Neovascular Age-Related Macular Degeneration

Neovascular age-related macular degeneration is a serious eye disease that can cause rapid vision loss when abnormal blood vessels grow behind the central part of your eye’s retina.

Table of contents

• What is neovascular age-related macular degeneration?
• Signs and symptoms
• Causes and how it develops
• Who is at risk?
• Global burden and impact
• How is it diagnosed?
• Treatment options
• Living with neovascular AMD

What is neovascular age-related macular degeneration?

Neovascular age-related macular degeneration (also called wet AMD, exudative AMD, or nAMD) is a progressive eye disease that affects the macula, which is the central part of the retina responsible for sharp, straight-ahead vision^[1]. The retina is the light-sensitive tissue at the back of your eye that sends information to your brain to enable sight^[2].

The defining feature of this condition is the growth of new, abnormal blood vessels beneath the macula. These blood vessels are fragile and prone to leaking blood and fluid^[3]. When these vessels leak, they can cause swelling, bleeding, and scarring that damages the macula^[2]. This damage leads to a loss of central vision, making it difficult to see fine details, read, recognize faces, or drive^[4].

Although wet AMD is less common than dry AMD, it is more serious and accounts for almost 90% of blindness associated with age-related macular degeneration^[1]. Wet AMD is always considered an advanced stage of the disease^[6]. However, it’s important to know that AMD does not cause complete blindness—your peripheral vision (ability to see things off to the sides) remains intact^[6].

wet AMD, exudative AMD, advanced neovascular AMD

• Macula
• Retina
• Choroid

Signs and symptoms

Many people with AMD do not immediately recognize the symptoms, mistaking them for normal signs of aging^[2]. However, when wet AMD develops, symptoms can appear suddenly and progress quickly^[4].

The most common symptoms include:

• Straight lines appearing bent, wavy, or crooked—this is often a warning sign for late AMD^[4]
• Blurred vision, particularly in the center of your visual field^[2]
• Dark, blurry areas or blank spots developing in the center of your vision^[4]
• Difficulty seeing at a distance or doing detailed work^[2]
• Trouble distinguishing between colors, with colors appearing less bright than before^[4]
• More difficulty seeing in low lighting^[4]

If you notice straight lines looking wavy or crooked, or if you develop any sudden changes in your vision, see your eye doctor right away^[4]. Early detection and prompt treatment can help preserve your vision.

Causes and how it develops

The exact cause of neovascular AMD is not fully understood, but the condition develops as the eye ages^[4]. The disease involves abnormal neovascularization, which is the medical term for the growth of new blood vessels^[3].

In wet AMD, these abnormal blood vessels grow beneath the macula. Health experts may also call these vessels macular neovascular membranes or choroidal neovascularization^[3]. Because these new blood vessels are fragile and poorly formed, they leak blood and fluid into the surrounding tissue. Over time, this leakage can turn into a scar that replaces the normal structure of the outer retina and leads to permanent loss of central vision^[4].

A key factor in this process is a protein called vascular endothelial growth factor (VEGF), which promotes the growth of abnormal new blood vessels in the eye^[4]. This is why many treatments for wet AMD target VEGF.

Who is at risk?

Your risk for developing neovascular AMD increases with several factors. Age is the strongest risk factor—the condition primarily affects elderly people, particularly those over age 60^[1][2].

Other important risk factors include:

• Family history: Having relatives with AMD increases your risk^[2][6]
• Race: The condition is more common among Caucasian populations compared to African, Hispanic, and Asian populations^[1][2]
• Smoking: Smokers are 2 to 5 times more likely to develop AMD^[2]
• Gender: Women are at higher risk than men^[2]
• Obesity: Being overweight increases risk^[2][6]
• High blood pressure: Hypertension is linked to increased risk^[6]
• Diet: A diet high in saturated fats or low in fish intake may increase risk^[4]
• Light iris color: People with lighter-colored eyes may be at increased risk^[4]

Because early AMD often has no symptoms, it’s important to get regular eye exams if you have risk factors, especially as you get older^[4].

