Age-related macular degeneration is a painless eye condition often referred to as AMD or macular degeneration. It is a progressive eye disease that affects up to 10% of adults over 65 years of age and is a leading cause of severe vision impairment and blindness in this age group.
Written by: Konstantina Danai Karagkiozeli, MSc, Science Communications Executive at Fighting Blindness (research@fightingblindness.ie ) And the ophthalmologists: Dr Matthew O’Riordan, Royal Victoria Eye and Ear Hospital Research Foundation, Dublin, Ireland – Mr Mark Cahill, Consultant Ophthalmologist, Progressive Vision Research, Dublin, Ireland
AMD causes the gradual loss of sight due to blurring or loss of central vision however the peripheral vision (vision to the side) is usually not affected. AMD is a chronic disease – it cannot be cured and in many patients sight cannot be restored after it is lost. However certain forms of the disease can be treated. Early detection is important to potentially stop the worsening of the disease and to protect an individual’s sight.
Some changes in the vision that could be early signs to spot the development of AMD include:
• Straight lines such as door frames or steps appearing wavy or distorted.
• Smudge, shadow or gaps appearing in the field of vision.
• A glare in bright light or decreased levels of vision in low lighting or darkness.
• Challenges in reading small print, even with glasses, and in recognising colours or find that colours begin to fade.
• Printed words seem very blurry
• Difficulty in recognising or distinguishing faces and may notice everyday activities such as driving or watching TV can become seriously affected over time.
If anyone is having any of the above symptoms, we strongly recommend they visit an eye care professional as soon as possible as early detection can help avoid further eyesight damage.
Additionally, a useful test for spotting the early signs of AMD is the Amsler Grid. It is an at-home test where if an individual sees that the lines appear missing or wavy, they may have AMD and should contact their eye doctor immediately. Full instructions on how to use the Amsler Grid can be found on the Fighting Blindness website https://www. fightingblindness.ie/living-with-sight-loss/eye-conditions/agerelated-macular-degenerationamd/ Please note that even if the grid looks normal, people should still attend regular eye exams for early detection of AMD. Also, frequent self-check-ups can catch the progression of the eye condition while in the early stages of AMD. People can monitor their sight and do a self-check up by closing one eye and look at window frames or door posts. If they see any distortion or realise sudden changes to their vision it is important to visit their doctor as soon as possible.
Independently of the above, to detect the earliest signs of AMD, it is recommended that everyone has an eye examination every one or two years by an optometrist or an eye doctor. This is particularly encouraged for people over 50 years of age, or who have a family history of AMD or both.
General eye check-ups are very important for people with AMD, as these individuals may still be at risk of developing other kinds of eye problems that affect the general population, some of which may be treatable. It is important to note if AMD is left untreated, serious sight loss can occur within 3-6 months so it is highly recommended to act fast in order to save as much as vision is left.
There are two forms of AMD, Early and Late. Only an eye care professional can tell which form an individual may have. In Early AMD the signs that the retina is being damaged are only visible to an eye care practitioner (optometrist or eye doctor). At this stage the damage does not affect sight and people are unaware of the condition. This highlights the importance of regular eye examinations to detect AMD in its early stages.
Some people progress from Early to Late AMD, where the condition causes loss of vision. There are two main types of Late AMD that can affect sight – Wet AMD and Dry AMD. The Dry form represents around 85-90% of all AMD cases, it causes gradual deterioration in your sight.
Wet AMD is a less common form of AMD but can develop more quickly and cause a rapid loss of vision. Wet AMD occurs when cells within the macula stop working and your body starts growing new blood vessels to fix the problem. The eye doctors may refer to this as neo-vascularisation.
It is important to note that AMD doesn’t cause a total loss of vision and, also, that it usually starts in one eye affecting the other only at a later stage.
What tools are available for patients who are experiencing limited sight for the 1st time: tools for their everyday life eg screen readers etc, services available eg for psychological support
Receiving a diagnosis of AMD can be overwhelming, but this is not a journey that anyone has to make alone. There are resources available to provide support for people living with AMD. The eye doctor who gives the initial diagnosis can be an important source of information on the condition, so we recommend contacting them first with questions.
Getting diagnosed with AMD doesn’t mean stopping doing the things a person love; people with AMD can still read or cook or participate in their favourite activities. Here are some tips to help adapt the home when a person has been diagnosed with AMD:
• Colours: bright rather than pastel colours are preferable on the walls, as well as creating contrasts with dark and light tones. Also, items in solid bright colours are preferable rather than patterned or made of transparent material e.g. avoid bottles made of plastic or clear glass. Other way to create contrasts is by choosing different textiles e.g. in bedsheets or towels.
• Lighting: it is highly recommended to make sure there is enough lighting in the home as it can really make a difference. A way to achieve this is using extra lighting when doing specific tasks. For example, when cooking, install under – the – cabinet lights, for reading a lighted magnifier can be used etc.
Furthermore, there are nightlights that turn on automatically when it is dark and motion-sensing stair lights which turn on automatically when the person reaches an individual step.
However, avoiding sun reflections from windows or glares is recommended, so installing shades, curtains or blinds could be beneficial.
• Organisation matters: there are ways that could help make a home safer and more functional, like coloured tapes, sticky notes etc. We suggest using bold labelling when organising clutter, drawer dividers, and bottles of different shapes to differentiate similar looking liquids e.g. water and vinegar.
