Age related macular degeneration - everything you need to know about this condition.
A useful e-book to help patients understand AMD and what can be done about it from Jaheed Khan, Consultant Ophthalmic Surgeon at the world famous Moorfields Eye Hospital,
www.london-retina.com
Original Title
Age related macular degeneration - What Every Patient Needs to Know
Age related macular degeneration - everything you need to know about this condition.
A useful e-book to help patients understand AMD and what can be done about it from Jaheed Khan, Consultant Ophthalmic Surgeon at the world famous Moorfields Eye Hospital,
www.london-retina.com
Age related macular degeneration - everything you need to know about this condition.
A useful e-book to help patients understand AMD and what can be done about it from Jaheed Khan, Consultant Ophthalmic Surgeon at the world famous Moorfields Eye Hospital,
www.london-retina.com
How to Contact Mr. J aheed Khan 4 Forward 6 What Patients & Staff Say about Mr. Khan 8 What Exactly IS Age-Related Macular Degeneration? 10 What Are the Symptoms of ARMD? 12 What Causes ARMD? 16 The Two Types of ARMD 18 How is Dry ARMD Treated? 21 How is Wet ARMD Treated? 22 What Can I Expect During a Consultation for ARMD? 24 Frequently Asked Questions about ARMD 26 Afterword 29 How to Contact Mr. J aheed Khan 30
Terms of Use and Disclaimer his eBook is Copyright 2014. All rights are reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted by any means: electronic, mechanical or photocopied, recorded or otherwise without written permission from the copyright holders.
You may distribute this eBook as long as it remains in its original form and unchanged in content.
The authors are both qualified surgeons and Mr. J aheed Khan has particular expertise in eye and cataract surgery.
Nevertheless this eBook is not intended to replace the need for a one-on-one consultation with and examination by a qualified and experienced eye surgeon. All advice given is intended for general guidance only.
If you have any disturbance in your vision or eyesight you are advised to seek medically qualified advice without delay.
Emergency medical care can be obtained through your GP or local Accident and Emergency Department.
Mr. J aheed Khan is also very happy to see patients both NHS and Privately.
His contact details for patients who wish to consult him privately are overleaf.
NHS patients will need to see their GP to be referred to him at Moorfields Hospital but private patients can telephone his secretary directly.
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How to Contact Mr. J aheed Khan rivately I practice at both Moorfields and at Harley Street either telephone or send my secretary an email. A GP referral is not necessary for Private Patients.
Moorfields Eye Hospital
Private Consulting Rooms J ohn Saunders Suite 9-11 Bath Street London EC1V 9LF
y name is J aheed Khan, and I am an eye surgeon at the world-famous Moorfields Eye Hospital in London.
I have almost twenty years experience as a doctor and fifteen years experience as an eye surgeon. In that time if theres one thing Ive learned its how vulnerable we all feel when we are unwell.
And we feel no more vulnerable when the problem we have is with our eyes.
Hospitals can be frightening places, and talking to doctors is not always easy.
Which is why Ive written this eBook. It is the culmination of all those years of experience in looking after patients and their eye problems.
In it I cover all the basics: what age-related macular degeneration is, how it causes problems with your vision, and how it can be treated. Theres no jargon, only straightforward, simple, M
clear explanation and advice. I also answer the questions I get most commonly asked in my clinics and wards in the hospital where I work every day, so if you have or are worried about ARMD theres a very good chance youll find the answer to your question here.
If you have any feedback or want to ask any questions about anything in this eBook, simply drop me an email via my secretary at:
secretary@clinicalondon.co.uk
I would be delighted to hear from you and will personally answer any questions you may have.
Best Wishes,
J aheed Khan Consultant Ophthalmologist.
Moorfields Eye Hospital, London. J une 2014.
What Patients & Staff Say About Mr. J aheed Khan Mr. Khan is not only an outstanding surgeon but more importantly a great communicator and caring Doctor. As a GP and commissioner I have total faith when referring my patients to Mr. Khan, that they will receive the best care available from a surgeon who constantly strives for excellence and treats them as individuals. I would not hesitate to recommend him to both my private and NHS patients. He is a real asset to both Moorfields and Hinchingbrook Hospitals. Mr. Khan is a brilliant doctor and was a pleasure to work with. J aheed Khan is a very competent Ophthalmologist with great patient care skills and the unique ability to explain complex condition in a manner comprehendible to the patient. J ust keep up the good work Dr. Khan. My wife, who accompanied me, and I were both very impressed by the care and consideration shown by the whole team when I had surgery. I just hope they haven't lost the knack by the time I get my other eye fixed. J oking apart the care of this team has made it a wonderful experience for me. A knowledgeable and trustworthy colleague with extensive experience in the diagnosis and treatment of retinal diseases. Up to date with the latest research and best practice, he is able to integrate this knowledge into the care of patients with ophthalmic conditions. I would have no hesitation in recommending him to friends and family. Mr. J aheed Khan is a thorough, compassionate and conscientious doctor. He listens to his patients and treats them with respect and care. He provides excellent medical care, both in clinic and in the operating theatre. I would highly recommend him. Mr. Khan is an excellent colleague to work with. He is always approachable and willing to help. His has an outstanding level of knowledge concerning eye disease and he is more than happy to offer his opinion whenever needed. He is trustworthy and respects both patients and colleagues. I have no hesitation to state that he is one of the best colleagues I worked with. I always enjoy working with Mr. Khan, he is friendly, confident and approachable. He always maintains a high standard of professionalism
in sometimes testing situations. Mr Khan is always willing to answer questions related to Ophthalmology that I may have and explains things in a manner in which myself and other colleagues understand. He is a team player within our department, many of his patients comment on his fantastic abilities.