Global burden and impact

Neovascular AMD affects approximately 20 million people worldwide^[2]. Age-related macular degeneration as a whole is the leading cause of significant vision loss in people over age 50 in developed countries^[1]. In the United States alone, about 200,000 new cases of neovascular AMD are diagnosed each year^[9].

The number of people affected by AMD globally is expected to rise dramatically. Estimates suggest that the worldwide population with AMD will reach 288 million by 2040, up from 196 million in 2020^[1][2]. This increase is due largely to increasing lifespans globally and changes in diet and lifestyle^[1].

The disease has a significant impact beyond vision loss. Impaired vision can affect your ability to carry out everyday tasks, work, and lead an active social life^[2]. People with wet AMD may find it difficult to see or recognize faces, read, drive, or watch television^[2]. This can lead to increased social isolation, depression, and anxiety disorders^[2].

How is it diagnosed?

A diagnosis of wet AMD is made through a clinical examination and several types of imaging tests^[4]. Your eye doctor will perform a dilated eye exam using a special microscope called a slit lamp to look at the back of your eye^[4].

Several specialized imaging tests may be used to confirm the diagnosis and assess the extent of the disease:

• Optical coherence tomography (OCT): This non-invasive imaging test creates detailed cross-sectional images of your retina and can show fluid buildup and structural changes. All clinical practice guidelines recommend OCT for initial diagnosis of wet AMD^[12]
• Fluorescein angiography (FA): A dye is injected into your arm, and special photographs are taken as the dye travels through the blood vessels in your eye, revealing leaking vessels^[4]
• Indocyanine green angiography (ICGA): Similar to fluorescein angiography but uses a different dye that can show blood vessels beneath the retina more clearly^[4]
• Optical coherence tomography angiography (OCTA): A newer, non-invasive imaging technique that can visualize blood vessels without injecting dye^[4]

Getting an annual eye test is the best way to detect any changes in vision early^[2]. If you have been diagnosed with AMD, you may be given an Amsler grid—a simple chart with straight lines—to check your vision at home daily^[20].

Treatment options

While wet AMD cannot be cured, its progression can be slowed or stopped with treatment, and in many cases, vision can be preserved or even improved^[4]. There are two main treatment approaches available.

Anti-VEGF injections

The most common and effective treatment for wet AMD is anti-VEGF injections. These medications work by blocking vascular endothelial growth factor, the protein that promotes the growth of abnormal blood vessels in your eye^[7]. The treatment has revolutionized wet AMD care in recent years^[4].

There are currently five FDA-approved anti-VEGF drugs available:

• Avastin® (bevacizumab)
• Lucentis® (ranibizumab)
• Eylea® (aflibercept)
• Beovu® (brolucizumab)
• Vabysmo® (faricimab)^[4]

When you receive this treatment, your doctor will first put numbing medicine in your eye, then clean your eye to prevent infection, and finally inject the anti-VEGF medicine into your eye with a very small needle^[7]. The procedure is done in the office and typically causes minimal discomfort due to the anesthetic drops^[4].

Anti-VEGF injections usually only work for a short time, so most people need repeated treatments^[7]. There are three common treatment schedules:

• Monthly injections: Regular injections given every month, though this approach is less commonly used now^[4]
• As-needed (PRN) approach: After three initial monthly injections, you receive treatment only when signs of disease activity return^[4]
• Treat-and-extend: After three initial monthly injections, the time between treatments is gradually increased as long as the disease remains controlled. Some patients may eventually only need treatment every 10 to 16 weeks^[4]

Your retina specialist will work with you to determine the best treatment schedule for your specific situation^[11].

Photodynamic therapy

Photodynamic therapy (PDT) is a less common treatment that doctors sometimes use along with anti-VEGF injections^[7]. This treatment uses a light-sensitive medicine called verteporfin combined with a special type of laser.

