73-year-old man with 6 weeks of progressively worsening central vision
What is your diagnosis?
The diagnosis is...
The image is consistent with a diagnosis of dry age-related macular degeneration (AMD):
- AMD is the leading cause of irreversible central vision loss among people 50 years and older.
- Dry AMD is the most common type (80% of patients) and is a chronic, slowly progressive disease. It involves subretinal drusen deposits, geographic atrophy of the retinal pigment epithelium, and macular thinning.
- Wet AMD is less common and can develop acutely, resulting in sudden-onset vision loss. It involves abnormal blood vessel growth under the retina. These abnormal vessels may leak, leading to fluid and blood beneath the retina.
Dry AMD.
Wet AMD.
What is the role of the primary care or emergency medicine physician?
- Obtain a history including the rate of vision loss, whether 1 or both eyes are involved, and whether vision is distorted (metamorphopsia) or portions of it are missing (scotomas).
- Check visual acuity.
- Refer nonurgently to ophthalmology for dry AMD.
- Refer urgently to ophthalmology for new-onset wet AMD or significant changes in visual acuity in patients with a history of AMD.
Dry AMD.
Wet AMD: large, soft drusen (white arrow) and retinal hemorrhages (black arrows).
What is the role of the ophthalmologist?
- Perform a slit-lamp dilated eye exam assessing for drusen, subretinal fluid, or hemorrhage.
- Perform optical coherence tomography (OCT) to identify the presence of subretinal fluid, retinal edema, and drusen.
- Perform Amsler grid testing to help identify blurry, distorted, or missing areas in the central field of vision. This grid is also given to the patient for home monitoring.
- Perform fluorescein angiography to identify abnormal blood vessel growth and leakage of subretinal fluid.
OCT image showing nonexudative AMD with drusen.
Amsler grid.
Fundus fluorescein angiography.
What is the treatment?
The Age-Related Eye Disease Study 2 (AREDS2) vitamin formulation—a specific combination of vitamins C and E, lutein, zeaxanthin, zinc, and copper—is recommended for patients with moderate to severe forms of dry AMD. These vitamins decrease disease progression.
For wet AMD, anti-vascular endothelial growth factor injections are most effective. Other treatments include photodynamic therapy and laser photocoagulation.
Intravitreal injection.
Learn more: Ophthalmology resources for medical students