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Macular Degeneration, Age-Related

Macular Degeneration, Age-Related is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Age-related macular degeneration (ARMD) is the leading cause of irreversible, severe visual loss in persons age >65 years.
  • ARMD results in pigmentary changes in the macula or typical drusen associated with visual loss to the 20/30 level or worse, not caused by cataract or other eye disease, in individuals >50 years of age, although some definitions exclude age or visual acuity criteria.
  • Stages
    • Atrophic/nonexudative
    • Neovascular/exudative
  • System(s) affected: nervous
  • Synonym(s): senile macular degeneration; subretinal neovascularization (SRN)

Epidemiology

  • Neovascular/exudative form is rare in blacks and more common in whites.
  • Predominant sex: female

Incidence
  • In the Framingham Eye Study (FES), drusen were noted in 25% of all participants who were ≥52 years of age. ARMD-associated visual loss was noted in 5.7%.
  • Atrophic/nonexudative stage accounts for 20% of cases of severe visual loss.
  • Neovascular/exudative stage accounts for 80% of cases of severe visual loss.
Prevalence

Per FES study:

  • People 65 to 74 years old: 11%
  • People ≥75 years old: 27.9%

Etiology and Pathophysiology

  • Breaks in the Bruch membrane allow choroidal neovascular membranes (CNVMs) to invade the retinal pigment epithelium (RPE) and grow into the subretinal space.
  • Atrophic/nonexudative: drusen and/or pigmentary changes in the macula
  • Neovascular/exudative: growth of blood vessels underneath the retina
  • Visible light can result in the formation and accumulation of metabolic by-products in the RPE, a pigment layer underneath the retina that normally helps remove metabolic by-products from the retina. Excess accumulation of these metabolic by-products interferes with the normal metabolic activity of the RPE and can lead to the formation of drusen.
  • Neovascular stage generally arises from the atrophic stage.
  • Most do not progress beyond the atrophic/nonexudative stage; however, those who do are at a greater risk of severe visual loss.

Genetics
  • Genetic susceptibility may be a factor in ARMD: ~25% genetically determined
  • Complement factor H is an important susceptibility gene for ARMD.
  • Although the development of ARMD may be predicted by specific alleles, the clinical response to antivascular endothelial growth factor (VEGF) is not.

Risk Factors

  • Obesity
  • Ethnicity: non-Hispanic whites
  • Cigarette smoking
  • Chlamydia pneumoniae infection
  • Family history
  • Excess sunlight exposure
  • Blue or light iris color
  • Hyperopia
  • History of cardiovascular disease
  • Short stature
  • Aspirin use
  • Female sex

General Prevention

  • Ultraviolet (UV) protection for eyes
  • Routine ophthalmologic visits
    • Every 2 to 4 years for patients age 40 to 64 years
    • Every 1 to 2 years after age 65 years
  • Patients who take statins, which modify lipid profiles, may have a reduced risk.

Commonly Associated Conditions

  • Presumed ocular histoplasmosis syndrome
  • Exudative retinal detachment
  • Vitreous hemorrhage
  • Other causes of CNVMs

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Citation

Stephens, Mark B., et al., editors. "Macular Degeneration, Age-Related." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816290/all/Macular_Degeneration__Age_Related.
Macular Degeneration, Age-Related. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816290/all/Macular_Degeneration__Age_Related. Accessed April 21, 2019.
Macular Degeneration, Age-Related. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816290/all/Macular_Degeneration__Age_Related
Macular Degeneration, Age-Related [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 21]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816290/all/Macular_Degeneration__Age_Related.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Macular Degeneration, Age-Related ID - 816290 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816290/all/Macular_Degeneration__Age_Related PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -