Ask Us Anything About… Age-Related Macular Degeneration

Description – The video begins inside a conference room at the University Physicians Center at Penn State Health Milton S. Hershey Medical Center. Two people are standing next to each other. Standing from left to right is, Dr. Ingrid Scott and Scott Gilbert.

Scott Gilbert – From Penn State Health this is Ask Us Anything About Age-Related Macular Degeneration, I’m Scott Gilbert. Well age-related macular degeneration is a medical condition that can result in blurred or even no vision in the center of the visual field for someone. It also is a condition or diagnosis that can cause some alarm so we want to get some answers about it for you. And we’re going to do that today with Dr. Ingrid Scott, she’s a retina specialist here at Penn State Health Milton S. Hershey Medical Center. Dr. Scott, we appreciate your time today. Let’s talk a little bit about what macular degeneration is, that is what’s happening inside the eyeball that causes it.

Dr. Ingrid Scott – Age-related macular degeneration is the most common cause of vision loss in people 50 years of age and older in this country and in the industrialized world. Age-related macular degeneration as its name implies is associated with age and is a degenerative process involving the macula which is the central part of the retina. The retina is the tissue that lines the inside of the eyeball and the macula is responsible for the central part of the vision.

Scott Gilbert – Okay so when that starts to deteriorate the center of the vision field deteriorates?

Dr. Ingrid Scott – Correct. So people generally will notice a fuzzy vision, perhaps a black spot in their vision. They might notice distortion in the central part of their vision. For example, straight lines appearing wavy, so the edges of windows or the edges of doors looking squiggly instead of straight.

Scott Gilbert – And the trends are that age-related macular degeneration is on the increase. Do we know why that is?

Dr. Ingrid Scott – So we are seeing an increase in age-related macular degeneration and this is primarily due to the aging of the population. So the population is getting older and so there are more people at risk for age-related macular degeneration.

Scott Gilbert – And you’re now watching Ask Us Anything About Age-Related Macular Degeneration from Penn State Health. We welcome your questions for Dr. Ingrid Scott, a retina specialist here, just put them in the comment field below this Facebook post and we’ll pose them to her. Even after the fact if you’re watching this video on playback, we can answer your question in the comment field. So you mention obviously with age-related macular degeneration older folks are perhaps more at risk but what are some additional risk factors that could be on top of that?

Dr. Ingrid Scott – So age is the predominant risk factor for age-related macular degeneration. Race is another risk factor so several epidemiologic studies have shown that Caucasians are at higher risk compared to other racial groups. There is a genetic predisposition, so although age-related degeneration is not inherited in a strict [inaudible] inheritance pattern, that is autosomal recessive, autosomal dominant, excellent recessive. If you have a first-degree relative who has age-related macular degeneration it does increase your risk for developing the disease. Now these three factors are all nonmodifiable risk factors so we generally consider risk factors as nonmodifiable, that is things that you can’t do anything about or modifiable and that is things that you can be able to do something about. So one of the most important modifiable risk factors for macular degeneration is smoking. Smoking increases not only your risk for macular degeneration but the progression of the disease if you are already diagnosed with macular degeneration. Another important modifiable risk factor for macular degeneration is sunlight exposure. So I think we’ve done a good job in this country of educating people about the association between sunlight exposure and skin cancer but we also need to be educating people about the importance of protecting not only the skin from sunlight but also the eyes. Dietary factors are also important. People who have a diet rich in dark green leafy vegetables, orange vegetables.

Scott Gilbert – That’s a good thing or not good thing?

Dr. Ingrid Scott – That is a good thing.

Scott Gilbert – Okay.

Dr. Ingrid Scott – So we want people to be eating a diet rich in dark green leafy vegetables, orange vegetables, fish because they contain omega-3, long-chain polyunsaturated fatty acids. And then finally high blood pressure and cholesterol are risk factors. So we would recommend that people control their hypertension and high cholesterol.

Scott Gilbert – And when it comes to those modifiable factors like hypertension, like you mentioned some of the others are those things that even after someone is diagnosed, they should take care to try to control?

Dr. Ingrid Scott – Yes, so they are associated not only with an increased risk of getting the disease but the progression, the rate at which the disease will advance.