What Exactly IS Age-Related Macular Degeneration? guess a sensible starting point is to assume that if you are reading this eBook you either have been told you have macular degeneration already; you know someone close to you who has macular degeneration and want to know more; or perhaps you know a little about the condition and worry that you may have it yourself.
But before we can talk about what Age-Related Macular Degeneration or ARMD is we need to look a little at how the eye works.
As you probably have heard before the eye is similar in many ways to a camera.
Light comes in the front, passes through a lens where it is focused to a sharp image on the light sensitive layer at the back, called the retina. It is similar in this respect to a camera: in an older camera the retina is represented by a piece of film. In a modern digital camera it is represented by an electronic sensor.
The retina of course, is extremely important, as this layer does the actual seeing of the image that is focused onto it through the lens.
A cross - section through the human eye
I
The retina is not the same all over; it has a specialized area called the macula that is able to pick out fine detail in what we see. The image of anything you look directly at is focused onto this small area, which is about the size of a pinhead because this is the area which is specialized to pick out detail. This means that any problem affecting the macula will interfere with your central vision rather than the edges of your vision. It also means that a problem here will make it difficult to see detail.
What are the Symptoms of ARMD? e have already seen how macular degeneration affects the central area of your vision, but what does the patient actually see? How does a problem at the macula actually affect your eyesight?
Above is an image showing what a patient with early ARMD might see. The central area of this patients vision is distorted and darker than the area around it. This is because of damage to the macula. You can see how difficult it can be to read or to recognize ordinary objects when you have this condition.
You can see the clock but cant see the hands! W
Difficulty telling the time
The picture above shows what a patient with macular degeneration might see if they look directly at a clock. Because they have problems with their central vision they can see the clock and they know what they are looking at but they cant tell the time because they cant clearly see the hands.
In fact, a famous artist called Lee Allen had macular degeneration and wrote a book about his experiences called A Hole in my Vision. This is an excellent description of what patients with ARMD actually see.
So patients with macular degeneration often complain of:
Tunnel vision Difficulty seeing straight in front of them they often have to turn their head to one side to see something straight in front of them Distorted vision. For example they may complain that the edge of a tall building, which they know to be straight looks distorted, wobbly, or blurred. In advanced macular degeneration they may get a blurred or even blank spot in the centre of their vision. Words and letters of text can look indistinct or blurry Colours look less bright It takes longer for your eyesight to adapt when moving from bright sunlight to a dimly-lit room
The Amsler Grid
This is a test for problems with the macula which might indicate macular degeneration:
The Amsler grid in someone with normal vision
The appearance of the Amsler grid in macular degeneration
As you can see from the pictures above, the straight lines of the grid appear distorted to patients with problems of the macula such as ARMD. To use the Amsler grid test put on your normal reading glasses and cover up one eye. Keep the picture of the grid 12-15 inches away from your face and focus on the black dot. As you do this ask yourself if the other lines of the grid look straight or wavy.
You then cover up the other eye and repeat the test. If the lines of the grid look wavy you could have macular degeneration.
But remember, you could have ARMD and still see the grid fairly clearly that is why if you are at all concerned about your vision you need to see an expert even if there is nothing wrong the reassurance you will get will be very well worthwhile.
A word of caution
It is important to remember that not all people with macular degeneration have all or even any of these symptoms. And not all people with these symptoms have macular degeneration, as other conditions of the eye can cause similar symptoms. Some of these other conditions can be serious, which is why it is so important to see a specialist if you have noticed any problems with your eyes,
One other important thing to note is that there are two types of macular degeneration. The first, dry macular degeneration develops slowly so people may not really notice the symptoms until later on.
The second is called wet macular degeneration and can develop very rapidly. People with wet macular degeneration often notice a rapid change in their vision, over weeks or even days. As you might imagine it is a much more serious condition and requires urgent assessment and treatment by a specialist in eye problems. Luckily we now have some good treatments for it if it is picked up early enough.