• Low-vision tools: these include talking clocks, large-button telephones, magnifying glasses (they have hand-held magnifying lenses or magnifying lenses worn like glasses), tablet computers with voice recognition features and audiobooks.
Aside from buying the above a person can try changing the computer settings, like the font size and contrast. There are lowvision software that magnify text, adjust contrast etc. Moreover, the closed-circuit television systems use video camera to magnify reading material and project it on the screeen.
• Safety: try to keep hallways and staircases clear from things like shoes, umbrellas or anything else that could become an obstacle. Avoid putting furniture in the middle of the rooms and even more the low-level ones like coffee tables. Installing handrails on both sides of the staircase can help a person balance better to prevent accidents.
People with AMD have reported that one of the most difficult parts is when announcing to their family and friends their diagnosis. However, this is only the start and a person can experience many different emotions. Talking about their experiences with a professional or with others who also have the same eye condition can be very beneficial. As such, we encourage people with AMD to seek help from a counsellor or join a support group.
Fighting Blindness offers a free and confidential counselling service (Insight Counselling). For further information please contact insight@fightingblindness.ie or call 01 6746496.
We are also running a mindfulness group every Wednesday which takes place online 11 am-12:15pm. For technology support and guidance, we run online the Dublin-based Technology Exchange Club every Monday 11am-1pm and another Technology Exchange Club, based in Cork every Saturday 11am-1pm. For spouses/partners of somebody affected by sight loss, we run online a Partner’s Peer Support Group on the first Wednesday of the month at 3-4:30pm.
To join or for further information, contact us at 01 674 6496 or email at insightgroups@fightingblindness. ie . All groups run on zoom. We can help with setting people up on zoom or we can assist with any technology queries. We look forward to hearing from you!
How they might control the symptoms – OTC therapies that are available (eye drops / cooling masks etc)
Currently, there are no medical treatments for Dry AMD. Instead, an eye care practitioner will
suggest lifestyle changes and addressing any individual risk factors for AMD. Smoking is an important risk factor for AMD and it is strongly recommended to quit smoking. Other lifestyle recommendations include a healthy diet consisting of green leafy vegetable, fresh fruit and oily fish, and regular exercise. These changes may slow the progression of AMD. They are also part of a healthy lifestyle and will benefit general health too.
Studies have shown that a combination of vitamins and antioxidants may help reduce the risk of progression of Early AMD to late-stage AMD. The recommendations include supplements containing vitamins C and E, zinc, copper, lutein and zeaxanthin. These supplements are available overthe-counter. Remember that these supplements are not a cure for AMD and to find out more about what supplements that may work best for a person, it is advised they speak with an eye doctor. Research efforts are on-going to develop therapies to prevent or treat dry AMD. Injections of a drug into the eye, given by an eye doctor, may soon be available to treat the advanced form of dry AMD. If approved, this would be the first available treatment for late-stage dry AMD.
Fighting Blindness partly funds exciting research in Trinity College Dublin labs that may lead to new treatments. A lab recently announced the development of a promising new gene therapy. Another lab is investigating if changes to the body’s circadian rhythm may lead to leaky blood vessels at the back of the eye and cause dry AMD. You can find those publications in the list with resources at the end of the article, together with a news piece announcing the recent awarding of a grant for the above research.
Wet AMD on the other hand, can be treated if diagnosed early. Treatment for Wet AMD involves a series of injections into the eye of drugs called anti-VEGF (anti-vascular endothelial growth factor). In Wet AMD, new abnormal blood vessels grow due to high production of the growth factor VEGF. These blood vessels are faulty and may leak fluid or blood into the macula. The treatment works by blocking VEGF and therefore reducing the growth of new blood vessels. However, if the damage has been left for a long time and scarring has already taken place, these treatments may not work well. An eye doctor will determine if a person is suitable for this treatment and discuss the most suitable treatment plan.
There soon may be other ways to deliver anti-VEGF drugs to the eye. A surgical operation could be performed to implant a drug reservoir filled with anti-VEGF in the eye. The reservoir would slowly release the drug over several months and reduce the need for regular injections. However, the device would stay in the eye and still need to be refilled with antiVEGF drugs. These devices are not yet ready for use.
There are alternative methods that are under development (not available yet) that could be less invasive, more user-friendly and self-administering. One of them are eye drops, but it is difficult to ensure that enough drug will reach the macula which is at the back of the eye. As a result, it is not currently possible to treat AMD with eye drops. Another potential treatment could be oral tablets. However, it is important to note that this method is not as targeted as eye injections, where the drug stays concentrated in the eye so other parts of the body are not affected.
As previously mentioned, it is important for people with AMD to have regular eye tests with an eye care professional. For people with AMD in one eye, the healthy eye will be at a greater risk of AMD. Regular monitoring may, therefore, allow for earlier detection of AMD changes or progression to wet AMD, and result in faster access to treatment.
Maximising the remaining vision that an individual has is a crucial step to take, and as discussed above there are many low vision aids such as telescopic and magnifying lenses which may be of benefit. The wide range of assistive technologies for people with visual impairments provides plenty of choice for users at all stages of sight loss and this technology has also removed many barriers to education and employment.
There are a number of useful websites which have information on AMD:
• AMD.ie – information on age related macular degeneration in Ireland.
• NCBI (National Council for the Blind in Ireland) provides support and services for people living with sight loss in Ireland.
• Irish Guide Dogs for the blind helps individuals and their families to achieve improved mobility and independence.
• The Irish College of Ophthalmologists eye doctor website
• Retina International also has an international AMD toolkit on their website
References available on request
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