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CC March 2017 Age Related Macular Degeneration (AMD)

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echoecho's version from 2017-06-05 04:46

Section

Question Answer
What is the second leading cause of irreversible vision loss (after diabetic retinopathy) among patients 50 years of age or older in developed countries?AMD (age-related macular degeneration)
In 2002, WHO estimated that how many million of people worldwide were affected by AMD?14
In the US, how many million of people have AMD? The number is projected to increase by what % by 20208; 50%
How many million of people will have the advanced stages of the disease (serious visual impairment and compromised quality of life)?3
Is the prevalence of AMD equal in men and women?yes
What are the multiple factors that influence AMD?1) older age (one population found 64% of those > 80 y.o had early and late signs of AMD) 2)ethnicity (predominant among whites) 3)genetics (various genes with polymorphism increase risk) 4) geography (more prevalent in developed countries
List three modifiable risk factors?1) smoking 2)obesity 3)HTN
The 5 year risk of advanced AMD is ____ times higher among current smokers?4
Define geographic atrophy?the advanced stage of dry AMD affecting the retinal pigment epithelium (RPE)
The risk of geographic atrophy is ____ times higher among ex-smokers?3
Has alcohol consumption been identified as a significant risk factor?no
What is likely the etiology and mechanism of disease in AMD?unclear, though likely the result of altered immune-inflammatory response to deposits of debris in individuals who are genetically predisposed
List the two classifications of AMD?1) dry (nonexudative or a tropic) 2) wet (neovaswcular)
What % of all cases are dry AMD? What are two characteristics of dry AMD?1) 90% 2) milder and gradual visual symptoms
What are the diagnostic features of dry AMD?yellow deposits of protein and lipid (druses) of various sizes beneath the retinal photoreceptors between the RPE and the Bruch's membrane
What are the late diagnostic features of dry AMD?loss of RPE and photoreceptors resulting in geographic atrophy and macular pigment changes
What % of all cases are wet AMD, but is the cause of what % of severe visual impairment (vision < 20/200)?1) 10% 2)90%
What are the diagnostic features of wet AMD?hemorrhages and exudates secondary to neovascularization of the choroidal blood vessels beneath the retina producing acute, rapid visual loss
List the symptoms which can occur in AMD and this depends on the type and stage of the disease?1) impaired central vision 2) scotoma (central visual field defects) 3)metamorphosis (distortion of images) 4)difficulty of dark adaptation 5) difficulty with reading and facial recognition
True or false? Early dry AMD may progress to an advanced stage of the disease, and a portion may progress to wet AMD and more advanced disease?true
One report reported 13.8% of patients who had b/l medium druses progressed to advanced AMD over a ____ year follow-up period?10
*** Currently, the US Preventive Services Task Force (USPSTF) concludes that there is _______ (insufficient vs. sufficient) evidence to recommend for or against routine screening of visual impairment among adults older than 65 years old?insufficient
History and physical exam including what 3 tests frequently can establish the diagnosis of AMD?1) visual acuity 2)dilated fund us copy 3) Amsler grid test
Describe OCT (optical coherence tomography)?employs laser scanning for evaluation of subretinal exudates, macular edema, druses and alteration/detachment of the RPE (retinal pigment epithelium)
Describe FA (fluorescein angiography)?sensitive to detecting the presence of choroidal neovascularization and ruling out other etiologies of retinal hemorrhage (aneurysm, a good streaks and polypoidal choroidal vasculopathy)
Describe IGA (indocyanine green angiography)?evaluates the choroidal circulation better than FA
At present is there any proven therapy to prevent dry AMD?no
***Patients are risk or with a new diagnosis of AMD should be counseled against what?cigarette smoking
What else should a new diagnosed AMD patient be doing in way of diet? eat a healthy diet (fresh fruits and vegetables with high content of natural antioxidants - though current evidence supporting this is weak)
Conflicting studies regarding risk for development or progression of AMD and aspirin are present, however, based on a large meta-analysis, was there increased risk? What are the recommendations of the AAO (American Academy of Ophthalmology) regarding taking ASA?1) no increased risk 2) continue taking ASA if recommended by a physician
