AGE-RELATED MACULAR DEGENERATION

Age – related Macular degeneration, also called, AMD is a common eye disease that may occur after the age of 50 and is the most frequent cause of loss of central vision.

The MACULA is the central part of the retina. Its function is to distinguish fine details and essentially torecognize, characters while reading and distinguish them from another. It allows us to write, read and ride. 

When the macula becomes ill, it can no longer perceive the details of the images even while the remaining peripheral parts of the retina, are not affected by the disease and continue to function normally.


Macula

The symptoms of this disease are:

1. Initially impaired color vision and contrast.

2. A reduction in vision (vision loss).

3. A deformation of the image and the disappearance of a part of it.

4. In later stages it appears as a black spot in the center of the visual field, which remains central with eye movements, preventing reading. This spot is called the Scotoma Central.



Decreased visual acuity
The Amsler test
Central scotoma

There is an initial form, which does not involve major visual changes, but that can evolve in two advanced forms, seriously debilitating:
a dry maculopathy (DRY) and a wet maculopathy (WET).

Macular degeneration

In dry Maculopathy, in 90% of cases, the defect in nourishment causes atrophy to the retina, making it thinner in an irreversible way.

In wet Maculopathy, 10% of cases result from the alterations in the metabolism involving the growth of new capillaries or CNV (Choroidal Neovascularization) in an attempt to oppose the lack of oxygen supply.

Unfortunately these new capillaries that form under the macula, leave escape liquids and blood because of their fragility thus causing damage.


Choroidal neovascularization
Subretinal neovascularization
Macular degeneration without exudation

The treatment of macular degeneration follows guidelines that include intravitreal injections, photodynamic therapy, laser and macular translocation surgery.

Laser therapy
terapia fotodinamica
INIEZIONE INTRAVITREALE

The antiangiogenic drugs are monoclonal antibodies that selectively attack the vessels in proliferation and block the development. Commercially available, these 3 antiangiogenic drugs (Lucentis, Macugen and Avastin), are injected into the vitreous chamber in the eye. They selectively bind to the principal of neovascularization growth factor (VEGF), locking it (drugs antiVEGF).

The Protocol adopted by Dr. Panico, provides a series of three endovitreali injections with one month intervals, as initial therapy.

Post that, repeated OCT checks are done each month and if required the fluorescein angiography test is also be done. If the OCT is positive for a recurrence, we practice a new intravitreal. 

It is here that you can try to surgically intervene with the retinal translocation. When these treatments fail or cannot be carried out, the evolution of the most severe forms of AMD both dry and wet increases,causing further loss of vision. We can alter the position of the retina sufficiently to move the pigmented epithelium to an area where it will be unaffected and then resume operation.


Dr. Panico’s Clinic is one of the 5 centres in Italy that provide this Service


amd e invecchiamento

Wet macular degeneration can also occur in people already affected by dry macular degeneration causing severe visual reduction in most cases. Age-related macular degeneration can

 affect either one eye or both, although this could happen at different times. The chances of this developing in the contra - lateral eye disease is 7% per year. It is currently affecting the elderly population in varying degrees. According to studies, it affects people in the ultra 75s.

ITALY in the ultra 50s may be affected more than 3.5 million.


FAQs for Age-Related Macular Degeneration

WHAT ARE THE CAUSES OF MACULAR DEGENERATION?

The causes are a combination of genetic and environmental factors resulting in the aging of the tissues of the macula. When the ultraviolet (UV) rays of sunlight penetrate the eye, they interact with oxygen to form aggressive molecules, called free radicals and these damage the rods and cones.

degenerazione maculare
patogenesi dell'amd

These are the cells responsible for vision. From the damaged cells, waste material called drusen in the form of yellowish heaps are produced in the thickness of the macula.

drusen

HOW MANY FORMS OF MACULAR DEGENERATION ARE THERE?

There is an initial form, which causes visual changes but which can evolve in two seriously debilitating advanced forms:

Dry and a wet macular maculopathy

forme degenerazione maculare

In dry Maculopathy, in 90% of cases, the defect in nourishment causes atrophy to the retina, making it thinner in an irreversible way.

In wet Maculopathy, 10% of cases result from the alterations in the metabolism involving the growth of new capillaries or CNV (Choroidal Neovascularization) in an attempt to oppose the lack of oxygen supply.

Unfortunately these new capillaries that form under the macula, leave escape liquids and blood because of their fragility thus causing damage.


neovasi coroideali

MACULAR DEGENERATION SENILE: FORM EXUDATIVE (neovascular

Can you prevent age-related Macular degeneration?

DEGENERAZIONE MACULARE SENILE SENZA ESSUDAZIONE

Retina

Subretinal neovascularization with liquid

Choroid

Age-related Macular Degeneration without exudation


fattori di rischio

AMD is a multi-factorial disease related to genetic predisposition, aging, exposure to adverse environments and lifestyle.

