Age Related Macular Degeneration (Wet AMD or Non-Neovascular Macular Degeneration)

*Please note that this information is for illustrative purposes only, providing a general overview on the topics listed. For any specific questions or concerns regarding your condition, please contact our office so that you can consult with the appropriate person or department to address your needs.

WET AGE RELATED MACULAR DEGENERATION (WET AMD)

Age Related Macular Degeneration (ARMD) is classified into stages according to disease presentation and clinical findings. The stages of ARMD are as follows:
Stage 1 - Early Dry ARMD without Geographic Atrophy (Stage 1 Dry AMD)
Stage 2 - Intermediate Dry ARMD without Geographic Atrophy (Stage 2 Dry AMD)
Stage 3 - Advanced Dry ARMD without Geographic Atrophy (Stage 3 Dry AMD)
Stage 4 - Advanced Dry ARMD with Geographic Atrophy (Stage 4 Dry AMD)
Stage 4 - Advanced Wet ARMD with Choroidal Neovascular Membrane (CNVM) and with or without Geographic Atrophy (GA)

Description of Terms

Choroidal Neovascular Membrane (CNVM) - Abnormal sub-retinal or intra-retinal blood vessel growth
Lipofuscin - Waste products of retinal photoreceptor metabolism
Drusen - Accumulation of lipofuscin in sub retinal spaces
Photoreceptors (Rods & Cones) - cells in the retina that receive and process light images to create a formed image that is sent to the brain.
Retinal Pigment Epithelium (RPE) - cells below the photoreceptors that engulf waste from overlying photoreceptors and process, eliminate and/or store these waste products.
Bruch's Membrane - Collagen membrane that forms the base for RPE cells and forms a barrier and separates the RPE from the underlying choroid and choriocapillaris
Choriocapillaris - network of capillaries below the RPE and Bruch's Membrane that brings oxygen and nourishment to the overlying tissues and removes waste products from the eye
Intra-Retinal Hemorrhage (IRH) - Blood within the retina
Cystoid Macular Edema (CME) - Fluid within the retina
Sub-Retinal Hemorrhage (SRH) - Blood below the retina
Sub-Retinal Fluid (SRF) - Fluid below the retina
Sub-Macular Hemorrhage (SMH) - Blood below the center of the retina
Sub-RPE Fluid - Fluid below the retinal pigment epithelium
Sub-RPE Blood - Blood below the retinal pigment epithelium

Pathogenesis

ARMD is a degenerative disorder of the retina and the tissues below the retina called the retinal pigment epithelium (RPE), Buch's membrane and choriocapillaris (small capillary like vessel in the choroid). ARMD becomes increasingly more prevalent with age. Patients with a family history or genetic predisposition for ARMD are at higher risk of developing ARMD. Patients who smoke carry a 3 - 4 time increased risk for developing Advanced Wet ARMD and /or Geographic Atrophy. Patients with HTN, hypercholesterolemia, atherosclerosis, dementia, vitamin deficiencies from inadequate consumption of green vegetables (Lutein & Zeaxanthin) and inadequate consumption of dark meat fish (fish oil) all have increased reiskk of developing Advanced ARMD.

ARMD begins with the accumulation of metabolic waste products from normal retinal metabolism in the space below the retina, within the cells below the retina (RPE) and/or below the RPE. The yellowish material that accumulates in these spaces is called lipofuscin. Lipofusion accumulation leads to the develpment of drusen. Drusen are small yellow lesions that can be seen in the macula (center of the retina) of patients with ARMD. The stage of ARMD is determined by the size of the drusen and number of drusen that are present in and around the macula.

Stage 1 - Few small drusen
Stage 2 - Few intermediate sized drusen or many small drusen
Stage 3 - Many intermediate drusen or any large drusen
Stage 4 Wet ARMD - Presence of a Choroidal Neovascular Membrane (CNVM)
Stage 4 Dry ARMD - Presence of Geographic Atrophy (GA)

Epidemiology

Stage 4 Advanced ARMD (Wet ARMD and Dry ARMD with GA) is the leading cause of legal blindness in the US in patients over 70.

The total number of people with Stage 4 Advanced ARMD is projected to rise from 285 million in 2010 to 439 million in 2030.

Stage 4 Advanced ARMD is responsible for 1.8 million of the 37 million cases of blindness throughout the world.

Stage 4 Advanced ARMD is the 3rd Leading cause of blindness worldwide behind only cataracts and glaucoma.

