Age Related Macular DegenerationA closer look.

Ramanath Bhandari, MDOphthalmology

www.SpringfieldClinic.com/DoctorIsIn

Age Related Macular Degeneration

• Is the leading cause of severe central vision loss in people over the age of 50 in the United States.

• It is estimated that 15 million North Americans currently have AMD.

• Risk factors for AMD include positive family history, cigarette smoking, light iris color, hypertension, hypercholesterolemia, and female gender.

Two types of AMD:

• AMD can be divided into two general types

• Dry AMD refers to atrophy of the retina and the appearance of drusen which are small yellow round lesions underlying the retina.

• Neovascular or Wet AMD generally has a worse prognosis and refers to bleeding underlying the retina and intraretinal or subretinal fluid.

Dry AMD

• Multiple Small drusen. • Central Atrophy is also

notable.

Dry AMD:

• The cause of visual loss in Dry AMD is atrophy or loss of retinal tissue and photoreceptors within the retina.

• So, Is there a treatment for this condition?

• Currently, the best guidance for treatment is the use of AREDs or AREDs 2 vitamins. And careful follow up with an amsler grid.

Dry AMD

• Amsler Grid is an important tool to monitor your symptoms between appointment visits to ensure no progression of disease.

Dry AMD and Eye Vitamins

• What components should be part of my eye vitamin?

• 500 mg of Vitamin C

• 400 IU of Vitamin E

• 80 mg of Zinc

• 2 mg of Copper

• 10-20 mg of Lutein

• 2 mg of Zeaxanthin

Dry AMD and Eye Vitamins:

• My friend or family member does not have macular degeneration, should they take an AREDS 2 vitamin to reduce the risk of macular degeneration? If they are not diagnosed with Age Related Macular Degeneration, then they will not benefit from an eye vitamin. The best advice is to maintain a diet rich in spinach and fish and take a daily multivitamin.

Dry AMD and AREDs 2 vitamins

• Beta Carotene is an anti-oxidant that was part of the original AREDs formula and was found to be of benefit in decreasing risk of progression of macular degeneration.

• However, Beta-Carotene increases the risk of lung cancer in smokers and former smokers and has been replaced with lutein and zeaxantin in the AREDs 2 formula

AMD and Genetic Testing?

• Macula Risk NXG (ArticDx) and RetnaGene AMD(Sequenom) are 2 currently available genetic tests for progression of AMD.

• However, there is no therapy at present outside of the eye vitamin guidance we give all patients that can alter the course of dry AMD disease.

• The American Academy of Ophthalmology does not support the routine genetic testing of patients at present.

Future Therapies:

• The Mahalo Trial, was a phase II trial of a Complement Inhibitor (Lampalizumab) that showed a reduction in the amount of atrophy in patient’s treated by about 20% and 40% in some specific subcategories.

• Stem Cell Transplants are being attempted at some cites across the US. But thus far are in very preliminary stages of assessing safety of the new treatments.

Neovascular (Wet) AMD

• Subretinal Hemorrhage is apparent centrally.

• This is consistent with a choroidal neovascular membrane.

Neovascular (Wet) AMD

• Did have much worse prognosis than Dry , up until 2006, when intravitreal injections Anti-Vascular Endothelial Growth Factor Agents were developed.

• At present, there are 2 widely used drugs that are commercially available for the treatment of wet AMD.

• Regeneron has developed Eylea (aflibercept) and Genentech has developed Lucentis (ranibizumab)

Anti-Vegf therapies

• The Anchor and Marina trials of Lucentis were the first trials for the treatment of Wet AMD that showed visual improvement in patient’s who received treatment.

• Prior to these therapies, the goal was reducing progression as opposed to returning vision.

Response to Anti-Vegf Agent

Ongoing Therapy

• The downside to these intravitreal injections is that they typically require ongoing treatment to maintain their efficacy.

• The drug only remains in the eye for approximately 1 month.

• The future of therapy may look to find a way to give a depot injection with longer duration of action and would possibly require less frequent injections.

Risks of Injection

• Regardless of who performs the intravitreal injection, all have a slight risk of infection.

• Approximately in 1/2000, which is about the same risk of infection as cataract surgery but an infection can be sight threatening.

• There is also a small increase in the risk of stroke with these injections, but it maybe secondary to the co-morbidities of the population being injected.

Future Therapies for Wet AMD

• Ophthotech is in a Stage 3 trial with a drug called Fovista which has a new target and is to be used concurrently with current therapies.

• It has shown some promise in Stage 2 trials with patient attaining greater improvements on both drugs.

Image Sourcing:

• All Images in this presentation were taken from the Retina Image Bank, A project from the American Society of Retina Specialists.

Thank you!