Department of Ophthalmology
Case Studies

Case 11


CC: Blurry vision x 2 weeks in left eye

 History

HPI: A 72 year old Caucasian female reports that approximately 2 weeks ago she noticed the onset of decreased vision in her left eye associated with a “black spot” close to the center of her vision. The spot is present with both near and far vision and does not move away. The vision has been slightly blurred for a while. She denies any recent trauma, eye pain, redness or discharge. Peripheral vision is normal.

POHx: None - has not seen an eye care provider in 20 years. No known history of trauma, surgery, lasers, strabismus, amblyopia, glaucoma, or other ocular conditions.

Ocular medications: None

PMHx: Hypertension, hypercholesterolemia, coronary artery disease s/p myocardial infarction s/p stenting of LAD 5 years prior

Medications: ASA, Plavix, Lipitor, Lisinopril, Metoprolol

FOHx: No evidence of blinding diseases, glaucoma or macular degeneration

Social Hx: Past 50 pack/year smoking history. No alcohol or drug use. Currently retired and living with her husband in Cedarburg.

 Exam

VAcc: OD 20/30; OS 20/100

Pupils: round and reactive bilaterally, no APD OU

CVF: Grossly intact bilaterally

EOM: Full bilaterally

Tap: OD – 16 mmHg; OS – 17 mmHg

Amsler grid exam: OD – normal; OS – Blurry spot near the center of the grid with wavy lines

External: No abnormalities noted

SLE OD OS
L/L wnl wnl
C/S white/quiet white/quiet
K clear clear
AC deep/quiet deep/quiet
I r/r r/r
L1+ NSC 1+ NSC


DFE:
OD – Sharp disc margins, c/d – 0.5, vessels normal size/course, scattered large soft drusen present within the arcades
OS – Sharp disc margins, c/d – 0.6, vessels normal size course, scattered soft drusen, subretinal hemorrhage in macular area
 

 Discussion

Differential Diagnosis-
The appearance of bilateral soft drusen and an area of subretinal hemorrhage in the left eye is consistent with the diagnosis of wet age-related macular degeneration. The subretinal hemorrhage is most likely due choroidal neovascularization (CNV). Other causes of subretinal hemorrhages and decreased vision include retinal arterial macroaneurysms, diabetic retinopathy, hypertensive retinopathy, valsalva retinopathy and other causes of CNV (high myopia, angioid streaks, presumed ocular histoplasmosis or trauma).

Definition-
Age-related macular degeneration (AMD) is a degenerative retinal disease. Two main types exist although many classification schemes are in use. Dry AMD is characterized by the appearance of hard or soft drusen and/or areas of retina pigmented epithelium (RPE) loss or hypertrophy. Large areas of RPE loss, termed geographic atrophy, are mainly responsible for decrease vision in this type of AMD. Wet AMD, comprising 15% of all AMD cases, results in severe central visual loss if not treated promptly. In wet AMD pathologic choroidal neovascular membranes develop under the retina, RPE or both resulting in destruction of retinal architecture and formation of fibrovascular scars and vision loss. Risk factors for the development of AMD are genetic and environment and include mutations in the complement factor H gene, family history of AMD, age and white race. Many associations with other diseases exist including smoking and hypertension. High risk populations for progression from dry to wet AM include those with large drusen, many intermediate-sized drusen, non-central geographic atrophy, or advanced AMD in the other eye.

Examination-
Patients with AMD are recommended to monitor their vision, each eye separate, with the Amsler grid (a series of horizontal and vertical lines forming a grid of squares). Appearance of a blind spot or waviness of the straight lines (metamorphopsia) could signal alterations in the photoreceptor layer and should be evaluated for the development of wet AMD. Fluorescein angiogram (FA) is the gold standard to identify areas of abnormal vasculature within or under the retina consistent with CNV. Typical findings include areas of hyperfluorescence +/- leakage. The optical coherence tomography (OCT) technique allows for identification of intra or subretinal fluid in the macula. In patients with CNV this corresponds to extravasation of fluid from leaky capillaries. Response to therapy is seen with improvement of vision, decrease of fluid in OCT and decrease of leakage and/or hyperfluorescence in FA.

Treatment-
The age-related eye disease study (AREDS) vitamin formulation is recommended for patients with severe forms of dry AMD. These vitamins (a specific combination of vitamins A, C, E, zinc and copper) have been shown to decrease the progression of AMD. For vision-threatening wet AMD, the most effective therapy is anti-vascular endothelial growth factor (VEGF) agents. Prompt treatment can stabilize or improve visual acuity in 2/3 of patients. Other less successful treatment modalities include photodynamic therapy and laser photocoagulation.

 Questions
  1. What are the typical signs and symptoms in patients with dry and in wet AMD?

  2. How should patients monitor their vision for the development of changes associated with progression of AMD and why is this important?

  3. What therapeutic options are available for patients with dry and wet AMD?

Contact Us

For questions regarding the cases:

Wanda M. Martinez, MD, PhD Email

Kimberly E. Stepien, MD Email

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