The best predictor of development of ARMD is the age of the patient:
Age 60 - 69 = 5% to 10% incidence of ARMD
Age 70 - 79 = 10% - 20% incidence of ARMD
Age 80 - 89 = 30% - 40% incidence of ARMD
Age 90 - 99 = 50% - 70% incidence of ARMD
Age 100 and above = 80% - 100% incidence of ARMD

Symptoms

Wet ARMD is asymptomatic in early stages but as the disease progresses, symptoms may include:

  • Sudden or gradual onset of blurred vision
  • Distortion of straight lines
  • Decreased central vision
  • Difficulty reading
  • Dark areas in central vision

Diagnostic Testing

Optical Coherence Tomography (OCT) is used to evaluate the macular anatomy and to rule out choroidal neovascularization (CNVM), intra-retinal fluid (IRF) or cystoid macular edema (CME), sub-retina fluid (SRF), sub-RPE fluid, macular thinning and atrophy overlying areas of RPE atrophy (GA) and choroicapillaris atrophy in patients with ARMD (rpai - sample OCT to appear soon).

Fundus Photography (FP) is used to document the level of ARMD and to compare to future FP evaluations to access progression at future exams.

Fluorescein Angiography (FA)
is used to evaluate the macular and peripheral circulation. Many patients with ARMD have staining of drusen, transmitted hyperfluorescence through areas of GA, leakage of fluorescein dye from CNVM or staining of an old disciform scar.

OCT Angiography (OCT-A) is a non-invasive test that is used to evaluate the vascular flow and anatomical changes in the macula of patient with ARMD.

ICG Angiography (ICG)
is used to evaluate the vascular changes in the choroid and choriocapillaris in patients with macular degeneration, sub retinal hemorrhage, pigment epithelial detachments, and atypical forms of ARMD such as idiopathic polypoidal choroidal vasculopathy (IPCV).

B-Scan Ultrasound (B-Scan)
is used to evaluate the retina in patients with corneal opacities, cataracts, retinal hemorrhage or any other condition that makes visualization of the retina difficult with indirect ophthalmoscopy. B-scan can detect a subretinal hemorrhage in a patient that has a vitreous hemorrhage (VH) that obscures the view of the retina.

Findings

ARMD can be associated with the following findings:

  • Drusen (small/nodular, intermediate, large/soft, confluent)
  • CNVM (sub-RPE, sub-retinal and/or intra-retinal)
  • Hemorrhage (sub-RPE, sub-retinal, intra-retinal or vitreous hemorrhage)
  • Exudate (sub-retinal or intra-retinal)
  • Pigment (sub-retinal or intra-retinal)
  • Pigment Epithelial Detachment (PED)
  • Disciform Scar (sub-retinal scarring from a regressed CNVM)
  • Peripapillary CNVM (abnormal vessels in the retinal periphery)

Medical Treatment for Stage 1 - 2 Dry  ARMD

A yearly eye exam with dilated fundoscopic exam (DFE) is recommended in all patients over 60 years of age.

The treatment of Stage 1 - 2 Dry ARMD includes daily multivitamins (such as Centrum Silver with Lutein), a diet rich in green vegetables (spinach, kale, collard greens, broccoli, etc.) and dark meat fish (tuna, salmon, sardines, and mackerel), avoidance of smoking, and Amsler Grid testing. The primary care physician should perform a complete medical evaluation to monitor the adequacy of the patients' blood pressure and cholesterol control.

Medical Treatment for Stage 3 - 4 Dry ARMD

A yearly eye exam with dilated fundoscopic exam (DFE) is recommended in all patients over 60 years of age.

The treatment of Stage 3 - 4 Dry ARMD includes AREDS 2 formula vitamins (Ocuvite Preservation, ICAPS, Viteyes, etc.), daily multivitamins (such as Centrum Silver with Lutein), a diet rich in green vegetables (spinach, kale, collard greens, broccoli, etc.) and dark meat fish (tuna, salmon, sardines, and mackerel), avoidance of smoking, and Amsler Grid testing. The primary care physician should perform a complete medical evaluation to monitor the adequacy of the patients' blood pressure and cholesterol control.

Medical Treatment for Stage 4 Wet ARMD

The treatment of Stage 3 - 4 Dry ARMD includes AREDS 2 formula vitamins (Ocuvite Preservation, ICAPS, Viteyes, etc.), daily multivitamins (such as Centrum Silver with Lutein), a diet rich in green vegetables (spinach, kale, collard greens, broccoli, etc.) and dark meat fish (tuna, salmon, sardines, and mackerel), avoidance of smoking, and Amsler Grid testing. The primary care physician should perform a complete medical evaluation to monitor the adequacy of the patients' blood pressure and cholesterol control.

