Maculopathy & AMD

Question 1

Age-related maculopathy (ARM)

1. Definition?
2. Characteristics? RPE changes?

Answer 1

1. Exaggeration of the ‘normal’ ageing process
2. Characterised by
   Drusen
   Hyperpigmentation
   or depigmentationof the RPE associated with drusen

Question 2

Age-related macular degeneration (AMD)

1. Definition? In relation to ARM?
2. Characterised by? (4)
   G
   P
   S
   S

Answer 2

1. Advanced, sight-threatening stage of ARM
2. Characterised by

• ​Geographic atrophy of the RPE with visible underlying choroidal vessels
• Pigment epithelial detachment (PED)
• Subretinalor sub-RPE choroidal neovascularization (CNV)
• Scar tissue, haemorrhage and exudates

Question 3

AMD risk factors?

Answer 3

1. Age
2. ARM
3. Race
4. Positive family history
5. Cataract
6. Biomarkers for cardiovascular disease
7. Smoking
8. Obesity
9. Hypertension

Question 4

Drusen

1. What cause it?
2. If not cleared, consequence?
3. Made up of?
4. Effect of Brunch’s membrane?
5. Appearance of lesions?

Answer 4

1. RPE removes & processes the discs of the outer segments of the photoreceptors
2. If not cleared by the RPE, deposits accumulate in Bruch’s membrane
3. Made up of lipids
4. Bruch’s membrane thickens as a result of the deposits
5. Discrete, sub-retinal yellow lesions

Question 5

Drusen

1. Symmetrical?
2. Number, size, shape?
3. Relationship to age?

Answer 5

1. Usually symmetrical in both eyes
2. Can vary in number, size, shape etc
3. Rarely seen before age 45 years
   Increase in size & number with advancing age

Question 6

Drusen types?

Answer 6

Question 7

Answer 7

Drusen and AMD

Question 8

Atrophic AMD

1. Other name? Aka?
2. Why atrophic?
3. Affect what structures?
4. Patient present with?
5. Affect one or both eye? Symmetrical or not?

Answer 8

1. “dry” AMD
2. Atrophy which progresses slowly
3. Affects:
   Photoreceptors
   RPE
   Choriocapillaris
4. Gradual vision impairment. Over months or years
5. Affects both eyes (often asymmetrically)

Question 9

Sign?

Answer 9

Atropic AMD

Greyish

Can’t really see where macula is

Question 10

Sign?

Answer 10

Atropic AMD

Can see edges of atrophy

If look clearly, can see blood vessels of choroid

Question 11

Sign?

Answer 11

Atrophic AMD

Big scar over macula

Majority of rods and cones ( haemorrhage)

Progress slowly over time.

Jean below

yellowish, atrophic , drusen not obvious, vision affected severely

Question 12

Sign?

Answer 12

Atrophic AMD

Window defect

Brightness of choroidal vessels

Ischaemic area - More profound appearance

Artifarct

Question 13

RPE detachment

What structure involve? What cause changes?

Pt complant of?

Vision affected?

Answer 13

1. Bruch’s membrane thickens up & impedes movement of fluid from RPE to choroid
2. Patient c/o Metamorphopsia
3. Central vision affected

Question 14

Describe the follow pictures

Answer 14

Question 15

RPE detachment

Course?

Answer 15

RPE detachment

1. Spontaneous resolution
2. Geographic atrophy
3. Sensory retinal detachment
4. RPE tear

Question 16

1. RPE TEAR

1. Where does it occur?
2. How does it happen?

Answer 16

RPE tear

1. Occurs at the junction of the attached & detached RPE
2. Happens if stress causes the tissue to rupture
   Can happen spontaneously or following laser Tx1
   Instead of everythin pushed upward, there’s a tear. RPE tears and detachment usually seen in wet AMD

Question 17

Describe image?

