Dry Age-Related Macular Degeneration (Dry ARMD)

Dry Age-Related Macular Degeneration (Dry ARMD)
SYMPTOMS In the early stages, patients are typically asymptomatic
In the later or more advanced stages, patients report gradual loss of central vision and metamorphopsia
SIGNS Typically bilateral
Normal age-related changes (Grade 1): Small drusen (< 63 microns in size) and/or RPE mottling
Early ARMD (Grade 2): Intermediate drusen noted (63 to less than 125 microns in size) with no RPE abnormalities
Intermediate ARMD (Grade 3): Large drusen noted (125 microns or more in size) and/or RPE abnormalities
Late/Advanced ARMD (Grade 4): Wet ARMD and/or geographic atrophy
Other signs include an Absent foveal reflex, Drusenoid RPE detachments (occurs due to confluence of soft drusen), and Outer retinal tubulations (associated with geographic atrophy)
WORK-UP Color vision, Full eye exam with dilated retinal exam, OCT analysis of the macula, OCT-Angiography, Fundus Autofluorescence, Fluorescein Angiography, Indocyanine Green Angiography, Fundus photos, Infrared retinal imaging, Watzke-Allen test, Macular photostress test, Amsler grid, Macular pigment optical density, Preferential hyperacuity perimetry, Genetic testing (determines potential rate of progression and type of treatment), Dark adaptation, Microperimetry
TREATMENT Lifestyle changes (Discontinue smoking, Diet rich in fruits and vegetables, Exercise, Control blood pressure)
Wear UV protection
Give take home Amsler grid in order to monitor for change
Begin AREDS II vitamins (may need an alternative if patient has an adverse reaction to zinc based on genetic testing)
Low vision devices in the later or more advanced stages
FOLLOW-UP Normal age-related changes (Grade 1): See patient back in 1 year
Early ARMD (Grade 2): See patient back in 6-12 months
Intermediate ARMD (Grade 3): See patient back in 4-6 months
Late/Advanced ARMD (Grade 4): See patient back in 3-6 months (if the patient presents with any evidence of wet ARMD, the patient needs to be referred to a retinal specialist ASAP)
ETIOLOGY RPE damage due to age, genetic factors, and environmental factors. Build-up of drusen occurs which leads to activation of the complement system and decrease in permeability through Bruch’s membrane
DIFFERENTIAL DX Wet Age-Related Macular Degeneration, Pattern dystrophy, Drug induced maculopathy, Stargardt disease, Inflammatory maculopathy
NOTES Staging of dry age-related macular degeneration is based on findings being within 2DD of the fovea
Age-Related Macular Degeneration (ARMD) is the leading cause of blindness in the elderly population
The number one risk factor for developing/progression of dry ARMD is smoking
There are five types of drusen associated with age-related macular degeneration (Hard, Soft, Cuticular, Pseudo, and Calcific)
Risks for conversion from dry to wet age-related macular degeneration include the presence of multiple large soft confluent drusen, the presence of wet age-related macular degeneration in one eye, the presence of RPE hyperpigmentation at the macula, being a smoker, and having high levels of C-reactive protein
Dry Age-Related Macular Degeneration (Dry ARMD): OCT of the macula showing multiple soft drusen in a patient with dry ARMD https://www.researchgate.net/figure/OCT-image-showing-drusens-in-dry-ARMD-seen-as-bumps-in-retinal-layers_fig2_310799723