Early and intermediate age-related macular degeneration: update and clinical review

Abstract

Age-related macular degeneration (AMD) is the leading cause of irreversible central vision loss in developed countries. With the aging of population, AMD will become globally an increasingly important and prevalent disease worldwide. It is a complex disease whose etiology is associated with both genetic and environmental risk factors. An extensive decline in the quality of life and progressive need of daily living assistance resulting from AMD among those most severely affected highlights the essential role of preventive strategies, particularly advising patients to quit smoking. In addition, maintaining a healthy diet, controlling other risk factors (such as hypertension, obesity, and atherosclerosis), and the use of nutritional supplements (antioxidants) are recommendable. Genetic testing may be especially important in patients with a family history of AMD. Recently, unifying criteria for the clinical classification of AMD, defining no apparent aging changes; normal aging changes; and early, intermediate, and late AMD stages, are of value in predicting AMD risk of progression and in establishing recommendations for the diagnosis, therapeutic approach, and follow-up of patients. The present review is focused on early and intermediate AMD and presents a description of the clinical characteristics and ophthalmological findings for these stages, together with algorithms for the diagnosis and management of patients, which are easily applicable in daily clinical practice.

Keywords: age-related macular degeneration; classification; early AMD; intermediate AMD; nutritional supplementation; prevention; risk factors.

Figure 1

Normal aging changes, with drupelets only (small drusen ≤63 µm) and no pigmentary abnormalities.

Figure 2

Early AMD with medium-sized drusen >63 µm and ≤125 µm and no pigmentary abnormalities. Abbreviation: AMD, age-related macular degeneration.

Figure 3

To define intermediate AMD is enough to have one or more large drusen (≥125 µm in the smallest diameter), a distance approximating the width of a major branch retinal vessel crossing the optic disc margin. Abbreviation: AMD, age-related macular degeneration.

Figure 4

Intermediate AMD with small, intermediate, and large drusen, most of them outside the macula center. Note: The yellow circle represents a size of 2 disc diameters showing that there are also drusen inside the macular center. Abbreviation: AMD, age-related macular degeneration.

Figure 5

Intermediate AMD with small, intermediate, and large drusen, most of them in the macula center. Abbreviation: AMD, age-related macular degeneration.

Figure 6

Intermediate AMD with hyperpigmentary or hypopigmentary abnormalities associated with some drusen ≥63 µm in diameter. Abbreviation: AMD, age-related macular degeneration.

Figure 7

Late AMD with large drusen, hyperpigmentary and hypopigmentary abnormalities, and geographic atrophy. Abbreviation: AMD, age-related macular degeneration.

Figure 8

Late neovascular AMD with a choroidal neovascularization surrounding by subretinal hemorrhages. Abbreviation: AMD, age-related macular degeneration.

Figure 9

Late AMD with both neovascular signs (choroidal neovascularization with subretinal hemorrhages) and geographic atrophy. Abbreviation: AMD, age-related macular degeneration.

Figure 10

Late AMD in a disciform stage secondary to neovascular AMD. Note: Subretinal fibrosis, lipid exudates, hyperpigmentary and hypopigmentary abnormalities, and geographic atrophy are present. Abbreviation: AMD, age-related macular degeneration.

Figure 11

Fundus autofluorescence picture of the left eye of a patient with advanced geographic atrophy AMD. Abbreviation: AMD, age-related macular degeneration.