Answer 17

RPE TEAR

Detachment= dome ( fluid pushed up)

Tear= flap

Patient c/o vision loss

Question 18

AMD Review

1. Common leading to ?
2. Relationship to aging? Uni or bilateral?
3. Affect what part vision?
4. Classification?

Answer 18

AMD review

1. Common cause of VIP and blindness in the western world
2. Associated with ageing, usually bilateral
3. Affects only central vision
   Peripheral vision remains intact
4. Classification:

• ​Dry: Slowly-progressing deterioration of vision
• Wet: Neovascularisation & CNVM causes sudden loss of vision

Question 19

AMD Review

1. Principle feature? Location?
2. Changes in photoreceptor outer segment?
3. If wet, what can grow?

Answer 19

1. Drusen between the RPE and Bruch’s membrane
2. RPE atrophy & degenerative change in photoreceptor outer segment
3. If “wet”, a vascular membrane can grow from the choroid towards the retina

Question 20

AMD Review

1. Difference between vision loss in DRY vs WET AMD ?
2. Effect what aspect of vision? (M)

Answer 20

AMD review

1. DRY : Progressive, gradual central vision loss
   OR
   WET: Sudden, profound vision loss
2. Affects reading & object recognition
   Metamorphopsia

Question 21

Neovascular “wet” AMD

Cause by? Originate from where?

List 3 growth patterns?

Answer 21

Neovascular “wet” AMD

1. C/b CNV originating from the choriocapillaris: grows through defects in Bruch membrane
2. 3 growth patterns:

• Sub-RPE: Most common in AMD
• Sub-retinal: Less common in AMD
  Likely in younger patients with myopia or chorioretinitis
• Combination of 1 & 2

Question 23

MECHANISM OF VISION LOSS?

1. Principle factor?
2. How does it develop? Where?
3. Can vision reverse?
4. Consequence of persistency?

Answer 23

Mechanism of vision loss

1. CNV = Choroidal Neovascularisation
2. develops as a result of leakage of blood & serum
   Under the retina
   Into the retina
   Under the RPE
3. Vision loss from accumulated fluid can be reversed
4. If persists =Loss of photoreceptors & RPE
   Discformscar forms
   Permanent vision loss
   IMAGE:
   - RPE detach, fluid accumulated & pushed up
   - RPE tears both - loss of foveal contour/foveal pit. Macula on either side- as soon as that in gene –> Vision loss

Question 24

Clinical Presentation of Neovascular AMD?
Vision? Visual field defect? (3)

Answer 24

1. Metamorphopsia
2. Positive scotoma
3. Blurred central vision

Question 25

Neovascular AMD Clinical sign?

Answer 25

Sub-retinal: RPE leak out pigment

Question 26

Neovascular AMD FFA Investigation 1. Role of FFA in FAZ? 2. Type of CNV? (3)

Answer 26

1. FFA important to **detect & precisely locate the CNV in relation to the FAZ** Urgent FFA if patient presents with recent onset of symptoms 2. *_Types of CNV_* * **_1. Classic_** Extrafoveal Juxtafoveal Subfoveal * **_2. Occult_** * **_3. Fibrovascular PED_**

Question 27

Types of CNV -Classic 1. Sign on FFA? _Location of CNV in:_ **Extrafoveal?** **Juxrafoveal?** **Subfoveal?**

Answer 27

1. **Well-defined membrane** which _fluoresces brightly_ on FFA * Extrafoveal: CNV is \> 200μm from centre of FAZ * Juxtafoveal: CNV closer than 200μm from centre of FAZ * Subfoveal: Centre of the FAZ is involved

Question 28

Types of CNV **Occult & Fibrovascular PED ( Pigment Epithelial detachment)** 1. Characteristics of Occult compared to classic? Sign on fundus? 2. Fibrovascular PED?

Answer 28

1. Occult: **Membrane not well defined** (compared with classic) and shows multiple areas of **_leakage_** 2. Fibrovascular PED: **Combination of CNV & PED**

Question 29

Sign?

Answer 29

Pocket of fluid need to be dried up with anti VEGF Also happen in DR and CRVO

Question 30

Course of untreated CMV

Answer 30

**Haemorrhagic PED** C/b _blood vessel rupture within the CNV_ VA= HM at best

Question 31

Course of untreated CMV

Answer 31

Vitreous haemorrhage Blood breaks through to the vitreous Rarely occur

Question 32

Course of untreated CMV

Answer 32

**Sub-retinal (disciform) scarring** Occurs after haemorrhage **_In-growth of new vessels_** from the choroid causes a **fibrous scar** at the _fovea_

Question 33

Course of untreated CMV 1. What is present? Cause? 2. Progression if more severe?

Answer 33

1. **Massive exudation** develops sometimes if _disciformscars_ are present C/b **chronic leakage from CNV** 2. If severe, **sub-retinal fluid spreads beyond macula = peripheral VA ↓**