Age Related Macular Degeneration (ARMD)

What is it?
Age-related macular degeneration is a degenerative disease of the central part of the retina (called the macula) that occurs as some individuals get older. The retina acts like the film in a camera, and proper function of the retina is vital for good vision. The most important part of the retina is the macula, as that is the part of the retina that provides our high-level central vision that we use for things such as reading, watching television, recognising faces, etc. If age-related macular degeneration develops, the macula loses its ability to function properly. As a result, central vision becomes very poor. ARMD is so common that it is the number one cause of severe visual impairment in Western countries. The cause of age-related macular degeneration is unknown, but factors that are known to play a part include age, genetics (it is more common in people who have a family history of age-related macular degeneration), smoking, and other environmental factors such as a poor diet may also play a role.

There are two main types of age-related macular degeneration:
Dry Age Related Macular Degeneration : This is the most common type. In this type a reasonable overall level of vision is usually maintained. Currently there is no specific medical treatment for this type of ARMD. Visual aids such as magnifying glasses can help with reading and other small detailed tasks. The need for visual aids can be assessed by our highly experienced team of specialist optometrists.

Wet Age Related Macular Degeneration: This is the least common type. It is due to leakage of blood or fluid underneath the macula. This accounts for approximately 10% of cases of age-related macular degeneration. If left untreated it can have devastating consequences and lead to total loss of a patient’s central vision.



Who gets it?
There are several groups that are known to be at higher risk than others in the likelihood of developing age-related macular degeneration: the elderly, those with a family history of age-related macular degeneration, and smokers.

What are the symptoms?
For those with early disease, there may be little in the way of symptoms, and the disease may only be recognised by your ophthalmologist inspecting the macula as part of a routine eye examination. However, as the disease progresses, symptoms of central distortion (so-called “metamorphopsia” - see diagram below) and loss of central vision occur. It is very unusual for age-related macular degeneration to affect the peripheral vision. Thus, even in end-stage disease, very few patients end up with complete visual loss, although they may be severely incapacitated by loss of their central vision, resulting in their being unable to read, watch television or recognise faces without great great difficulty.


Distortion of vision (“metamorphopsia”)

How is age-related macular degeneration treated?
Until recently, there were very few effective treatments for age-related macular degeneration, and even today there are signifcant limitations on current therapy. For example, no treatment is currently available to treat dry age-related macular degeneration, but this type is less devastating and more slowly progressive than wet age-related macular degeneration. However, in the past few years, an array of exciting new treatments known as anti-VEGF therapies have become available and these have transformed the management of wet ARMD. These treatments may not only stabilise the vision due to wet ARMD, they may also improve it in certain patients. There are significant drawbacks to the treatment however, not least the fact that the treatment consists of injections into the eye (usually repeated every month for at least three months and often longer). These anti-VEGF therapies include Avastin and Lucentis. An additional concern is the cost of these new therapies.

Lucentis: This drug has been specifically developed for use in age-related macular degeneration. Lucentis is currently the treatment of choice for ARMD as per NICE guidelines. (www.lucentis.com)

Avastin: This is another anti-VEGF agent first used in the treatment of colon cancer. It was subsequently found to be effective in the treatment of age-related macular degeneration when given by injection into the eye (“intra-vitreal” injection). It may be as effective as Lucentis, but there are many ongoing trials comparing the effectiveness of the two agents. Currently, at Manchester Royal Eye Hospital, a new comparative trial (GMAN) of different "Avastin" regimes is underway for patients with "wet" ARMD. It is important to remember that although the new therapies are a major advance on previous treatments, there are still certain individuals with wet ARMD for whom therapy is not indicated.

Do intravitreal injections hurt?
Clearly the idea of having an injection into your eye is not a pleasant thought. However, the eye is easily anaesthetised using eye drops which "numb" the eye so that you dot not feel the injection, or at most just a tiny pin prick sensation. Patients are usually surprised at how painless a procedure it is.

What are the risks of intravitreal injection?
For the vast majority of patients an intravitreal injection is a very safe procedure. The major risk is the development of infection inside the eye after the injection which can damage the vision permanently, although fortunately this is extremely uncommon. All intravitreal injections are given using sterile operating procedures in a dedicated clean room, only used for this purpose, or in an operating theatre, so that there is the smallest possible risk of any infection. There is also a small risk of bleeding, the development of a cataract, retinal detachment and glaucoma. These conditions, however, are usually treatable. The risks should therefore be considered but also should be kept in perspective.

The consultants who undertake the treatment of age-related macular degeneration are:

Mr Tariq Aslam
Mr Felipe Dawarhir-Scala
Mr Steve Charles
Mr Saj Mahmood
Mr Niall Patton
Mr Paulo Stanga