Makindo Medical Notes

ℹ️ About

• 👴 ARMD is the leading cause of blindness in the UK and many developed countries.
• 👀 It usually affects both eyes, though progression may differ between them.
• 🚬 Risk factors: smoking, ageing, family history, hypertension, prolonged sun exposure without UV protection.
• 🎯 ARMD primarily affects central vision, impacting reading, driving, and facial recognition.

🧬 Aetiology

• 🔬 Dysfunction of the retinal pigment epithelium (RPE) → degeneration of macular photoreceptors.
• 🌱 Advanced disease may involve abnormal new vessel growth beneath the retina (choroidal neovascularization) → bleeding and scarring.

🔄 Types of ARMD

• Dry (atrophic) ARMD 🟡: 90% of cases. Slow progression, drusen deposits (yellow spots), gradual RPE atrophy → central vision loss over years.
• Wet (exudative) ARMD 🔴: 10% of cases but causes most severe vision loss. Abnormal choroidal neovascularization → leakage/bleeding → rapid loss. Urgent treatment required.

🩺 Clinical Presentation

• 📖 Central vision blurring: hallmark sign, peripheral vision preserved.
• ⬛ Scotomas: dark or blank patches in central vision → difficulty reading/recognising faces.
• 〰️ Metamorphopsia: distortion of straight lines (Amsler grid test useful).
• ✨ Drusen: yellow deposits seen on retinal exam, early marker of dry ARMD.

💊 Management

• 🌱 Lifestyle: Stop smoking, eat leafy greens + oily fish, control blood pressure.
• 💊 Vitamins: AREDS-2 formula (Vit C, Vit E, lutein, zeaxanthin, zinc, copper) slows dry ARMD progression.
• Wet ARMD treatments:
  • 💉 Anti-VEGF injections: e.g., ranibizumab (Lucentis), aflibercept (Eylea). First-line, highly effective if given early.
  • 💡 Photodynamic therapy: verteporfin dye + laser to seal abnormal vessels.
  • 🔥 Laser therapy: less common; risk of collateral retinal damage.
• 🔎 Vision aids: Magnifiers, electronic readers, low-vision support services.

📈 Prognosis

• 🟡 Dry ARMD: slow course; significant central vision loss possible over years. Regular monitoring important.
• 🔴 Wet ARMD: rapid progression without treatment. Early anti-VEGF therapy can stabilise or even improve vision in many patients.

🔑 Clinical Pearls

• 🟡 Drusen = early dry ARMD marker → monitor closely.
• 〰️ Distorted lines on Amsler grid = possible wet ARMD → urgent referral.
• 💉 Anti-VEGF has transformed outcomes; most patients can now maintain vision.
• 🚬 Smoking is the most important modifiable risk factor — always emphasise cessation.

📚 References

• NHS – ARMD Guide
• American Academy of Ophthalmology – AMD Treatment

Cases — Age-Related Macular Degeneration (ARMD)

• Case 1 — Dry ARMD 👁️: A 76-year-old woman reports gradual, painless loss of central vision and difficulty reading small print. Exam: drusen deposits and retinal pigment epithelial changes on fundoscopy. Diagnosis: dry (atrophic) ARMD. Managed with lifestyle advice (stop smoking, diet rich in antioxidants), low-vision aids, and regular monitoring.
• Case 2 — Wet ARMD 🌊: A 72-year-old man presents with sudden distortion of straight lines (metamorphopsia) and rapid central vision loss. Amsler grid: central distortion. OCT: subretinal fluid; fluorescein angiography shows choroidal neovascularisation. Diagnosis: wet (neovascular) ARMD. Managed urgently with intravitreal anti-VEGF injections (ranibizumab/aflibercept).
• Case 3 — ARMD and driving safety 🚗: A 79-year-old woman complains of central scotoma interfering with reading and recognising faces. Visual acuity below DVLA driving threshold. Fundoscopy: extensive drusen with macular scarring. Diagnosis: advanced ARMD affecting quality of life and driving. Managed with referral to low-vision services, occupational therapy, and social support.

Teaching Point 🩺: ARMD is the leading cause of irreversible central vision loss in older adults. - Dry ARMD: gradual, drusen deposits, no effective cure → lifestyle + monitoring. - Wet ARMD: rapid progression, choroidal neovascularisation, treat with anti-VEGF injections. Peripheral vision is usually preserved, so patients rarely go completely blind. Always assess impact on daily living and driving safety.