AKT · Ophthalmology/Retina & vitreous

Age-related macular degeneration

Degeneration of the central macula (dry/atrophic; wet/neovascular)

Overview

Degeneration of the central macula and the leading cause of central visual loss in older people. Dry (atrophic) AMD is gradual, with drusen and geographic atrophy; wet (neovascular) AMD involves choroidal neovascularisation with rapid central distortion and is treated with intravitreal anti-VEGF. Central vision is lost; peripheral/navigational vision is preserved.

Recognise

Gradual loss of CENTRAL vision, difficulty reading/recognising faces; metamorphopsia (straight lines look wavy — Amsler grid)
Dry: drusen and pigmentary changes, then geographic atrophy (slow); Wet: rapid central distortion/scotoma, haemorrhage/exudate at the macula
Central scotoma with preserved peripheral vision; risk factors: age, smoking, family history, hypertension

Red flags

Sudden central distortion/new scotoma → suspected WET AMD: refer to be seen urgently (within days) for anti-VEGF — the window to preserve vision is short
New symptoms in the second eye → urgent same as above

Differentials & how to tell them apart

Cataractuniform blur and glare without central distortion; macula normal

Diabetic maculopathyexudates/oedema in a diabetic; OCT and history differentiate

Macular hole / epiretinal membranecentral distortion with characteristic OCT appearance

Age-related macular degeneration — macular drusen
Rene Cheung, Angelica Ly / CC BY 4.0 — Wikimedia Commons

Investigations

Visual acuity + Amsler grid; dilated fundoscopy; OCT (the key test — fluid/neovascular membrane); fluorescein/OCT-angiography to confirm wet AMD.

Management

Wet AMD → urgent intravitreal anti-VEGF; dry AMD → AREDS2 + lifestyle, low-vision support

1Confirm with OCT. Wet AMD: refer to the macular service to be seen urgently (within days). Dry AMD: AREDS2 supplements for intermediate/advanced disease, smoking cessation, Amsler self-monitoring and low-vision support.Gate: Sudden central distortion = suspected WET AMD → see urgently for anti-VEGF; delay loses central vision permanently
2Wet AMD: ongoing intravitreal anti-VEGF per protocol. All: certify visual impairment when eligible, low-vision rehabilitation, treat associated depression.

Intravitreal anti-VEGF (aflibercept/ranibizumab) — WET AMD — first-line, repeated injections; can preserve/improve vision

AREDS2 vitamin supplements — slow progression of intermediate/advanced dry AMD in the fellow eye

Smoking cessation — the key modifiable risk factor

Key points

Central distortion (wavy lines on the Amsler grid) + drusen = AMD. Wet AMD is the urgent, treatable form — sudden distortion needs anti-VEGF fast. Peripheral vision (and mobility) is retained.

Monitor & prognosis

Amsler grid at home; OCT-guided injection intervals.

Wet AMD often stabilised with prompt anti-VEGF; dry AMD progresses slowly.

Source: NICE CKS AMD; NICE NG82; RCOphth