What Causes Macular Degeneration?
acular degeneration is commonly called Age-Related Macular Degeneration or ARMD because it tends to affect older people. In fact it is the commonest cause of blindness and loss of central vision in the over-65s.
Cause of Macular Degeneration?
Nobody really knows what causes ARMD. However, there are certain risk factors aspects that can increase the likelihood of developing the condition. These include:
Age As you might expect, ARMD is commoner in older people, particularly in the over-65s. However, it can still develop in people in their 40s and 50s so once again, no matter how old (or young!) you are a change in your vision needs to be taken seriously. Gender More women than men tend to get ARMD, but that may simply be because women live longer than men do. Family History ARMD can run in families, which indicates that some people are born with certain genes that make the condition more likely. Nothing can (as yet) be done about that but it does mean that if you have other family members with the condition you should be perhaps more vigilant about your vision yourself. Smoking Smoking seriously increases your risk of developing ARMD, as it does with many other conditions. Stopping smoking whatever your age is a very good idea and may reduce your risk of developing ARMD Ultraviolet Light Sunlight is composed of visible light which we can see but also invisible light which we cant infra-red and ultra-violet light. Ultraviolet light causes tanning of the skin and appears to be a risk factor for developing ARMD too. M
Diet There does appear to be a link to diet and ARMD but the case is not clear-cut. There is some evidence that a diet rich in the vitamins A,C and E as well as zinc may be beneficial. Race ARMD is commoner in Caucasians (white people) compared to other races
It is important to remember though that these are merely risk factors very large numbers of people without any identifiable risk factor go on to develop the condition every year.
The Two Types of Macular Degeneration
acular degeneration occurs in two different forms, Dry and Wet. They are called Dry and Wet because of what is actually happening in the eye, and what the eye specialist sees when he examines you, not because of how the eye feels or because it is watery or dry.
Dry (non-exudative) Macular Degeneration
This is the commonest type of ARMD. It usually develops very slowly, which means that the symptoms you get the changes in your vision are also very slow to develop. For this reason people often learn how to cope with the symptoms and may not seek advice until it is quite advanced. Dry ARMD can develop into wet ARMD at any stage. It is also perfectly possible to have dry ARMD in one eye and wet ARMD in the other (Dame J udi Dench has exactly this problem)
Dry Macular Degeneration the white spots are called Drusen
Wet (Exudative) Macular Degeneration
Up to perhaps 15% of people with ARMD have wet macular degeneration. This is different to dry macular degeneration as it is caused by new blood vessels growing underneath the retina. These vessels are very fine and delicate and leak fluid and blood M
and it is this that causes the problems with the patients eyesight.
The appearance of the back of the eye in wet ARMD
How do you know if you have ARMD?
The simple answer is that you cannot diagnose the condition in yourself.
Only a doctor with special expertise in conditions affecting the eye an ophthalmologist can accurately diagnose ARMD. Neither can your GP or optician make the diagnosis, although they may suspect ARMD is the cause of your symptoms.
The other thing is that the symptoms can often creep up on you as they may take a long time to develop. And of course, by the time you notice the symptoms the damage has already occurred.
With both types of macular degeneration people progressively lose their central vision and that can be very disabling and distressing. Although they never go completely blind they can still see in the periphery - poor vision can mean people lose confidence in getting out and about in unfamiliar places and stay indoors. Poor vision can mean people socialise less and become withdrawn. And poor vision makes us more likely to fall or injure ourselves in other ways.
That is why I find treating eye problems so rewarding: because helping to improve patients eyesight can give people a whole new lease of life and return some of their independence and self- confidence.
How is Dry Macular Degeneration Treated?
eople with any type of ARMD must be carefully assessed and monitored over a period of years by an expert, because many people with dry ARMD will go on to develop the more aggressive and severe wet form of the disease.
There is no specific treatment for dry AMD although some studies (The Age-Related Eye Disease Study, AREDS) have shown that taking high-doses of certain vitamins and zinc slowed down vision loss in people with intermediate or advanced AMD. Another study ('AREDS II') is looking at the effects of other vitamins (including Lutein and Zeaxanthin which are found in the macula) on people with ARMD.
The supplements that are thought to help are:
Vitamin C Vitamin E Beta-Carotene Zinc oxide Cupric oxide
Certain foods contain higher levels of these compounds, foods such as:
Oranges Kiwi fruit Tomatoes Carrots (Yes they really are good for your eyes!) Leafy green vegetables Mangoes Peas Sweetcorn
Supplementing your diet with these foods may help your vision and will certainly give you other general health benefits, but please consult your doctor/eye specialist before taking them. P
How is Wet Macular Degeneration Treated?
eople with wet macular degeneration until recently were in considerable trouble, because there was no really effective treatment available. Laser had been used (and occasionally is still used) but was not particularly effective in treating the condition.
