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AGE-RELATED MACULAR DEGENERATION (AMD)

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)

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  1. AGE-RELATED MACULAR DEGENERATION (AMD) 1. Drusen 2. Drusen and AMD 3. Atrophic AMD 4. Exudative AMD • Pigment epithelial detachment (PED) • Choroidal neovascularization (CNV)

  2. Drusen Histopathology Hard Soft • Larger, ill-defined spots • Small well-defined • spots • May enlarge and coalesce • Usually innocuous • Increased risk of AMD

  3. `` FA of drusen Degree of hyperfluorescence depends on: • Extent of overlying RPE atrophy (window defect) • Amount of staining • Lipid content

  4. Drusen and AMD - progression Exudative AMD Atrophic AMD

  5. Atrophic AMD Progression Initially drusen and non-specific RPE changes Late RPE (geographic) atrophy

  6. Atrophic AMD Fluorescein angiogram Management Hyperfluorescence from RPE window defect Low-vision aids if appropriate

  7. Signs of Pigment epithelial detachment Sub-RPE fluid may be clear or turbid Circumscribed, dome-shaped elevation

  8. FA of pigment epithelial detachment No increase in size of lesion Progressive increase in hyperfluorescence Early, well-defined hyperfluorescence

  9. ICG angiogram of pigment epithelial detachment Later, thin surrounding hyperfluorescent ring Early, well-defined hypofluorescence No increase in size of lesion

  10. Possible subsequent course of PED Spontaneous resolution Geographic atrophy CNV RPE rip

  11. 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

  12. 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

  13. FA of classical CNV Leakage into subretinal space and around CNV Late staining Very early ‘lacy’ filling pattern

  14. ICG angiogram in PED with occult CNV PED is hypofluorescent CNV is hyperfluorescent (hot spot)

  15. Possible subsequent course of CNV Subretinal (disciform) scarring Haemorrhagic sensory and RPE detachment Massive subretinal exudation Exudative retinal detachment

  16. Potential indications for laser treatment of CNV • Classic extrafoveal CNV on FA • Occult extrafoveal CNV on ICG Pre-treatment FA of classic CNV

  17. 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

  18. 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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