Age-Related Macular Degeneration Treatments: Determining Appropriate Use - Episode 2

Stages of Progression in Age-Related Macular Degeneration

Peter L. Salgo, MD: If we’re saying that people have to recognize this disease—and this is a big, big disease, bigger than I think many physicians know—then what are the signs and symptoms of this disease? How does it present? Macular damage is a big thing.

Charles Wykoff, MD, PhD: It is. I think one of the earliest symptoms that people will notice is simply light-dark disassociation.

Peter L. Salgo, MD: What does that mean?

Charles Wykoff, MD, PhD: If you go from a bright area outside or a brightly lit room into a darker room—the classic example is going into a restaurant—you just won’t be able to adapt to darker settings as quickly as others. That’s the most common symptom, if you look across all types of AMD. That mostly represents the early, mild, or intermediate forms of dry AMD. But when you get into significant visual acuity loss, you’re talking about either bleeding in the back of the eye, which is wet macular degeneration, or geographic atrophy, which is death of the central macula. Both of those can cause vision loss.

Peter L. Salgo, MD: Wet refers to blood, really.

Charles Wykoff, MD, PhD: It really does. Wet, neovascular, they’re really the same phrase talking about the growth of abnormal blood vessels distorting and destroying the central retina.

Peter L. Salgo, MD: In terms of presentation, wet AMD versus dry AMD: how do they differ?

Charles Wykoff, MD, PhD: It’s confusing. It’s worth taking just a moment to describe this. Everybody with macular degeneration has dry macular degeneration. That’s a baseline, mild, or intermediate form. And then, if you develop the advanced form, you either develop wet macular degeneration with bleeding or advanced dry macular degeneration. It’s unfortunate that the early and the advanced forms can both be called dry. But advanced dry macular degeneration is also called geographic atrophy.

Peter L. Salgo, MD: And the speed with which this can progress, what do we know about it?

Jared Nielsen, MD: It is a degenerative disease, and for most people, the course of macular degeneration is very slow. But once somebody develops wet macular degeneration, the onset can be quite rapid. From the onset of symptoms that a patient might notice, they can lose vision permanently in just a matter of days.

Peter L. Salgo, MD: Days?

Jared Nielsen, MD: Yes.

Peter L. Salgo, MD: If you’ve only got a few days to work with this, it’s incumbent upon everybody to know what they’re dealing with, right? So, where’s the trigger point? How do we need to manage this?

Jared Nielsen, MD: When a person begins to recognize that they have something wrong with their center vision, that needs to be evaluated. There’s a great public awareness campaign to bring more of these important findings to light so that patients can report it to their physicians. Often times, Charlie and I will see people who have presented to our office and we ask, “When did this start?” “About 3 or 4 months ago, I noticed I wasn’t seeing very well. I just thought it would go away.” Then, unfortunately, we see them a little bit later than we would like to—where we can intervene more effectively.

Peter L. Salgo, MD: It seemed like you wanted to say something.

Peter Dehnel, MD: Gentlemen, is there anything that can be done on the prevention side? Because it seems that by the time somebody is developing this sense of lost vision, was there an earlier

opportunity that we missed, either on the managed care side or on the clinical side? What can we do?

Jared Nielsen, MD: Well, following recommendations for regular eye exams to screen for this disease is really important. After somebody is the age of 55 or has a high-risk factor, they need to go and have a dilated eye exam to take a look. They also need to be aware of what’s happening in their family members because this is a genetic disease for most individuals.

Peter L. Salgo, MD: You say risk factors. Let’s lay them out. What are the risk factors?

Jared Nielsen, MD: Family history is certainly one of the big ones, smoking history is a big one, and age is the biggest one. I think those really encapsulate the major risk factors for this disease. Another important thing—just to address what can be done—is that there have been very good studies conducted by the National Eye Institute, which will show that using an AREDS vitamin supplement can delay the progression to advanced AMD. And so, patients that meet the criteria for taking these supplements should be on them. Another thing that primary care can really help out with is to make sure that patients who have this disease are indeed taking the supplements.

Peter L. Salgo, MD: And these supplements are over-the-counter, but they have to be prescribed? Where do you get them?

Jared Nielsen, MD: They’re over-the-counter drugs, correct. Sometimes, that’s a difficult cost burden for people who are often on a fixed income, because now—in addition to their regular medicines—they’ll be taking a vitamin supplement, which is important for them to take to decrease their risk of developing vision loss.

Charles Wykoff, MD, PhD: I agree. It’s critical to distinguish the modifiable from the nonmodifiable risk factors. So, for smoking, don’t smoke. For heart health, keep all your cardiovascular factors well controlled. And then there are some caveats with the vitamin issue. The challenge is that not all people at risk of AMD should be on the vitamins. It’s a relatively small population of our entire global population who should be on the vitamins, so don’t put everybody on vitamins just because they’re at an age where they could have macular degeneration. You’ve got to get the dilated eye exam. I completely agree with Jared: All adults over 50 years old should get at least 1 exam a year.