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AGE-RELATED MACULAR DEGENERATION (AMD). 1. Drusen. 2. Drusen and AMD. 3. Atrophic AMD. 4. Exudative AMD. Pigment epithelial detachment (PED). Choroidal neovascularization (CNV). Drusen. Histopathology. Hard. Soft. Larger, ill-defined spots. Small well-defined spots.

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AGE-RELATED MACULAR

DEGENERATION (AMD)

1. Drusen

2. Drusen and AMD

3. Atrophic AMD

4. Exudative AMD

  • Pigment epithelial detachment (PED)

  • Choroidal neovascularization (CNV)


Drusen

Histopathology

Hard

Soft

  • Larger, ill-defined spots

  • Small well-defined

  • spots

  • May enlarge and coalesce

  • Usually innocuous

  • Increased risk of AMD


``

FA of drusen

Degree of hyperfluorescence depends on:

  • Extent of overlying RPE atrophy (window defect)

  • Amount of staining

  • Lipid content


Drusen and AMD - progression

Exudative AMD

Atrophic AMD


Atrophic AMD

Progression

Initially drusen and non-specific RPE changes

Late RPE (geographic) atrophy


Atrophic AMD

Fluorescein angiogram

Management

Hyperfluorescence from RPE window defect

Low-vision aids if appropriate


Signs of Pigment epithelial detachment

Sub-RPE fluid may be clear or turbid

Circumscribed, dome-shaped elevation


FA of pigment epithelial detachment

No increase in size of lesion

Progressive increase in

hyperfluorescence

Early, well-defined

hyperfluorescence


ICG angiogram of pigment

epithelial detachment

Later, thin surrounding

hyperfluorescent ring

Early, well-defined

hypofluorescence

No increase in size of lesion


Possible subsequent course of PED

Spontaneous resolution

Geographic atrophy

CNV

RPE rip


Choroidal neovascularization (CNV)

  • Less common than atrophic AMD but more serious

  • Metamorphopsia is initial symptom

  • Most lesions are not visible clinically

Suspicious clinical signs

Subretinal blood or lipid

Pinkish-yellow subretinal lesion

with fluid


Angiographic classification of CNV

Well-defined (classical)

Occult

  • Extrafoveal > 200 m from centre of

  • FAZ

  • Poorly defined

  • Juxtafoveal < 200 m from centre of

  • FAZ

  • Obscured by PED, blood or exudate

  • Subfoveal - involving centre of FAZ


FA of classical CNV

Leakage into subretinal

space and around CNV

Late staining

Very early ‘lacy’ filling

pattern


ICG angiogram in PED with occult CNV

PED is hypofluorescent

CNV is hyperfluorescent (hot spot)


Possible subsequent course of CNV

Subretinal (disciform) scarring

Haemorrhagic sensory and

RPE detachment

Massive subretinal exudation

Exudative retinal detachment


Potential indications for laser treatment of CNV

  • Classic extrafoveal CNV on FA

  • Occult extrafoveal CNV on ICG

Pre-treatment FA of classic CNV


Technique of laser photocoagulation of CNV

  • Perimeter is treated with overlapping 200 m (0.2-0.5 sec) burns

  • Entire area is covered with high energy burns

Late staining around

margin is normal

Lack of leakage following successful treatment


Results of laser photocoagulation of CNV

  • Initial risk of severe visual loss reduced by over 50%

  • Frequent subsequent recurrence with subfoveal involvement

Recurrence of CNV several months after initially successful treatment


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