Age-Related Macular Degeneration (AMD)

What the macula does

The retina is the light-sensitive layer at the back of the eye. Its center, the macula, is only about 5 mm across but is packed with cone cells that give sharp, detailed and color vision. You use it to read, drive, recognize faces and see fine detail. Under the retina lies a support layer (the retinal pigment epithelium) and a blood-rich layer (the choroid). AMD damages these structures.

Types and stages of AMD

Dry AMD

Yellow deposits called drusen build up under the retina, and the support cells gradually thin and die.

Wet AMD (neovascular)

Abnormal blood vessels grow from the choroid under the macula, driven by a protein called VEGF. They leak fluid and blood, which distort and damage the retina quickly. Wet AMD makes up a minority of cases but causes most severe vision loss. Any stage of dry AMD can convert to wet.

Symptoms

• straight lines, such as door frames or tiles, look wavy or bent (distorted vision)
• blurred or fuzzy central vision
• a dark, gray or empty area in the center of vision
• needing brighter light for reading and close work
• difficulty recognizing faces
• colors look less bright
• slow adjustment from bright light to dim light

Because the other eye often compensates, early changes in one eye may go unnoticed. Peripheral vision is preserved, so people can usually walk around independently.

Some people with significant vision loss see vivid, silent visual hallucinations such as patterns, faces or scenes, knowing they are not real. This is Charles Bonnet syndrome, a reaction of the brain to lost visual input, not a mental illness.

Risk factors

• Age: risk rises sharply after 60
• Smoking: roughly doubles to triples the risk, and is the most important factor you can change
• Family history and specific genes (such as CFH and ARMS2)
• White race
• High blood pressure, heart disease, high cholesterol and obesity
• Diet low in leafy green vegetables and fish

Diagnosis

An eye doctor (ophthalmologist or optometrist) will:

• test visual acuity and check with an Amsler grid, a square grid of lines with a central dot
• examine the retina after dilating the pupils
• perform optical coherence tomography (OCT), a quick, painless scan that shows retinal layers, drusen and fluid. It is the key test for diagnosing and monitoring wet AMD
• sometimes use fluorescein or OCT angiography to show abnormal blood vessels
• take retinal photographs and fundus autofluorescence images to track geographic atrophy

Treatment

Dry AMD

• AREDS2 supplements: for people with intermediate AMD or late AMD in one eye, a specific formula of vitamin C, vitamin E, zinc, copper, lutein and zeaxanthin reduces the risk of progression to advanced AMD by about 25% over 5 years. It does not help early AMD or prevent AMD. The original AREDS formula contained beta-carotene, which raises lung cancer risk in smokers and former smokers; AREDS2 replaced it.
• Geographic atrophy treatments: pegcetacoplan and avacincaptad pegol, FDA-approved eye injections given monthly or every other month, slow the growth of atrophy. They do not restore vision.
• Monitoring for conversion to wet AMD with regular exams and home Amsler grid checks.

Wet AMD

• Anti-VEGF injections: medicines such as aflibercept, ranibizumab, bevacizumab and faricimab are injected into the eye after numbing drops. They stop abnormal vessels from growing and leaking. Most people keep their vision stable, and about a third gain vision. Injections usually start monthly, then are spaced out to every 8 to 16 weeks if the eye stays dry.
• Photodynamic therapy is used occasionally.
• Starting treatment early, within days to weeks of symptoms, gives the best results.

Low vision rehabilitation

Magnifiers, high-contrast and large-print materials, good task lighting, electronic reading devices, screen readers, and training in using peripheral vision (eccentric viewing) help people stay independent.

Complications and outlook

AMD does not cause complete blindness because side vision remains. Advanced AMD in both eyes can make reading, driving and recognizing faces impossible. Vision loss raises risks of falls, depression and social isolation, which low vision services and support can reduce. With anti-VEGF treatment, outcomes for wet AMD have improved dramatically.

Prevention

• Do not smoke, and stop if you do.
• Eat leafy green vegetables (spinach, kale), colorful fruit and vegetables, and fish at least twice a week.
• Control blood pressure and cholesterol, and stay active.
• Wear sunglasses that block UV light.
• Have regular dilated eye exams after 50, and test each eye on an Amsler grid weekly if you have AMD.

Frequently asked questions

What is the difference between wet and dry macular degeneration?

Dry AMD involves slow thinning of the macula and drusen deposits, causing gradual vision loss over years. Wet AMD occurs when abnormal blood vessels grow and leak under the macula, causing faster, more severe loss. Wet AMD is treated with eye injections; dry AMD is monitored and treated with supplements in some stages.

What are the first signs of macular degeneration?

Early AMD often has no symptoms and is found on eye exams. The first noticeable signs are usually needing more light to read, slight blurring of central vision, and straight lines appearing wavy. Sudden distortion or a new dark spot needs prompt assessment.

Can macular degeneration be cured?

There is no cure, but treatment can control it. Anti-VEGF injections stabilize vision in most people with wet AMD. AREDS2 supplements slow progression of intermediate dry AMD, and newer injections slow geographic atrophy. Low vision aids help with daily tasks.

Does macular degeneration cause total blindness?

No. AMD affects central vision, but side (peripheral) vision is preserved. People with advanced AMD may be legally blind and unable to read or drive, but they can usually still move around and see shapes at the edges of their vision.

Should I take AREDS2 vitamins?

AREDS2 vitamins are recommended for people with intermediate AMD or advanced AMD in one eye. They have not been shown to prevent AMD or help early AMD. Ask your eye doctor which stage you have before starting them.