Age related macular degeneration

doi:10.1136/bmj.321.7263.741

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Jennifer J Arnold, consultant ophthalmologist (jjarnold@pacific.net.au)a,
Shirley H Sarks, honorary senior research associateb

^a Aberdeen Royal Hospitals NHS Trust, Aberdeen,
^b Prince of Wales Medical Research Institute, Randwick, NSW, Australia

Correspondence to: J Arnold

Background

Definition

Age related macular degeneration is the late stage of age related maculopathy. It has two forms: atrophic (or dry), characterised by geographic atrophy, and exudative (or wet), characterised by choroidal neovascularisation, which eventually causes a disciform scar. 1 2

Interventions

Beneficial:

Thermal laser photocoagulation

Photodynamic treatment with verteporfin

Unknown effectiveness:

Proton beam and scleral plaque radiotherapy

Submacular surgery

Unlikely to be beneficial:

External beam radiation

Ineffective or harmful

Subcutaneous interferon alfa-2a

Incidence/prevalence

Age related macular degeneration is the commonest cause of blind registration in industrialised countries. The atrophic form is more common than the more sight threatening exudative form, affecting about 85% of people with age related macular degeneration.3 End stage (blinding) age related macular degeneration is found in about 1.7% of all people aged over 50, and incidence rises with age (0.7-1.4% in people aged 65-75, 11.0-18.5% in people aged over 85).4-6

Aetiology/risk factors

The aetiology is multifactorial. Age is the strongest risk factor. Ocular risk factors for the development of exudative age related macular degeneration include the presence of soft drusen, macular pigmentary change, and choroidal neovascularisation in the other eye. Systemic risk factors are hypertension, smoking, and positive family history. 7 8 A role for diet and exposure to ultraviolet light is suspected but unproved.

Prognosis

Age related macular degeneration impairs central vision, which is required for reading, driving, face recognition, and all fine visual tasks. Atrophic age related macular degeneration progresses slowly over many years, and time to legal blindness (visual acuity <20/200) is highly variable (usually about 5–10 years). 9 10 Exudative age related macular degeneration is more threatening to vision and is responsible for 90% of severe visual loss in people with age related macular degeneration. It usually manifests with a sudden worsening and distortion of central vision. It progresses rapidly (typically over weeks or months) until scarring is complete and no further vision is lost, at …