1. The ETA is the main risk factor.

Age-related macular degeneration affects 30% of people with more than 75 years.

2. INHERITANCE. 

When there are cases of macular degeneration (AMD) in the family, the risk that another member in the family develops the disease increases by 19 times. 

The incidence of familial cases is between 5% and 20%.

3. Gender and Rice 

A woman over 75 years of age has twice the chance than a man of the same age to contract this disease. Similarly, Caucasians have a higher probability than those of other races. While you cannot change your age, your gender, race or your own family tree, you can surely change a few habits to protect your eyes. 


4. HEART DISEASE. 

Having high blood pressure or heart disease reduces blood circulation to the eyes.


5. SUNLIGHT 

The cells of the macula are highly sensitive to sunlight. People with blue eyes are more prone to the damage caused by the sun.


6. DIET 

The macular cells are extremely sensitive to the damage done by free radicals. Monitoring cholesterol, saturated fats and alcohol will help reduce the risk and unwanted exposure.

7. SMOKE 

Smoking reduces the amount of protective antioxidants present in the eye doubling the risk of onset of age-related macular degeneration.


What can you do to protect your eyes?


• Wear sunglasses when exposed to sources of ultraviolet light.

• Wear hats with visor to protect the eyes from direct sun rays or reflections.

• Keep in check your blood pressure and cholesterol levels.

 • Monitor any cardiovascular disorders. 

• Lead a healthy life with regular physical activity. 

• Eating fish regularly helps

• Avoid smoking.

• Limit saturated fats in your diet.

• Limit your intake of alcohol.

• Follow a diet low in fat and rich in fruits and green leafy vegetables. 

If you are unable to follow a diet with sufficient intake of the necessary nutrients, you can instead consume supplements containing balanced amounts of antioxidants, including lutein.


obesità

Photochemical oxidative damage is an important aspect in the pathogenesis of AMD.


Selenium and other trace elements contribute to ensure the efficiency of essential enzyme complexes as part of the defenses against oxidative stress.

The antioxidant vitamins A, C and E are able to play a prophylactic role against age-related macular damage.

Carotenoids protect the macular area.

The omega 3 fatty acids are essential to help modulate inflammation.


WHAT TREATMENTS ARE AVAILABLE?

terapie e farmaci antiangiogenici

The anti-angiogenic drugs are monoclonal antibodies that selectively attack the proliferating vessels and block the development, without affecting the physiological tissue. They are currently the elective therapy for exudative forms of AMD.

This treatment leads to remission and marked improvements, but the patient has to continuously follow it as there is always the risk of recurrence. The blockade of neovascularization is temporary, as there a chronic stimulus to vascular proliferation. After one or two years of therapy you can observe a remarkable improvement and a stable healing process. Currently, 3 antiangiogenic drugs (Lucentis, Macugen and Avastin) are commercially available. These drugs are injected into the eye (in the vitreous chamber) and selectively bind the principal of neovascularization growth factor (VEGF) and lock (anti VEGF drugs).

The Protocol adopted by DR. Panico provides a series of three endovitreali injections with one- month intervals as initial therapy. Following this are the repeated OCT check-ups every month and a fluorescein angiography if necessary. 


niezione intravitreale di antiangiogenici

Topical anesthesia is given to the patient in the operating room to ensure maximum sterility. We advice the use of antibiotic eye drops continuously for 5 days to prevent infectious complications.

 We give importance to TMB that currently prevents invasive tests with IV lines of dyes.



terapia fotodinamica

Photodynamic therapy with verteporfin (or PDT), involves the intravenous injection of a photosensitive substance (ie sensitive to light), which when activated by a non-thermal light, causes the closure of the blood neovascularization without damaging the other healthy tissues. Such therapy is performed in hospitals or in specialist centers and sometimes has to be repeated. After the introduction of anti VEGF drugs, it is used only in special cases.

veterporfina

Laser therapy has proved to be effective in reducing the long-term central visual loss, due to some forms of neovascularization.

Laser treatment is given to a small number of people in case:

1. The membrane is out of the macula 

2. The injury is very small and limited


TRANSLOCATION RETINAL

When these treatments fail or cannot be carried out, severe forms of AMD (both dry and wet), further worsen leading to loss of vision. In this case, you can surgically intervene with retinal translocation.


panico sala operatoria

It has been observed that the disease does not directly harm the retina, but the underlying layer, the pigment epithelium that nourishes it. This is where the idea of rotating the retina within the eye comes from. It is a complex operation, with an element of risk, but with an assurance that the visual autonomy will return to normal. This surgical technique improves the reading ability in 30% of cases and stabilizes the situation in 50% of operated patients.

In the remaining 20% of the cases however, we haven’t had positive results.

Functional recovery requires that the area around the macula on the retina is in good condition. This is pre-operatively specific need to perform a Microperimetry exam in the affected eye to determine the actual vision of the surrounding retinal area.

