Age-Related Macular Degeneration

Age-related macular degeneration is a leading cause of vision loss in older adults, affecting nearly 20 million Americans. While it can blur your central vision and make everyday tasks more challenging, it doesn’t cause complete blindness, and treatments are available to help protect your sight.

Table of contents

• What is Age-Related Macular Degeneration?
• Types and Stages of AMD
• Symptoms of AMD
• Risk Factors
• How AMD is Diagnosed
• Treatment Options
• Living with AMD

What is Age-Related Macular Degeneration?

AMD, ARMD, age-related maculopathy, macular degeneration

• Macula
• Retina
• Eye

Age-related macular degeneration (AMD) is an eye disease that can blur your central vision. It happens when aging causes damage to the macula — the part of the eye that controls sharp, straight-ahead vision^[1]. The macula is the central part of the retina, which is the light-sensitive tissue at the back of your eye^[2].

AMD is a common condition and a leading cause of vision loss for older adults^[1]. Almost 20 million U.S. adults have some form of age-related macular degeneration^[2]. Globally, around 200 million people are thought to be living with AMD, a number expected to reach 288 million by 2040^[4].

AMD doesn’t cause complete blindness, but losing your central vision can make it harder to see faces, read, drive, or do close-up work like cooking or fixing things around the house^[1]. People with macular degeneration aren’t completely blind because their peripheral vision (ability to see things off to the sides) remains fine^[2].

Types and Stages of AMD

There are two types of AMD: dry and wet. Nearly 90% of people with macular degeneration have the dry form^[2].

Dry AMD (Atrophic AMD)

Dry AMD develops when tiny yellow protein deposits called drusen form under your macula. The built-up deposits dry and thin your macula^[2]. This is when the macula gets thinner with age^[1].

Dry AMD happens in three stages: early, intermediate, and late. It usually progresses slowly over several years^[1].

• Early stage: Your macula changes, but vision isn’t affected. Early dry AMD doesn’t cause any symptoms^[2].
• Intermediate stage: Vision may get blurry or wavy. Some people still have no symptoms, while others may notice mild symptoms like mild blurriness in their central vision or trouble seeing in low lighting^[1].
• Late stage (advanced): Central vision fails. This advanced form is also called geographic atrophy, where significant atrophic areas (areas of wasting) develop in the retina^[6].

Vision loss with the dry form of macular degeneration tends to occur gradually. Most people don’t completely lose central vision. In some cases, the dry form can change to the wet form^[2].

Wet AMD (Exudative or Neovascular AMD)

Wet AMD is a less common type of late AMD that usually causes faster vision loss. About 10% of people with macular degeneration have the wet form, which is more severe^[2].

Any stage of dry AMD can turn into wet AMD, but wet AMD is always late stage^[1]. It happens when abnormal blood vessels grow beneath the retina and macula. These blood vessels leak blood and fluid, causing damage^[1]. The hallmark of wet AMD is choroidal neovascularization (CNV), which occurs when abnormal blood vessels grow beneath the retina and can bleed or leak, causing distortion of the retina’s structure^[6].

Because of fluid buildup, a bulge forms in your macula. This type can quickly lead to total loss of central vision^[2]. The good news is that treatment options are available for wet AMD^[1].

Symptoms of AMD

The symptoms of AMD depend on the stage. AMD is a progressive disease, which means symptoms usually get worse over time^[1].

In early stages, AMD may have no symptoms at all^[6]. Early dry AMD doesn’t cause any symptoms^[1].

In intermediate dry AMD, some people still have no symptoms. Others may notice mild symptoms like mild blurriness in their central vision or trouble seeing in low lighting^[1].

When the disease progresses, the symptoms become more noticeable. In late AMD (wet or dry type), many people notice that straight lines start to look wavy or crooked. You may also notice a blurry area near the center of your vision. Over time, this blurry area may get bigger or you may see blank spots^[1].

