Age-related macular degeneration (AMD)

What is AMD?

Age-related macular degeneration or AMD is a disease of the macula, an area in the centre of the retina.

The retina is the light-detecting membrane at the back of the eye. The macula contains a particularly high density of light receptors, especially cones (the receptors that detect colour) and so the macula is particularly important for seeing fine detail and objects directly in front of us. It plays a vital role in helping people to read, write, drive and perform other detailed tasks. It also enables us to recognise faces and see colour.

There are two types of AMD:

Dry AMD is the most common form of the condition. Light receptor cells in the retina function less well as a person gets older. The cells don't take in enough vital nutrients and become less efficient at clearing by-products of cell functioning. This causes tiny abnormal deposits, called drusen, to build up under the retina, making it uneven.

In time, retinal cells degenerate and die causing sight loss. This occurs very gradually over many years. Dry AMD has three stages:

• Early AMD - small to medium drusen with no symptoms or loss of vision.
• Intermediate AMD - early symptoms such as a blurred spot in the centre of vision, and more light needed for reading.
• Advanced AMD - more extensive destruction of light sensitive cells and worsening vision.

Wet AMD accounts for ten to 15 per cent of cases. It’s also known as 'neovascular AMD' because it involves the growth of new blood vessels behind the retina. These new blood vessels are very fragile and so may leak fluid or blood, lifting up and distorting the retina. This results in distortion of vision and scarring that causes rapid visual loss. Everyone who develops wet AMD has the dry form first. Wet AMD can develop very quickly and it’s not possible to predict who'll develop wet AMD or when it will occur.

Causes of AMD

It's unclear what causes AMD, but it’s probably a combination of genetic vulnerability combined with environmental factors. Those with a family history of the condition are at increased risk, as they may carry the same genes.

AMD becomes more likely as a person ages because, over time, we’re exposed to more and more environmental insults or other illnesses which aggravate the AMD disease process and contribute to damage to the cells in the macula.

Symptoms of AMD

Both eyes are usually affected, although one eye may be affected before the other. The good eye usually compensates for the affected eye and for many years this can disguise the fact that there’s a problem. There's no pain or redness of the eyes.

As the macula is in the middle of the retina it’s central vision that's affected, and patients retain some residual vision. However this only provides the edges of what a person is trying to look at, and the focus (and colour strength) in this area is poor. Whatever the person tries to bring to the centre of their vision, to see more clearly, simply becomes dark or lost.

Any activity that requires detailed, clear vision is compromised, and in the late stages of the disease sight loss is so severe that patients are offered registration as partially sighted or blind.

Who's affected by AMD?

In developed countries it’s estimated that one in 50 people over 50 years of age, and up to one in five people over the age of 85 have AMD. Although wet AMD is less common (about one in ten cases) it’s more critical because it can progress so rapidly.

A person is at greater risk of developing AMD if someone in the family has the condition. Lifestyle factors also are important – smokers are three times more likely to develop AMD (probably because this causes oxidation damage to the light-receptor cells, or damages their blood and oxygen supply), and high blood pressure, being overweight, having small eyes (linked to long sight), and blue iris pigmentation all increase the risk. It’s also more common in women than men.

AMD treatments

Currently, there's no reliably proven medical treatment for dry AMD. However, not smoking and eating a healthy diet may help to slow the rate of deterioration. A regular dietary supplement of vitamins C and E, and zinc may help to slow down visual loss for some people who already have AMD.

There has been particular interest recently in two carotenoid dietary substances known as lutein and zeaxanthin, which in some cases seem to reduce the development and progression of AMD. Although studies don’t consistently demonstrate a benefit, people at high risk of AMD may want to consider taking supplements of these substances.

Additional lighting and magnifiers can help those with dry AMD to make better use of their residual sight.

When AMD develops, urgent treatment is usually advised. Medical breakthroughs in the treatment of wet AMD mean that, in most cases, treatments can prevent further visual loss, and in some cases bring some improvement of sight.

There are three types of treatment for wet AMD. They all aim to control the formation of new, leaky blood vessels:

• Photocoagulation uses a hot laser to seal leaking blood vessels, but can only be used in a minority of cases where the leakage isn't directly in the centre of the macula. It’s a destructive treatment that can damage surrounding healthy tissue, and new blood vessels frequently grow back afterwards, necessitating repeated treatments.
• Photodynamic therapy (PDT) uses a light-based treatment to seal leaking blood vessels. This involves injecting a drug called verteporfin which circulates in the blood stream and coats the inside of the abnormal blood vessels. The drug is then activated by shining a light at the coated blood vessels, triggering it to destroy them. This isn’t destructive to surrounding tissues but repeated treatments may be needed.
• In the past few years new treatments have been developed which interfere with the damaging process of new blood vessel development (neo-angiogenesis) which is central to wet AMD. Several drugs target a protein involved in this process, called vascular endothelial growth factor or VEGF. High levels of VEGF can cause proliferation of blood vessels and fluid leakage. The drugs, known as VEGF-inhibitors or anti-VEGF, need to be injected into the eye, under the macula. The number of injections varies. Although in research trials the injections were given either every four or every six weeks, in practice doctors have to decide on the most appropriate treatment regime based on their assessment of the patient's response to the drugs. VEGF-inhibitor treatments have been shown to halt sight loss and in some cases restore it.

Preventing AMD

Apart from the growing risk as people age, there appears to be a genetic influence that significantly increases the risk of developing AMD, particularly if other risk factors are present. While ageing and genetic predisposition can't be modified, other risk factors can.

Smoking - people who smoke triple their risk of developing AMD. The risk may be as high as 34 times that of a non-smoker if there's also a family history of AMD.

When people stop smoking the risk decreases, but this can take up to 20 years so it's important not to start.

Ultraviolet (UV) light - although it's thought that UV light doesn't reach the retina, and so doesn't increase the risk of developing AMD, wearing high-quality sunglasses in bright sunlight is recommended to protect eye health generally.

Nutrition - the role of vitamins and minerals and antioxidants in helping to prevent AMD isn't clear. Some scientific evidence suggests a diet rich in antioxidant vitamins and minerals, including lutein and zeaxanthin may help reduce the risk of a person developing AMD, although other studies suggest the scientific evidence isn't yet strong enough to recommend this.

However, a diet rich in antioxidant vitamins and minerals is unlikely to cause any harm. It makes sense to eat plenty of fruit and vegetables each day, particularly leafy green vegetables (the best sources of lutein and zeaxanthin include kale, spinach, turnip greens, romaine lettuce, broccoli, zucchini, garden peas and Brussel sprouts).

People with moderate AMD, should consult a doctor before taking additional amounts, especially high-dosage supplements.

Advice and support

Royal National Institute of the Blind

• Tel: 0845 766 9999
• Email: helpline@rnib.org.uk
• Website: www.rnib.org.uk

Macular Disease Society

• Tel: 0845 241 2041
• Email: help@maculardisease.org
• Website: www.maculardisease.org