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Macular Degeneration
Diagnosis/Definition
- Age related macular degeneration (ARMD) is the leading cause of legal blindness (i.e., acuity less than 20/200) in Americans over the age of 65 although it can develop as early as 50 years.
- While the indolent atrophic variety of the disease is by far the most common (90%), it rarely causes severe visual loss.
- Any abrupt change in acuity or the onset of new visual distortion (metamorphopsia) may indicate a progression into the more visually disabling exudative form.
- Timely referral of these patients may enable beneficial laser treatment to be performed.
Initial Diagnosis and Management
- The first ophthalmoscopically visible signs of ARMD are drusen, small discrete yellow-white deposits under the retina surrounding the fovea.
- As the disease progresses, these drusen coalesce and the overlying retina becomes atrophic.
- Although visual loss can ensue, it is usually mild (20/25 – 20/60) and referral to the ophthalmologist at this stage can be done on a routine basis.
Ongoing Management and Objectives
- In approximately 10% of ARMD patients, blood vessels from the underlying choroidal layer will invade the retina.
- The leakage of serum or blood from these abnormal vessels into or beneath the retina causes an abrupt change in vision.
- “Urgent (24-48 hours)” referral to the ophthalmologist at this stage will enable further evaluation, including slit lamp biomicroscopy and retinal angiography.
- A significant percentage of patients may benefit from anti-VEGF treatment modalities.
Indications for Specialty Care Referral
The primary care provider should refer any patient in whom the atrophic form of ARMD is suspected on the basis of: past ocular history, reduced visual acuity (i.e. <20/40), ophthalmoscopic evidence of retinal pigmentary degeneration.
The primary care provider should refer urgently (i.e. 72 hours) any patient suspected of recently developing the exudative form of ARMD on the basis of complaints of abrupt decrease in acuity (<20/30) or recent onset of visual distortion (metamorphopsia), ophthalmoscopic evidence of intra or subretinal hemorrhage in and around the fovea, in the absence of diabetes or other retinal vascular disease.
Criteria for Return to Primary Care
Once diagnosed, patients with early, dry, or atrophic ARMD should be followed yearly by a general ophthomologist or retina specialist.
PCS should reinforce to patients vigilant monitoring of their own vision (checking visual acuity and Amsler Grid).
Abrupt or profound changes in documented values warrant prompt return to Ophthalmology.
New consults are not needed for follow-up visits within a year.
Patients with ARMD should be encouraged to take a multiple vitamin containing the Age Related Eye Disease Study (AREDS) formulation.
Patients who are smokers should not take high dosages of beta carotene contained within the AREDS formula. The patient’s ophthalmologist can recommend an alternative multivitamin.