Scott Gilbert – You’re watching Ask Us Anything About Age-Related Macular Degeneration from Penn State health, I’m Scott Gilbert alongside Dr. Ingrid Scott who welcomes your questions. And also, we welcome your sharing of this Facebook post on your page to help us get this information out to even more people. Now you mention a couple of the signs and symptoms I want to see if you know anybody watching this video may think oh-oh that sounds like me but does it have any symptoms that may mimic other things or vice versa, you know other conditions may seem like this when it’s not?

Dr. Ingrid Scott – Yes, so I think as people get older, sometimes they assume that a gradual blurriness of their vision, a decrease in perhaps color perception they automatically assume that this is due to just aging or perhaps a cataract. But it would be recommended that they come in and be evaluated because these could be signs of macular degeneration as well.

Scott Gilbert – And how is it diagnosed, what is that process that you follow as a physician?

Dr. Ingrid Scott – So age-related macular degeneration can be diagnosed on the basis of a dilated retinal examination. Now the eye doctor may also want to perform some ancillary tests, such as fluorescein angiography which is basically injecting a yellow dye into the vein in your arm. That dye will then go to the little blood vessels in the eyes and images are taken and we can look for abnormal blood vessel development which is seen in the advanced stage of macular degeneration or wet macular degeneration. Another test that the eye doctor may want to perform is a non-invasive test, it’s basically a special kind of photograph it’s called OCT or optical coherence tomography. And it provides the retina specialist with a cross-sectional image of the retina so that the eye specialist can see are there the signs of dry macular degeneration which are these little yellow deposits called drusen, are there the development of abnormal blood vessels that are leaking. So the cross-sectional image would basically show leakage of fluid into the retina.

Scott Gilbert – And as you mentioned there are different types, there’s dry and wet macular degeneration. What’s the difference there?

Dr. Ingrid Scott – So while most people with age-related macular degeneration will have the dry form, about 80 to 85% of patients with macular degeneration. Ninety percent of the severe vision loss due to macular degeneration is actually due to the wet form. So when you think of stages of macular degeneration you can think of dry versus wet and we can talk about that first. But you can also talk about early, intermediate and advanced.

Scott Gilbert – So dry can turn into wet down the road?

Dr. Ingrid Scott – So dry macular degeneration is characterized by deposits of yellow material underneath the retina. This accumulation of material then basically interferes with the ability of the retinal cells to receive the nutrients they need, and it leads to loss of cells. The wet form of macular degeneration is when there is the growth of abnormal blood vessels underneath the retina. So first of all the blood vessel shouldn’t even be there. And second of all because they’re abnormal they’re not stable, they’re friable, they leak fluid, they bleed, and so that can result in vision loss. Now in terms of severity you can think of it in terms of early, intermediate and advanced macular degeneration. So early macular degeneration would be the presence of small drusen, drusen again are those little yellow deposits that I mentioned earlier underneath the retina. Intermediate macular degeneration is characterized by extensive intermediate size drusen or maybe one or more large drusen. And then advanced macular degeneration would be either the presence of more extensive tissue damage which results in basically a loss of vision or black areas of vision called geographic atrophy or the development of wet macular degeneration. Wet macular degeneration by definition is advanced macular degeneration.

Scott Gilbert – So obviously the goal is to catch it early because that increases the chances of successful treatment. So what are the best ways to detect it early?

Dr. Ingrid Scott – So an important feature would be to make sure that you’re getting a dilated retina exam at least once a year. If your eye doctor then sees risk factors for macular degeneration. If your eye doctor sees the development of drusen or perhaps some pigmentary changes they may want to have you have a dilated retina exam more often. But at least you want to make sure you get a dilated retina exam at least every year. The eye doctor may provide you with what’s called an Amsler grid which is basically a grid of, it’s almost like a checkerboard of black lines, vertical and horizontal lines on a white piece of paper, there is a dot in the center. And your eye doctor may recommend that you look at this piece of paper, look at the central dot, and make sure that the lines, that the checkerboard around that dot are nice and straight. If the lines are squiggly, if some of the lines are missing, if you’re seeing a black splotch then that would be a reason to come in and see your eye doctor before your next scheduled appointment.

Scott Gilbert – If you’re just joining us this is Ask Us Anything About Age-Related Macular Degeneration from Penn State Health, I’m Scott Gilbert. Dr. Ingrid Scott is a retina specialist here and she welcomes your questions so just add them to the comment field below this Facebook post and we’ll try to get you some answers. So even if caught early is it curable or is it only treatable?

