MACULAR DEGENERATION 
 by Dr. Dana Graichen, M.D.

Macular degeneration (AMD) is one of the most devastating conditions that can lead to blindness in thousands of elderly patients. AMD is a degenerative condition affecting the central retina (macula) of patients in their 60’s and older. There are two major categories. In the “dry” type, abnormal deposits develop under the retina (drusen), atrophy and clumping of pigment occur. Dry AMD tends to progress slowly and can lead to complete loss of central vision.  In “wet” macular degeneration, abnormal blood vessels grow beneath the retina, resulting in fluid or blood under the retina. This can occur relatively suddenly, with acute decrease in vision or distortion of vision. Until recently there was no affective treatment. Four years ago, photodynamic therapy (PDT) was approved and offered some advantages over conventional laser. For the first time, wet macular degeneration involving the macular center could be treated without obliterating central vision. Unfortunately, relatively few patients are candidates for PDT, the procedure is quite expensive, and usually requires more than one treatment. Also, although less destructive than convention thermal laser, PDT still causes significant tissue damage. A little over a year ago, the first medical treatment for AMD was approved by the FDA. Macugen was developed to block a blood vessel growth factor that had been identified as a causative factor in wet AMD.  On the positive side, many more patients are candidates for treatment with Macugen vs PDT. On the negative side, the drug is very expensive, must be injected directly into the eye every 6 week, and, while some patients respond very well with significant improvement in vision, most patients continue to lose vision over time. Less than a year ago, a new drug called Avastin began to be used “off label” for wet AMD. Since then, thousands of patients have been treated with Avastin. No eye or systemic side effects have been reported with injections of Avastin. The drug seems to be more effective than Macugen and  the dosing interval is longer (8-10 weeks) and is much less expensive. However since it is not covered by medicare, it ends up costing the patient more. A new drug called Lucentis, very similar to Avastin, is expected to be approved later this year. It is expected to be more effective than Macugen. It’s also expected to be much more expensive than Macugen and to require repeated injections every 4 weeks.

Although there is a significant genetic component to AMD, recent studies (AREDS for age-related eye disease study) have shown a significant benefit to certain high-dose vitamin and mineral supplements. The increased risk from smoking and the benefit from dark green leafy vegetables is well known. Other studies are ongoing looking at other nutrients such as omega-3 fats (found in some fish and flax seed oil) and xanthines.

In summary, AMD can still be a devastating condition. The recent advent of medical treatments for wet AMD is very exciting. For the first time, we are seeing many patients actually improving instead of just deteriorating at a slower rate.