AGE-RELATED MACULAR DEGENERATION

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AGE-RELATED MACULAR DEGENERATION

• Damage of the central retina, or macula
• Two types
• Nonexudative (DRY ) - drusen (hyaline deposits)
  and areas of alternating bands of
  depigmentation/ hyperpigmentation in the retinal
  pigmented epithelium
• Exudative (WET) - neovascularization

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AMD

• Symptoms
• Asymptomatic initially
• Loss of central vision (reduced visual acuity
  causing difficulties with detail discrimination)
• Metamorphopsia (i.e., distortion of objects)
• Central scotomas
• Increased glare sensitivity
• Contrast sensitivity
• Decreased color vision.
• Peripheral vision remains intact, and the patient
  does not progress to total blindness

Amsler grid
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Etiology of AMD

• Unclear, but known contributing factors include
• Older age
• Smoking
• Hypertension
• Hyperlipidemia
• Vascular insufficiency to the retina and the
  choroids
• History of ultraviolet (UV) light exposure
• FHx of AMD (which increases risk three- to
  fourfold)

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Prevention and Treatment

• High-dose regimen of vitamin C, vitamin E, beta
  carotene, and zinc shown to decrease risk of
  developing vision loss caused by advanced AMD in
  patients with intermediate AMD or advanced AMD in
  one eye.
• Patients without AMD and those with early AMD did
  not benefit from supplementation.
• Control of vascular disease risk factors,
  exercise to increase circulation, and sunglasses
  for UV light protection.
• Photodynamic therapy and intravitreal injections
  of antivascular endothelial growth factor and
  corticosteroids have shown promise in treating
  subsets of patients with macular degeneration.

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GLAUCOMA

• Increased ocular pressure that can damage the
  ganglion cell layer of the retina
• Symptoms loss of peripheral vision that can lead
  to decreased central acuity, difficulty
  functioning in dim light, decreased contrast
  sensitivity, glare disability, and decreased
  dark/light adaptation.
• Risk factors Age gt 40, Hispanic, African
  American, Family history, diabetes, HTN, eye
  injury, myopia, chronic steroids
• Treatment topical prostaglandins, beta blockers,
  adrenergics, carbonic anhydrase inhibitors, and
  oral medications, laser therapy, and filtering
  surgery.

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CATARACTS

• Opacifications of the crystalline lens of the eye
• Risk factors Age, female sex, corticosteroid
  use, diabetes, smoking, ocular UV-B light
  exposure
• Symptoms decreased visual acuity, decreased
  color perception, decreased contrast sensitivity,
  and glare disability
• Treatment alter prescriptions for eyeglasses or
  contacts, tobacco cessation, UV protection,
  surgical extraction.

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DIABETIC RETINOPATHY

• Nonproliferative - dilated retinal veins,
  intraretinal hemorrhages, microaneurysms, cotton
  wool spots, hard exudates, and macular edema
• Proliferative - neovascularization, vascular
  fibrosis, and preretinal and vitreous hemorrhages

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DIABETIC RETINOPATHY

• Symptoms
• decreased visual acuity, contrast sensitivity,
  color perception, and dark/light adaptation,
  glare disability, distortion, and scotomas
• Treatment
• Photocoagulation

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Screening

• ADA recommends that children with diabetes have
  an initial eye examination after 10 years of age
  if they have had diabetes for three to five
  years, followed by annual examinations thereafter
• AAO recommended eye exam schedule
• Normal examination or minimal nonproliferative
  retinopathy annually
• Mild to moderate nonproliferative retinopathy
  without macular edema - every 6 to 12 months
• Severe nonproliferative diabetic retinopathy
  every 2 to 4 months

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Quiz

• Which one of the following is an adverse effect
  of alpha blockers?
• A. Increased incidence of prostate cancer.
• B. Increased incidence of high-grade prostate
  cancer.
• C. Orthostatic hypotension.
• D. Ejaculatory dysfunction.