Avastin, Lucentis & Eylea are all Anti-Vascular Endothelial Growth Factor (Anti-VEGF) medications are all treatments for Wet ARMD. This class of medication is typically the first line treatment for Wet ARMD. Anti-VEGF agents can induce regression of a CNVM which can be helpful to reduce the risk of growth and activity of the CNVM which reduces risk of leakage, exudation and hemorrhage in Wet ARMD patients. Anti-VEGF agents has associated risks of increased risk of HTN, stroke or heart attacks (1 - 3%) and a small associated risk of intra-ocular infection called endophthalmitis (0.1%).

Photodynamic Therapy (PDT) uses a light activated photosensitive dye (which is injected into the patients vein and circulates to the eye where it binds to the CNVM) which is activated by a non-thermal laser which causes intravascular thrombosis (clotting insidne the abnormal blood vessels that block the flow of blood and oxygen to the abnormal tissues) within the abnormal vessels in the CNVM. PDT is typically used to treat CNVMs that extend close to or below the fovea. It may be used in combination with Anti-VEGF agents and/or steroids for the treatment of Wet ARMD. PDT has an associated risk of transient back pain during infusion (5 %), photosensitivity (risk of severe skin burns with prolonged UV light exposure) for 5 - 7 days and a permanent central blind spot (1% - 2 %).

Focal Laser Photocoagulation (focal) is rarely used to treat wet ARMD other that to treat lesions greater than 200um from the fovea or peripapillary CNVMs. It may be used in combination with Anti-VEGF agents and/or steroids for the treatment of Wet ARMD.

Intravitreal Triamcinolone (IVT) is a steroid injected into the vitreous cavity to treat Wet ARMD patients who have persistent cystoid macular edema (CME) or sub-retinal fluid (SRF) resistant to Anti-VEGF therapy and/or PDT. IVT therapy typically has a treatment effect for 4 - 6 months and may need to be repeated if CME returns. IVT is typically used as a second or third line treatment for CME or SRF because of associated risks of cataract progression, glaucoma (40%), and the need for glaucoma surgery (5%) to control intraocular pressure.

Triesence (Triamcinolone) is a long acting steroid that is injected into the vitreous cavity to treat wet ARMD patients who have persistent cystoid macular edema (CME) or sub retinal fluid (SRF) resistant to Anti-VEGF therapy and/or PDT. Triesence therapy typically has a treatment effect for 4 - 6 months and may need to be repeated if CME returns. Triesence is typically used as a second or third line treatment for CME or SRF because of associated risks of cataract progression, glaucoma (40%), and the need for glaucoma surgery (5%) to control intraocular pressure.

Ozurdex is a long acting steroid implant that is injected into the vitreous cavity to treat Wet ARMD patients who have persistent cystoid macular edema (CME) or sub-retinal fluid (SRF) resistant to Anti-VEGF therapy and/or PDT. Ozurdex therapy typically has a treatment effect for 3 months and may need to be repeated if CME returns. Ozurdexis typcially used as a second or third line treatment for CME or SRF because of associated risks of cataract progression, glaucoma (40%), and the need for glaucoma surgery (5%) to control intraocular pressure.

​Cryotherapy is a freezing treatment applied externally to the eye to treat Wet ARMD in rare patients that present with extra-macular CNVM (an abnormal blood vessel growth under the retina in the far retinal periphery). Cryotherapy is associated with the risk of scar tissue formation called epiretinal membrane (ERM) or proliferative vitreoretinopathy (PVR) in some patients.

​Surgical Treatment

Pneumatic Displacement & Intravitreal Tissue Plasminogen Activator is used to displace sub-macular hemorrhage (SMH) when there is little to no vitreous hemorrhage (VH). SMH is bleeding below the macula (center of the retina). Surgery to dissolve the blood (with TPA) and then displace the blood away from the macula (intravitreal gas bubble and alternate positioning) is performed in the office. TPA is injected into the vitreous cavity and the patient is kept lying on their back for 20 minutes to allow the TPA to settle on the macula. Then a gas bubble is injected into the vitreous. The patient positions himself/herself for 3 hours facing down and 3 hours heads up alternating these positions for 3 days to displace the SMH. Pneumatic displacement with TPA is usually successful in displacing the SMH but the success rate decreases the longer the SMH has been present (because the blood begins to turn into a scar that is resistant to dissolving from the TPA).

Vitrectomy surgery with physical removal of the vitreous hemorrhage is the treatment for a patient with Wet ARMD and a massive sub-retinal hemorrhage (SRH) and/or dense vitreous hemorrhage (VH) when there is suspected or known blood or sub-macular homorrhage (SMH). SMH is bleeding below the macula (center of the retina). Surgery is used to remove VH and drain or displace SMH to prevent the blood from causing permanent damage to the photoreceptors in the macula which causes permanent central vision loss.

