PANCE Blueprint EENT (7%)

Macular degeneration (Lecture)

Patient will present as → a 62-year-old male who arrives for his follow-up visit for chronic central visual 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 funduscopic 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: hemorrhage, neovascuration. New abnormal vessels grow under central retina which leak and bleed causing retinal scarring.
retina

Comparison of dry and wet macular degeneration

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 subretina
    • neovascularizationmacular grayish-green discoloration
  • Dry - Age-Related Macular Degeneration
    • drusen deposition
    • areas of retinal atrophy (depigmentation)
    • retinal pigment epithelium motteling (pigmentation)
  • Amsler grid: line distortion seen on grid

Wet Age-Related Macular Degeneration

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

Dry Age-Related Macular Degeneration

  • Zinc and antioxidant vitamins
IM_NUR_AgeRelatedMacularDegenerationAMD_v1.5_ 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.

Age-Related Macular Degeneration (AMD) Picmonic

Question 1
Which of the following does the macula provide?
A
Night vision
Hint:
Night vision is a function of rod photoreceptors, which are found in the peripheral retina.
B
Color vision
Hint:
Color vision is a function of cone photoreceptors
C
Peripheral vision
Hint:
The peripheral retina is responsible for peripheral vision.
D
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?
A
Glaucoma
Hint:
Glaucoma occurs in about 6% of diabetics. Neovascularization of the iris can cause closed angle glaucoma.
B
Cataracts
Hint:
Cataracts can occur secondary to diabetes, but are not caused by proliferative retinopathy.
C
Vitreous hemorrhage
D
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?
A
Blepharitis
Hint:
Blepharitis is a chronic bilateral inflammatory condition of the lid margins
B
Cataracts
Hint:
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.
C
Central retinal artery occlusion
Hint:
Central retinal artery occlusion presents as a rare cause of sudden profound monocular visual loss.
D
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.
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