Additional symptoms in late-stage AMD include:

• Colors may seem less bright than before^[1]
• More trouble seeing in low lighting^[1]
• A decrease in the intensity or brightness of colors^[6]
• Distortion (warping) of straight lines^[6]
• A gradual or sudden loss of central vision, or dark, blurry areas in the center of vision^[6]

Straight lines looking wavy is a warning sign for late AMD. If you notice this symptom, see your eye doctor right away^[1].

Risk Factors

Your risk for AMD increases as you get older. People age 55 and older are more likely to have AMD^[1]. The risk of developing advanced age-related macular degeneration increases from 2% for those ages 50-59 to nearly 30% for those over the age of 75^[4].

The exact cause of AMD is unknown, but the condition develops as the eye ages^[6]. The risk for AMD is also higher for people who^[1]:

• Have a family history of AMD
• Are Caucasian
• Smoke

Additional risk factors include^[2]:

• Being overweight
• Having high blood pressure (hypertension)
• Eating a diet high in saturated fats

Possible risk factors also include female gender, high cholesterol, lower level of education, sunlight exposure, light iris color, low dietary fish intake, far-sightedness, higher body mass index, cardiovascular (heart) disease, and having a diet low in lutein and zeaxanthin/antioxidants^[6].

If you’re at risk for AMD because of your age, family history, or other factors, it’s important to get regular eye exams. Ask your doctor how often you need to get eye exams. Early AMD doesn’t have any symptoms, so don’t wait for your vision to change^[1].

How AMD is Diagnosed

An eye doctor makes an AMD diagnosis through a clinical examination with a slit lamp and by using several types of imaging^[6]. Your eye care provider can see signs of AMD even when symptoms aren’t evident^[2].

An eye doctor may diagnose macular degeneration by reviewing medical and family history and doing a complete eye exam. Other tests may be done, including^[11]:

• Examination of the back of the eye: An eye doctor puts drops in the eyes to dilate them and uses a special tool to examine the back of the eye. The eye doctor looks for a mottled appearance caused by yellow deposits called drusen that form under the retina.
• Test for changes in the center of vision: An Amsler grid may be used to test for changes in the center of the vision field. If you have macular degeneration, some of the straight lines in the grid may look faded, broken, or distorted.
• Fluorescein angiography (FA): During this test, an eye doctor injects a dye into a vein in the arm. The dye travels to and highlights the blood vessels in the eye. A special camera takes pictures as the dye travels through the blood vessels.
• Indocyanine green angiography (ICGA): Like fluorescein angiography, this test uses an injected dye^[11].
• Optical coherence tomography (OCT): This imaging technique is also used to diagnose AMD^[6].

Treatment Options

There is no cure for age-related macular degeneration, but there are treatments and support available to help slow down the changes in your vision and help you have the best quality of life^[9]. The type of treatment depends on the stage and the type of late-stage AMD you have: dry AMD or wet AMD^[9].

Treatment for Dry AMD

There’s currently no treatment for late dry AMD, but you can find ways to make the most of your remaining vision^[1]. However, people with intermediate-stage dry AMD may benefit from taking a special mix of supplements to decrease their risk of losing central vision^[10].

In clinical trials, an over-the-counter combination of vitamins and minerals called the AREDS2 formula showed benefit in preventing progression of intermediate dry AMD to late dry AMD. AREDS2 also may slow development of wet AMD^[10].

For advanced dry AMD with geographic atrophy, two drugs have been approved for use in the United States: Syfovre (pegcetacoplan) and Izervay (avacincaptad pegol). Both aim to reduce inflammation in the eye and are administered through eye injections either monthly or every other month^[14]. It’s important to note that the aim of both drugs is to slow the speed of deterioration. Neither drug claims to restore vision^[14].

Treatment for Wet AMD

Wet AMD cannot be cured, but its progression may be blocked with the use of intravitreal (in-the-eye) anti-VEGF injections. These injections may preserve, and even recover, vision^[6].

