Clinical Presentation
Decreased central vision 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. Age-related macular degeneration may
be asymptomatic during the early stage. 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.
Early or Dry or Non-Neovascular or
Non-Exudative or Age-Related Macular Degeneration
Early or dry or non-neovascular or
non-exudative age-related macular degeneration accounts for 85-90% of cases. The
clinical presentation of non-neovascular or non-exudative or early or dry age-related
macular degeneration 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 age-related macular degeneration
is usually of ischemic cause.
Neovascular
or Exudative or Late or Wet Age-Related Macular Degeneration
Neovascular or exudative or late or wet age-related macular degeneration
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 age-related
macular degeneration is usually due to the leakage of fluid from the
blood vessels.
Age-Related Macular Degeneration_Initial Assesment 2History
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
Ophthalmologic Examination
A dilated fundus examination is recommended
for patients ≥55 years of age to screen for macular degeneration. Ocular evaluation includes a dilated eye exam
using a binocular slit-lamp biomicroscopy which may reveal any of the
following: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 age-related macular degeneration (eg large drusen, soft indistinct drusen, extensive drusen area, hyperpigmentation)
- Signs of exudative age-related macular degeneration 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
Age-Related Macular Degeneration_Initial Assesment 3