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• Which one of the following statements about the
  surgical treatment of benign prostatic
  hypertrophy is correct?
• A. Laser prostatectomy is associated with
  decreased libido.
• B. Transurethral incision of the prostate is more
  likely to cause retrograde ejaculation than
  transurethral resection of the prostate (TURP).
• C. Transurethral needle ablation is recommended
  only for men with severe symptoms who are not
  surgical candidates.
• D. Retreatment rates are higher with
  transurethral microwave therapy than with TURP.

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• Which one of the following medications is
  recommended for the treatment of tinea capitis in
  children?
• A. Oral terbinafine (Lamisil).
• B. Oral ketoconazole (Nizoral).
• C. Topical ketoconazole.
• D. Oral itraconazole (Sporanox).

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• Which one of the following is the recommended
  initial test for the diagnosis of tinea unguium
  (onychomycosis)?
• A. Histologic analysis.
• B. Potassium hydroxide microscopy.
• C. Fungal culture.
• D. Wood's lamp examination.

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• Which one of the following statements about
  seizures in patients with primary brain tumors is
  correct?
• A. Patients who present with seizure have a
  worse prognosis than those who do not present
  with seizure.
• B. Patients who present with seizure have a
  better prognosis than those who do not present
  with seizure.
• C. Seizures are more common in patients with
  high-grade gliomas.
• D. Long-term seizure prophylaxis is recommended
  for all patients after surgery.

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• Which one of the following imaging studies is
  preferred for the initial anatomic evaluation of
  brain tumors?
• A. Functional magnetic resonance imaging (MRI).
• B. Computed tomography.
• C. Gadolinium-enhanced cranial MRI.
• D. Positron emission tomography.

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• A patient has dilated retinal veins, intraretinal
  hemorrhages, microaneurysms, cotton wool spots,
  and hard exudates. There is no macular edema.
  Which one of the following diagnoses is the most
  likely?
• A. Age-related macular degeneration.
• B. Nonspecific changes of aging.
• C. Diabetic retinopathy.
• D. Cataracts.
• E. Open-angle glaucoma.

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• Which one of the following treatments represents
  optimal management of diabetic retinopathy
  without macular edema?
• A. Intraocular vitamins.
• B. Tight control of blood glucose.
• C. Laser photocoagulation.
• D. Oral corticosteroids.

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X-Type

• The initial evaluation of patients with symptoms
  of benign prostatic hyperplasia typically
  includes which of the following? A. Digital
  rectal examination.
• B. Urinalysis.
• C. Prostate-specific antigen measurement.
• D. Serum creatinine measurement.

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• Which of the following statements about the
  management of tinea corporis is/are correct?
• A. Culture confirmation of the diagnosis is
  recommended.
• B. Diagnosis is usually clinical or based on
  potassium hydroxide microscopy findings.
• C. Most patients require oral therapy.
• D. Topical antifungals are usually sufficient
  for treatment.

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• Which of the following signs and symptoms is/are
  seen at presentation in one third or more of
  patients with primary brain tumors?
• A. Nausea or vomiting.
• B. Headache.
• C. Papilledema.
• D. Memory loss.

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• A 54-year-old patient with 20/70 vision has had a
  recent worsening of a physiologic tremor. Which
  of the following statements is/are correct?
• A. He is legally blind.
• B. A stand magnifier is an appropriate
  low-vision aid for this patient.
• C. He should be examined by an ophthalmologist
  or optometrist every two to four months.
• D. He is at risk for falls.

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References

• EDWARDS J. Diagnosis and Management of Benign
  Prostatic Hyperplasia. American Family Physician.
  May 15, 2008
• ANDREWS M, BURNS M. Common Tinea Infections in
  Children. American Family Physician. May 15, 2008
• CHANDANA S, MOVVA S, ARORA M. Primary Brain
  Tumors in Adults. American Family Physician. May
  15, 2008
• ROSENBERG E, SPERAZZA L. The Visually Impaired
  Patient. American Family Physician. May 15, 2008