices to improve vision.

Can You Live Normally With Macular Degeneration?

Age-related macular degeneration can cause severe vision loss but rarely causes total blindness. With timely diagnosis and proper care, most people who develop macular degeneration can maintain vision and live near-normal lives. The Macular Society recommends the following adaptations in daily life to make life easier, including support systems, visual aids, and adjustment strategies:

Even and bright lighting in the home with pale decor to reduce glare and improve vision
Vision aids like reading stands and magnifiers.
Large face clocks, larger fonts on mobile phones, and large print or audio format books, magazines, and newspapers
A “talking” feature on household equipment such as ovens, scales, and timers
Use of bright, contrasting colors to differentiate items, for example doors and windows from walls, colored kitchen equipment like glasses and chopping boards, brightly colored tape wrapped around handles of utensils, and colored stickers on most used settings of appliances
Adaptations like using clothes pegs to keep pairs of shoes together, placing a rubber band around one bottle to tell shampoo and conditioner apart, using thicker pens to make your own writing easier to read back, and using a signature guide or writing frame to keep writing straight

Preventative Measures and Slowing Progression

How Do I Lower My Risk of Macular Degeneration?

Research suggests that you can lower your risk of age-related macular degeneration or slow vision loss from macular degeneration by making healthy lifestyle choices, such as:

How Do You Stop Macular Degeneration From Progressing?

Lifestyle changes such as eating a healthy diet, avoiding saturated fat, exercising, avoiding smoking, and protecting your eyes from ultraviolet light can help prevent or slow vision loss if you have AMD. These same lifestyle changes can also lower the risk of developing both the wet and dry form of AMD. Nutritional supplements such as AREDS and AREDS 2 can also slow the progression of age-related macular degeneration.

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