During the procedure, your doctor will give you a shot of verteporfin in your arm, put numbing medicine in your eye, place a special contact lens on your eye, and then shine a laser onto the abnormal blood vessels^[7]. The laser activates the medicine, which then breaks down the blood vessels causing your vision loss. Some people will need more than one PDT treatment^[7].

Treatment outlook

Current treatments can slow the progression of wet AMD and help preserve vision, but they do not cure or reverse the disease’s course^[1]. You will likely need ongoing treatment and regular monitoring. Many patients experience relatively quick resolution of fluid and bleeding within 3 to 4 injections during the initial treatment phase^[11].

Research continues into newer therapies, including gene therapies and other novel approaches that may offer additional treatment options in the future^[1].

Living with neovascular AMD

Learning that you have neovascular AMD can be worrisome, but most people with the condition can retain good vision for their entire lives with proper treatment and management^[18]. The best way to adapt to any vision loss is to learn new ways of doing things.

Monitoring your vision at home

If you have been diagnosed with wet AMD, it’s very important to check your vision daily using an Amsler grid^[20]. Put the grid somewhere you’ll see it every day, such as on your refrigerator or bathroom mirror. Contact your eye specialist immediately—ideally on the same day—if you notice your vision getting worse or develop new symptoms^[16].

Adapting your home environment

Small changes at home can make a big difference in maintaining your independence:

• Make the lighting in your home bright and even. Use task lighting to highlight what you are working on^[17]
• Increase lighting in key areas like the kitchen, bathroom, and reading spaces^[19]
• Use high-contrast settings—for example, use brightly colored glasses when making drinks, or different colored chopping boards for different foods^[17]
• Paint window and door frames a different color from the walls to make them easier to see^[17]
• Remove tripping hazards and use color contrast on stairs, corners, and edges to help them stand out^[20]

Using helpful devices and technology

Many devices can help you with daily activities:

• Magnifiers and electronic magnification devices for reading^[17]
• Large-face clocks, watches, and mobile phones^[17]
• “Talking” equipment such as microwaves, watches, scales, and timers^[17]
• Smartphones and tablets with accessibility features like voice commands and text-to-speech^[19]
• Books, newspapers, and magazines in large print or audio formats^[17]

A low vision specialist can evaluate your needs and recommend specific aids and devices tailored to your situation^[18][19].

Lifestyle and health management

Taking care of your overall health can help slow the progression of AMD:

• Eat a balanced diet that includes lots of fruit, fish, and green leafy vegetables^[16]
• Exercise regularly to support overall health^[16]
• Maintain a healthy weight^[16]
• Stop smoking if you smoke^[16]
• Control your blood pressure and cholesterol with medication or lifestyle changes^[13]

Talk to your doctor about taking supplements targeted to eye health, such as vitamins C and E, zinc, copper, lutein, and zeaxanthin. However, these supplements are not suitable for everyone, so always consult with your doctor first^[13][16].

Staying active and connected

Social connections and physical activity are important for your overall well-being:

• Join support groups to connect with others who understand your challenges^[18]
• Participate in fitness programs, even those designed for people with low vision^[18]
• Continue to engage in hobbies and activities you enjoy, adapting them as needed^[18]

Most people with low vision are surprised to find how much information they can obtain from their senses of hearing, touch, and peripheral vision^[18]. Learning to use these other senses more effectively can help you maintain independence.

Getting support

Living with AMD can be difficult, and it’s normal to feel worried or sad about vision changes. If you’ve been feeling low for more than 2 weeks, see your doctor—they can offer support and treatment if you need it^[16]. Various organizations also provide support, information, and resources for people living with macular degeneration^[18].

Remember to continue having routine eye tests, usually every 2 years, as these can pick up other eye problems that your AMD check-ups do not look for^[16].