*** For patients who have intermediate or advanced dry AMD, the AAO recommends what?considering antioxidant vitamin and mineral supplementation based on findings of 2 large clinical trials and AREDS2
What does the original formula of supplementation in AREDS consist of?1) vit C (500 mg) 2) vit E (400 IU) 3) beta-carotene (15 mg) 4) zinc oxide (80 mg) 5) cupric oxide (2 mg)
In the study, those who were at risk of developing advanced stages of AMD and took the AREDS supplement over ____ years had a relative risk reduction of 25% of progression to further vision loss?6.3
Subsequently, beta-carotene has been found to be associated with increased risk of ____ cancer among smokers?lung
Because of the above, what is the formulation of AREDS2 currently?beta carotene was removed from the original formula and replaced by lutein plus zeaxanthin, omega-fatty acid or both
Comment on the change of formulation to AREDS2 as it relates to omega-3 fatty acids benefit and lutein benefit?1) omega-3 fatty acid supplementation showed NO additional benefit 2) luetin plus zeaxanthin may have some effect in reducing progression to advanced AMD among subgroup with large druses
Was lutein plus zeaxanthin associated with an increased risk of lung cancer?no
Because of not all formulations are the same in the above studies so the AAO has a list of products, true or false?true
*** What is now accepted as preferred first-line therapy for the treatment of wet AMD and are recommended by the 2014 AAO Preferred Practice Pattern panel?VEGF inhibitors (vascular endothelial growth factor inhibitors)
List what VEGF inhibitors do?1)suppress growth of neovessels 2)decreasing exudates and hemorrhages 3) reduce progression of disease 4) restoring lost vision
When are VEGF inhibitors most effective?when administered early (<7 weeks compared to > 21 weeks) after onset of symptoms of wet AMD
What medication was first approved by the FDA in 2004 for treating endovascular AMD?Pegaptanib sodium (Macugen)
Describe what Pegatanib is?it is a messenger RNA aptamer that BINDS and inhibits VEGF (vascular endothelial growth factor)
In clinical studies, pegaptanib reduced ____ vision loss but failed to improve ____?progressive; vision
Is Pegaptanib rarely used now?yes
What has Pegaptanib been replaced with?intravitreal injection of monoclonal antibodies that bind and inhibit VEGF (vascular endothelial growth factor)
Pegaptanib has been replaced by what medications?1) Ranibizumab (Lucentis) received FDA approval in 2006 2) Bevacizumab (Avastin) is widely used as FDA off-label option due to its comparable efficacy and much lower cost
*** A 2014 Cochran review concluded that anit-VEGF-monoclonal antibodies (Ranibizumab and Bevacizumab) and messenger RNA aptamers (Pegaptanib) are effective in maintaining visual acuity, but only the ______ improve visual acuity?monoclonal antibodies
Generally, intravitreal VEGF monoclonal antibodies are dosed _____?monthly
What are the complications of intravitreal VEGF?1) endophthalmitis 2)retinal hemorrhage 3)retinal detachment 4)increased intraocular pressure
What is the newest FDA-approved agent for treating endovascular AMD?Aflibercept (Eylea), which is a fusion protein containing VEGF receptor ligand-binding chains. Given q 8 weeks intravitreal
*** A 2016 Cochran found that afilbercept (Eylea) is equally effective in proving visual acuity and morphological outcomes in eyes with _______ AMD when compared to monthly ranibizumab treatments?endovascular
There is some evidence that vit and mineral supplements used in dry AMD may be of benefit to what other individuals? those with early dry AMD in one eye and wet AMD or visual loss due to AMD in the other
Why are some other therapies such as laser photocoagulation and surgery (excision of neovascular macular degeneration or translocation of macula to a different retinal site) infrequently performed?because of disappointing outcomes and serious potential complications
memorize
Implantable miniature telescopes can be helpful in carefully selected patients, with end-stage neovascular AMD
Question Answer
Patients with low vision should be referred to a ___-___ specialist?low vision
*** SUMMARY = AMD is a significant cause of vision loss in the USA, affecting ______ million people over the age of 50 y.o.?8; ?
memorize
*** SUMMARY = The nonexudative (dry) form is more common, but the ______ (wet) form is more aggressive and accounts for 90% of vision loss attributed to AMD? Neovascular (wet)
Question Answer
*** SUMMARY =True or false? Controversy exits regarding strategies for prevention and reduction of vision loss using antioxidants and vitamin and mineral supplements?true
*** SUMMARY = How is neovascular AMD treated?intravitreal injections of biological agents including mono loan antibodies that inhibit vascular epithelial growth factor (VEGF)
memorize