The procedure is performed under local anesthesia, in either our outpatient surgical center (Essex Specialized Surgical Institute and Ramapo Valley Surgical Center) or local hospital (Clara Maass Medical Center, Englewood Medical Center and Hackensack University Medical Center. (rpai) Please check back soon to view a video of the actual surgery on this page.

The surgery is performed through three 25-gauge ports (about the width of a wire paper clip). The surgery begins by placing an infusion cannula, a light pipe & a vitrectomy cutter through each of the 3 ports. The infusion cannula keeps a constant pressure in the eye while the vitrectomy cutter removes the vitreous gel and vitreous hemorrhage. As the gel is removed, balance salt solution replaces the gel in the vitreous cavity. The gel that is adherent to the retina gently lifted off the optic nerve and macula to separate the adhesions.

​The light pipe is used by the surgeon to see the vitreous being removed inside the eye. After the hemorrhage and gel are removed, your physician will make a retinotomy (small hole in retina) used to drain the blood below the macula (SMH).

No sutures are typically needed in up to 95% of cases. Antibiotic ointment and a patch are placed over the eye for one night and removed the following day by the technician in our office.

​Risks and Benefits of Surgery

Vitrectomy Surgery - The benefits of vitrectomy surgery, in general, are the potential for improved vision (by preventing photoreceptor damage), reduced distortion of straight lines (when present pre-operatively), and reduction or elimination of hemorrhage & floaters.

Some of the risks of vitrectomy surgery include:

  • More rapid cataract progression (in 65 - 80% of patients the lens may harden or become cloudy more rapidly after the vitrous gel is removed) that may require cataract surgery 1 - 2 years after the vitrectomy procedure.
  • Vitreous (less than 5%) or choroidal (less than 1%) hemorrhage
  • Retinal break or tear (less than 5%) or Retinal Detachments (less than 1%)
  • Infection/Endophthalmitis (less than 1 in 1,000 patients)
  • Permanent loss of vision/blindness (approximately 1 in 10,000)
  • These are some of the more common and serious side effects of surgery, but there are additional risks of surgery not listed above.

Post Operative Care

Patients are typically started on antiobiotic and steroid eyedrops the day after surgery. The frequency of these drops will be determined by your surgeon on the first post-operative day. Some patients have a temporary increase in intra-ocular pressure after even uncomplicated surgery and may require additional pressure lowering drops or oral medication.

Post Operative Expectations

Vision is usually blurry the first day after surgery. Continued visual improvement often occurs over the first 6 - 8 weeks but some patients experience improvement even up to 6 months after surgery.

Patients typically experience little to no pain following surgery.

Surface or external irritation (feeling of having something in your eye) is common. A deeper or more intense eye pain is not typical and may signal a more serious issue such as high intraoccular pressure, serous or hemorrhagic choroidals or infection. A deeper or more intense eye pain needs to be reported to your physician immediately.

Post Operative Restrictions

Post-operative restrictions are for 4 weeks after surgery and include:

  • Face down positioning for 3 - 7 days.
  • Anything that creates a Valsalva Maneuver such as coughing, sneezing, blowing your nose, straining with bowel movements or exertion, and some of the following:
  • Bending at the waist putting your head below your waist line (such as bending to tie your shoes). Bending at the knees with your head up is allowed.
  • Heavy lifting greater than 15 - 20 lbs.
  • Strenuous activity (including lifting weights, running, yoga, pilates, aerobics, yard work, snow shoveling, laundry, housecleaning, sexual intercourse) is not recommended as it will increase your risk of developing a retina tear or detachment. Walking, for exercise, after surgery is allowed (in patients who do not require post-operative head down position).
  • Showering is allowed immediately after surgery but be sure to keep your eyes closed to prevent shower water from entering your eye.
  • Swimming after surgery should be avoided for 4 weeks. you may go into a pool (not under water for the first 4 weeks).
  • If a gas bubble was used, avoid going 2,000 feet above sea level (no flying)
  • Working restrictions is job dependent. Patients with desk jobs or who perform light stationery office work may sometimes resume work 2 - 3 days after surgery. Patients with jobs that require heavy lifting or strenuous activity may be required to be out of work for 2 - 4 weeks. Ask your physician about your individual work restrictions. We will be happy to provide you with a doctor's note for your work and/or complete your temporary disability paperwork.
  • Driving restrictions will be dependent on your post-operative vision and should be discussed with your physician after surgery.
*Please note that this information is for illustrative purposes only, providing a general overview on the topics listed. For any specific questions or concerns regarding your condition, please contact our office so that you can consult with the appropriate person or department to address your needs.