Anti-VEGF drugs have been developed to help stop neovascularization and preserve vision for AMD patients. VEGF (vascular endothelial growth factor) regulates the growth of abnormal new blood vessels in the eye^[6]. There are currently five different anti-VEGF drugs: Avastin (bevacizumab), Lucentis (ranibizumab), Eylea (aflibercept), Beovu (brolucizumab), and Vabysmo (faricimab)^[6].

Local anesthetic eye drops are given before the injections to numb the eye and minimize discomfort^[6]. There are three anti-VEGF treatment regimens: pro re nata (PRN) or “treat and observe,” “treat and extend,” and monthly injections^[6].

Additional treatment options for wet AMD include:

• Photodynamic therapy (PDT): This involves injections and laser treatment^[1]
• Laser surgery: Before anti-VEGF drugs were introduced, wet-AMD patients were treated with laser photocoagulation or photodynamic therapy^[6]

Anti-VEGF drugs have greatly improved wet-AMD treatment since 2005. Patients today have a much better chance of maintaining their central vision so they can read, drive, recognize faces, and live normal lives^[6].

Living with AMD

Learning that you have age-related macular degeneration can be worrisome for you and your family. Fortunately, most people with macular degeneration can retain good vision for their entire lives. Even those who lose their central vision almost always maintain their side, or peripheral vision^[17].

Through training and adaptive devices, leaning into your other senses, and practicing a healthy lifestyle, you can improve your level of independence and quality of life^[17].

Lifestyle Changes and Prevention

Managing macular degeneration goes beyond the doctor’s office. Lifestyle habits and proactive choices can slow the progression of the disease and help you maintain independence^[19]:

• Eat for eye health: A diet high in leafy greens, colorful fruits, and foods rich in omega-3 fatty acids can support retinal function. Dark green leafy vegetables like broccoli and spinach, fatty fish, nuts such as almonds and walnuts, and fresh fruit have been shown to improve eye health when enjoyed as part of a balanced diet^[19].
• Quit smoking: Smoking is one of the leading risk factors for macular degeneration. Quitting can slow the condition’s advancement^[19].
• Wear protective eyewear: Sunglasses that block harmful UV rays shield your eyes from unnecessary stress^[19].
• Control blood pressure and cholesterol: Managing these conditions with medication or lifestyle changes can help^[15].

Adapting Your Home Environment

People with macular conditions often find things take longer than before but, by learning new techniques, they can manage very well^[16]. Here are some helpful ideas:

• Improve lighting: Make the lighting in your home bright and even. Use task lighting to highlight what you are working on. Often, improving lighting and reducing glare is enough^[16].
• Use contrast: Use big, bright, bold, and contrasting colors to make it easier to differentiate items. For example, paint window and door frames a different color from the walls, use different colored chopping boards for different food types, or wrap brightly colored tape around the handles of utensils^[16].
• Low vision aids: Make the most of aids like non-slip mats, reading stands, and magnifiers. Use “talking” equipment such as microwaves, watches, scales, and timers. Large face clocks, watches, and mobile phones can be easier to see^[16].
• Technology assistance: Smart speakers and voice assistants can do everything from setting an alarm to turning on lights. You can also adjust the size of words and images on computers, tablets, or mobile phones^[18].

Visual Rehabilitation

Visual rehabilitation can help you adjust and function better with your remaining vision, although it cannot restore vision that has been permanently lost^[17]. Let your eye doctor know what kind of limitations you are experiencing due to your vision loss. Your doctor can prescribe optical devices, such as magnifiers, and may refer you to a vision rehabilitation center, eye clinic, or other organization where a low-vision therapist can make personalized recommendations^[17].

Most people with low vision are surprised to find out how much information they can obtain from their senses of hearing, touch, and peripheral vision^[17]. Try positioning things to make use of areas of sharper vision. With practice, you may find you can improve your ability to do tasks with peripheral vision. This is sometimes called “eccentric vision”^[18].