The ideal candidate for a retinal translocation surgery is a person wearing an eyeglass and whose symptoms have appeared less than six months ago. The candidate would have deficits of reading skills and has an experience of no more than three months. We carry out a minimally invasive 25G vitrectomy and cause a retinal detachment by injecting the liquid through tiny holes.

We then proceed to cut the retina along the periphery of 360 degrees.

It’s possible to rotate the retina sufficiently to "move" the pigmented epithelium to a zone wherein it will be healthier and where it can resume its function. After injecting silicone oil, the retina is stabilized. Meanwhile, the laser treatment for 360 degrees produces a perfect adhesion.

Since the retina has been rotated, the vision with that eye will be rotated. It runs a small operation to induce a counter-rotation of the eye muscles, in conjunction with the silicone oil removal.


Dr. Panico’s clinic is one of the only 5 centres in Italy that practices this type of surgery. 

How do you diagnose Age- related Macular Degenretaion)?


The diagnosis of age - related macular degeneration can be made only by an ophthalmologist.


Ophthalmoscopy

Standard eye examination allows direct observation of the retina, the macula, and the point where the optic nerve connects to the eyeball (papilla).


It can be performed with different observing systems:

1. Direct ophthalmoscope.

2. Indirect ophthalmoscope.

3. Biomicroscopy with various lenses.



oftalmoscopia

The OCT

OCT is an acronym for Ottica, Coherence Tomography emphasizing on modern and non-invasive examination. It is essential in the diagnosis and provides a quantification of the problem.

There is no contact between the probe and the structures of the eye, except for a light beam which in a few seconds get a retinal high-resolution map.

The OCT is an ultrasound which replaced ultrasound with a laser light.

The amount of information gathered by the reflected beam of the eye is remarkably higher and can recognize structures measuring 7 thousandths of a millimeter (7 microns).

It allows visualizing the layers of the retina, provided in detailed images and evidently minimum alterations.


The OCT Heidelberg Spectralis Blue Peak, installed in Dr. Panico’s clinic, one unique instrument for imaging of the retina.

esame a fondo dell'occhio

It’s a tomograph spectral domain that combines the OCT technology with a confocal laser scanning.

This technology combines active eye tracking and blue laser autofluorescence resulting in an instrument unrivaled for advanced diagnostics of the retina.

1. It makes 40,000 scans per second with measurable detail POCHI Micron (histology in vivo).

2. The Auto rescan function allows the OCT SPECTRALIS to position itself at the same places, in subsequent tests of the same patient, managing to capture changes in retinal anatomy with a detail of 1 micron.


This helps people understand its usefulness in detecting any deterioration of maculopathy, pucker, edema and macular holes, central serous choroiditis and diabetic retinopathy.



retinopatie diabetiche

Age-Related Macular Degeneration

fluoroangiography

The Fluorescein Angiography of the retina (FAG) can be recommended in controversial cases if you suspect the existence of multiple pathologies. Fluorescein angiography involves injecting a dye into the arm and taking photographs of the fundus to see the distribution of the dye among the damaged vessels.

It rarely causes allergic reactions.

The dyes used for routine are fluorescein sodium, whereas indocyanine green are dyes more used for special insights.


fluoroangiografica

1. Image with indocyanine (ICG) of macular degeneration

2. Fluoroangiografica image (FAG) of macular degeneration

What risks are faced by relatives or descendants of patients with AMD?

When there are cases of macular degeneration (AMD) in the family, the risk that another member in the family may develop the disease increases by 19 times. 

However, the incidence of familial cases is between 5% and 20%. 

Relatives of patients with AMD at an advanced stage, show the first manifestations of the disease more frequently at an early age.


gemelli omozigoti

In monozygotic twins, with all the same genes, clinical manifestations have been described as overlapping indicating that the genetic component is important.


Is there a test for identifying the risk factor?

The knowledge of the genetic risk and all the mechanisms that lead to the development of macular degeneration, involves a careful and systematic research of risk factors. This helps develop therapeutic strategies to prevent the loss of visual function.


rischio genetico

This justifies an analysis of genetic polymorphisms for assessing the risk of developing AMD. Before any symptoms start showing, we need to find out if the person concerned is exposed to predisposing factors such as age, smoking, etc. or belongs to an affected family.

test non invasivo bocca

There are non-invasive and completely painless tests that can be taken to identify the risk of developing macular degeneration in the future. 


Where can the test be taken?

We conduct these tests in our studio. We also offer a pickup service from OUR STUDIO where we recently have started offering a pickup service of samples.


introduzione amd
test genetico

Who can get affected by AMD?

 DESCENDANTS AND RELATIVES OF PATIENTS s

This disease affects the descendants and relatives of the patient suffering from Age-related Macular Degeneration. It also affects those who are not following healthy eating habits according to their age. Those who smoke and drink alcohol are more at risk than the others. 


degenerazione maculare legata all'età
amd neovascolare
pazienti rischio clinico alto
precisione test
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