Dr. Ingrid Scott – So as with many things in aging macular degeneration is not curable but there are treatments, there are management strategies that we use. So for dry macular degeneration we counsel the patients with regard to lifestyle modifications. So lifestyle modifications would include stopping smoking, incorporating dark green leafy vegetables, orange vegetables, fish into your diet. Making sure your blood pressure and cholesterol are controlled. Making sure you protect your eyes from the sun. Patients who have intermediate stage macular degeneration in both eyes or advanced macular degeneration in one eye would be recommended to take nutritional supplements. These are over-the-counter, you don’t need a prescription. These supplements have been proven in clinical trials by the National Eye Institute to slow the progression of vision loss in patients with those stages of macular degeneration. And they have also been shown to decrease the risk of conversion from dry macular degeneration to wet macular degeneration.

Scott Gilbert – I just want to say though it’s probably important to get a physician’s guidance on which supplements are the ones to use for that?

Dr. Ingrid Scott – Which supplements and also when to start them. So it’s not and I should emphasize this, it’s not that these nutritional supplements are recommended for everyone. They have not been proven to be beneficial in patients with early stage macular degeneration. I want to emphasize again it’s been proven to be helpful in patients who have intermediate stage macular degeneration or advanced macular degeneration in one eye.

Scott Gilbert – Your previous answer partially addressed this but it sounds like it is possible to get this in just one eye or even both?

Dr. Ingrid Scott – So macular degeneration tends to be symmetric but I mean it tends to involve both eyes but the extent or the severity of the disease may differ. So it’s not uncommon at all for patients to have dry macular degeneration in one eye and perhaps wet in in the other. It is thought to be a continuum of disease so that patients will start with the dry macular degeneration and then about 15% of patients will convert and develop the more advanced wet form of macular degeneration. And for that, for the wet macular degeneration the currently available treatment options are frequent injections of medicine into the eye. And generally what I mean by frequent is we start by injecting the eye every month with the medicine. And then depending on how the patient responds we can decrease the frequency.

Scott Gilbert – And in the interest of improving detection and treatment for macular degeneration I imagine there must be research underway?

Dr. Ingrid Scott – So there is a lot of research being conducted in macular degeneration. So a lot of the research now is focused on developing drugs that can be injected into the eye less frequently. So instead of injecting a medicine into the eye every month they are looking at drugs that would only need to be injected every three months. There’s a drug being investigated every four months. There’s a drug being investigated where the patient would need to go to the operating room one time to get basically kind of a reservoir placed around the eye. And then that reservoir could be reinjected with medicine in the office about every six months. Another field of research that’s being conducted is called artificial vision where little micro electrodes are implanted. There are some that would go on top of the retina, some beneath the retina.

Scott Gilbert – That sounds pretty high-tech.

Dr. Ingrid Scott – That’s a little high-tech yeah. And then the patient would wear glasses and the light rays would be basically focused on the microelectrodes and those electrodes would automatically then stimulate the areas of the brain responsible for vision.

Scott Gilbert – Fascinating. Does having cataract surgery increase one’s risk for macular degeneration?

Dr. Ingrid Scott – So it used to be thought that cataract surgery did increase the risk of macular degeneration and in fact the early studies did show some conflicting results. The study that I had mentioned earlier by the National Eye Institute that demonstrated the benefit of the nutritional supplements looked at this and of course they studied thousands of patients. And they concluded that cataract surgery does not increase the risk of macular degeneration. And the hypothesis is that the reason there was some controversy in the literature earlier is that some of the patients before cataract surgery had macular degeneration but because of the presence of the cataract it wasn’t seen, it wasn’t detected. And once the cataract was taken out then the age-related macular degeneration could be diagnosed.

Scott Gilbert – So it was more of a matter of when it was detected that kind of led to that conclusion?

Dr. Ingrid Scott – That is the thought. So now it is not felt to — age-related macular degeneration is not felt to be a contraindication to cataract surgery.

Scott Gilbert – All right we’ve covered a lot of good information here. Anything else you want people to know if they’re watching this video and they’re thinking you know this might be me, this might be a relative, I want to learn more?

Dr. Ingrid Scott – I would just recommend if there’s any concern at all that they really have a dilated retina exam.

Scott Gilbert – Sounds good. Dr. Ingrid Scott, thank you for your time today. We encourage you again to add your questions or comments below this Facebook post even if you’re watching it on playback and we will get you some answers. And we appreciate you watching Ask Us Anything About Age-Related Macular Degeneration from Penn State Health.