Age-Related Macular Degeneration Initial Assessment

Clinical Presentation

Decreased vision loss and distortion of seeing straight lines (metamorphopsia) are the most common symptoms of age-related macular degeneration. The early stage manifestations of age-related macular degeneration include decline of reading ability in dim light, glare difficulty, dark and light adaptation difficulty (eg the patient wakes up at night and unable to read the clock because of seeing a central dark patch in the visual field that disappears within a few minutes as the eye adapts), the need to use magnifiers and bright light to be able to see as well as the patient used to, and the gradual progressive central vision loss. While the late-stage manifestations of age-related macular degeneration include metamorphopsia or the patient complains that straight line appearing crooked or wavy that can be confirmed by using Amsler grid, difficulty in reading small sizes of print and then later with larger print and/or words, and the profound and rapid central vision loss.  

Non-Neovascular or Non-Exudative or Early or Dry Age-Related Macular Degeneration  

The clinical presentation of non-neovascular or non-exudative or early or dry AMD is the presence of soft drusen ≥63 microns in diameter that causes areas of hyperpigmentation in the outer retina or choroid, areas of hypopigmentation of the RPE as a result of gradual breakdown of the RPE, and photoreceptors has loss of function. Non-neovascular or non-exudative or early or dry AMD is usually of ischemic cause.

Neovascular or Exudative or Late or Wet Age-Related Macular Degeneration 

Neovascular or exudative or late or wet AMD has the following clinical presentation: Presence of CNV which is the perforation of the choriocapillaris vessels and growth through the Bruch’s membrane and entry to the subretinal pigment epithelium and/or subretinal spaces, serous and/or hemorrhagic detachment of the sensory retina or RPE, presence of hard exudates in the retina, fibrovascular proliferation in the subretina and sub-RPE, and the presence of disciform scar. Neovascular or exudative or late or wet AMD is usually due to the leakage of fluid from the blood vessels. 

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History

A thorough history in patients with macular degeneration includes ocular history especially the presence of precursor lesions, any family history of age-related macular degeneration, medical history including hypersensitivity reactions, social history especially smoking, and finally, medications and nutritional supplements.

Physical Examination

Ocular evaluation includes a dilated eye exam using a binocular slit-lamp biomicroscopy which may reveal any of the following:

• Presence of drusens that appears as bright yellow spots or pale-yellow spots
• Presence of geographic atrophy that appears as sharply demarcated or defined scalloped edges of partial or complete depigmentation as a result of RPE atrophy
• Lesions indicating risk for progression to advanced AMD (eg large drusen, soft indistinct drusen, extensive drusen area, hyperpigmentation)
• Signs of exudative AMD like subretinal or sub-RPE neovascularization that appears as gray lesions, serous detachment of the neurosensory retina, RPE detachment, hemorrhages in the subretinal pigment epithelium, subretina, intraretinal or preretinal and breakthrough bleeding into the vitreous may occur, hard exudates within the macular area, epiretinal, intraretinal subretinal or sub-pigment epithelial scar or glial tissue or fibrin deposits, retinal angiomatous proliferations and retinochoroidal anastomosis

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