Case 17 - Retina and vascular pathology
87-year-old man - Bilateral gradual painless vision loss x 1 year - Difficulty reading - Good general health
An 87-year-old man has noticed a gradual, painless decrease in vision in both eyes over the past year; he is in good health but having increasing difficulty reading. The fundus photograph demonstrates the condition of both eyes.
Multiple DRUSEN - discrete, round, yellowish-white deposits beneath the RPE at Bruch's membrane, concentrated in the macula. +/- RPE changes (hypo/hyperpigmentation/geographic atrophy). Drusen = lipofuscin + complement + debris from photoreceptor outer segment processing by RPE over a lifetime. Drusen -> RPE dysfunction -> cone photoreceptor failure -> down central VA and contrast sensitivity -> difficulty reading.
Age-Related Macular Degeneration (AMD) - Dry (Non-Exudative) Type. AREDS Classification: Early (<63 um drusen), Intermediate (medium/large drusen or RPE changes - supplement indicated), Advanced (geographic atrophy OR wet AMD with CNV). Dry = 85-90%; gradual. Wet = 10-15%; CNV -> sudden central VL.
Dry AMD: AREDS2 supplements (Vit C 500mg + E 400IU + Lutein 10mg + Zeaxanthin 2mg + Zinc 80mg + Cu 2mg) - down progression to advanced AMD by ~25%. NO beta-carotene in smokers (up lung cancer). Amsler grid daily - new metamorphopsia = SAME-DAY urgent referral. Smoking cessation + UV protection. Emerging: Syfovre/Izervay (complement inhibitors, FDA 2023, for geographic atrophy). Wet AMD: intravitreal anti-VEGF (bevacizumab/ranibizumab/aflibercept/faricimab).
AMD is the leading cause of irreversible vision loss in adults over 60 in developed countries. Drusen -> Bruch's membrane breaks -> choroidal vessels grow through -> wet AMD conversion. The key conversion signal: new METAMORPHOPSIA on Amsler grid = same-day urgent evaluation for CNV. AREDS2 is only indicated for intermediate or advanced AMD. Anti-VEGF revolutionized wet AMD; complement inhibitors are the first treatment for geographic atrophy.
Findings + symptoms Multiple DRUSEN - discrete, round, yellowish-white deposits beneath the RPE at Bruch's membrane, concentrated in the macula. +/- RPE changes (hypo/hyperpigmentation/geographic atrophy). Drusen = lipofuscin + complement + debris from photoreceptor outer segment processing by RPE over a lifetime. Drusen -> RPE dysfunction -> cone photoreceptor failure -> down central VA and contrast sensitivity -> difficulty reading. Diagnosis Age-Related Macular Degeneration (AMD) - Dry (Non-Exudative) Type. AREDS Classification: Early (<63 um drusen), Intermediate (medium/large drusen or RPE changes - supplement indicated), Advanced (geographic atrophy OR wet AMD with CNV). Dry = 85-90%; gradual. Wet = 10-15%; CNV -> sudden central VL. Treatment Dry AMD: AREDS2 supplements (Vit C 500mg + E 400IU + Lutein 10mg + Zeaxanthin 2mg + Zinc 80mg + Cu 2mg) - down progression to advanced AMD by ~25%. NO beta-carotene in smokers (up lung cancer). Amsler grid daily - new metamorphopsia = SAME-DAY urgent referral. Smoking cessation + UV protection. Emerging: Syfovre/Izervay (complement inhibitors, FDA 2023, for geographic atrophy). Wet AMD: intravitreal anti-VEGF (bevacizumab/ranibizumab/aflibercept/faricimab). TEACHING PEARL AMD is the leading cause of irreversible vision loss in adults over 60 in developed countries. Drusen -> Bruch's membrane breaks -> choroidal vessels grow through -> wet AMD conversion. The key conversion signal: new METAMORPHOPSIA on Amsler grid = same-day urgent evaluation for CNV. AREDS2 is only indicated for intermediate or advanced AMD. Anti-VEGF revolutionized wet AMD; complement inhibitors are the first treatment for geographic atrophy.
