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Macular degeneration (Lecture)

Patient will present as → a 62-year-old male who arrives for his follow-up visit for chronic, gradual central vision loss. He describes a phenomenon of wavy or distorted vision that has deteriorated rather quickly. The patient is frustrated because he "just can't drive anymore,” and he is "having difficulty seeing words when he reads.” When looking at a specific region of the Amsler grid, he reports a dark “spot” in the center, with bent lines. On the fundoscopic exam, you note areas of retinal depigmentation along with the presence of yellow retinal deposits.

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Gradual PAINLESS loss of CENTRAL vision (versus glaucoma, which presents with a peripheral → central loss)

  • The macula is responsible for central visual acuity, which is why macular degeneration causes gradual central field loss
  • Macular Degeneration is the most common cause of permanent legal blindness and visual loss in the elderly > 75
  • Dry macular degeneration (85% of cases): atrophic changes with age – slow, gradual breakdown of the macula (macular atrophy), with DRUSEN (DRY)= yellow retinal deposits
  • Wet macular degeneration: an advanced form of dry age-related macular degeneration. New blood vessels growing beneath the retina (neovascularization) leak blood and fluid, damaging the retinal cells. These small hemorrhages usually result in rapid and severe vision loss

Dilated funduscopic findings are diagnostic; color photographs, fluorescein angiography, and optical coherence tomography assist in confirming the diagnosis and in directing treatment.

  • Wet - Age-Related Macular Degeneration - hemorrhage or fluid in the subretina
  • Dry - Age-Related Macular Degeneration
    • Drusen deposition
    • areas of retinal atrophy (depigmentation)
    • retinal pigment epithelium mottling (pigmentation)
  • Amsler grid: line distortion seen on the grid


Normal Amsler Grid

Amsler grid - distorted vision (metamorphopsia)

Amsler grid as it might be viewed by a person with age-related macular degeneration

Wet Age-Related Macular Degeneration

  • VEGF inhibitors (e.g., bevacizumab)
  • Photodynamic therapy
  • Zinc and antioxidant vitamins

Dry Age-Related Macular Degeneration

  • Zinc and antioxidant vitamins

Macular Degeneration


Age-related macular degeneration (AMD) is the most common cause of irreversible central vision loss. It affects patients over 60 years of age and is related to retinal aging. There are two types: dry (nonexudative) and wet (exudative). Dry AMD accounts for the majority of the diagnoses of the condition, while wet AMD is the more severe form. Prolonged exposure to UV light, smoking, lighter colored eyes, and hyperopia are risk factors.

Play Video + Quiz

Question 1
Which of the following does the macula provide?
Night vision
Night vision is a function of rod photoreceptors, which are found in the peripheral retina.
Color vision
Color vision is a function of cone photoreceptors
Peripheral vision
The peripheral retina is responsible for peripheral vision.
Central vision acuity
Question 1 Explanation: 
The macula is responsible for central visual acuity.
Question 2
A patient with type 2 diabetes mellitus presents for a yearly eye exam. Ophthalmoscopic exam reveals neovascularization. Which of the following is the most likely complication related to this finding?
Glaucoma occurs in about 6% of diabetics. Neovascularization of the iris can cause closed angle glaucoma.
Cataracts can occur secondary to diabetes, but are not caused by proliferative retinopathy.
Vitreous hemorrhage
Optic neuritis
Question 2 Explanation: 
Proliferative retinopathy, as evidenced by neovascularization, is associated with an increased risk of vitreous hemorrhage.
Question 3
Which of the following is the leading cause of permanent visual loss in a patient over the age of 75?
Blepharitis is a chronic bilateral inflammatory condition of the lid margins
Cataracts are the clouding of the lens sufficient to reduce vision. Most develop slowly as a result of aging, leading to gradual impairment of vision.
Central retinal artery occlusion
Central retinal artery occlusion presents as a rare cause of sudden profound monocular visual loss.
Macular degeneration
Question 3 Explanation: 
Age-related macular degeneration is the leading cause of permanent visual loss in the older population. The exact cause is unknown, but the prevalence increases with each decade over age 50 years.
There are 3 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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