Thankfully, over the last few years there has been something of a revolution in treating wet ARMD as new treatments have become available. The most exciting of these are the anti-VEGF drugs Lucentis and Eyelea.
How do anti-VEGF Medicines Work?
VEGF or Vascular Endothelial Growth Factor is a naturally produced 'signaling' substance in the body that is thought to be partly responsible for the growth of the abnormal blood vessels in the eye that are responsible for Wet AMD.
Lucentis and Eyelea work by blocking the action of the VEGF in the eye and so reduce the growth of these blood vessels.
Unfortunately, the only way we can get these medicines where they need to be is with an injection in to the eye.
Now although this sounds very unpleasant and dramatic, the good news is that it is nowhere near as awful as it sounds. Let me reassure you that it is nowhere near as bad as you might think - most people aren't even aware of the injection happening!
This is because I always give drops into the eye to make it go numb first of all. These local anaesthetic drops prevent the injection from hurting you.
Next, I always use a very fine needle to give the injection - it is much finer than the ones used to take blood tests from your arm. The needle is almost as thin as a human hair.
P
And finally I always give the injection just into the very corner of your eye - you won't see any nasty needles or feel anyone very close to your face.
After this you will be able to go home you do not need to be admitted to hospital for treatment and I will arrange a follow-up appointment to see how you are getting on.
What Can I Expect During a Consultation for ARMD?
fter booking your appointment you will be greeted at the clinic by one of my nurses and reception staff. You will then be brought in to the clinical room where I will see you personally you will not be seen by a junior doctors or specialist trainee as often happens in the NHS.
We will go through details of your medical history as well as discuss the problems you have been having with your eyesight. I will then examine your eyes thoroughly.
Your vision will be checked and your pupils dilated to allow the back of the eye to be examined. Your pupils are dilated with drops that take about 30 minutes to work. They will make you sensitive to light and cause your vision to be blurry. The drops allow me to see the inside of your eye more easily. The effect of the drops usually wears off in about six hours though sometimes it can happen overnight. It is not safe to drive until the effects have worn off.
I will look at the inside of your eye using a special microscope called a slit lamp. You place your chin on a rest and I will ask you to look in various directions while shining a light into your eye. This allows me to see your retina and any changes that ARMD may have caused. Although very bright, the light cannot damage your eye.
Often I can tell you whether you are likely to have ARMD or not from this examination. However, you may need a test called a Fluorescein angiogram to find out for certain if you have ARMD and if so to determine which type, wet or dry.
The fluorescein angiogram
The fluorescein angiogram looks at the network of blood vessels underneath your retina can't be seen by examining your eyes with a slit lamp. You are given an injection in the arm of Fluorescein, a yellow dye that shows up the blood vessels at the back of the eye. The injection isnt painful but does make some people feel a bit A
sick sometimes.
Once the dye has been injected pictures of the back of your eye are taken as the dye is travelling through the blood vessels. This takes about 10 minutes.
It is a very common test and very few people have any serious side effects. The injection may give your skin a slight yellow tinge from the dye and it soon passes into your urine, which may also appear a darker yellow than normal (possibly for up to two to three days) but often it fades quicker than that. Some people are dazzled for a while after the flashing lights but most people find the test straightforward.
These tests help the ophthalmologist decide which type of ARMD you have and so guides him to the correct treatment.
Frequently Asked Questions
Can you have ARMD in only one eye?
Yes, you can. However it is much commoner to have ARMD in both eyes. The reason you only notice symptoms in one eye though is because it is worse in that eye.
Can you have dry ARMD in one eye and wet ARMD in the other?
Yes, you can. In fact, it is possible to have both wet AND dry ARMD in the same eye! This shows just how important it is to have your eyes looked after by an expert.
Dame J udi Dench, the actress in fact has dry ARMD in one eye and wet ARMD in the other.
Dame J udi Dench - M in the Bond films
Does ARMD ever get better?
No. Dry ARMD usually gets worse only very slowly though, which is obviously good news. Wet AMD however can progress very quickly, causing serious problems with your vision. However, if picked up early you can see a dramatic improvement with treatment.
Does dry ARMD always go on to wet ARMD?
No. You can have dry AMD for many years and still not get wet AMD. The big 'but' though is you need to keep a very close watch on people with dry ARMD because quite a few go on to develop wet ARMD - and Wet ARMD is a serious (but treatable) condition.
Will vitamins prevent dry ARMD getting worse?
We're still not sure. There is some evidence that it slows the condition down at least - but this is not yet proven.
Does dry ARMD require injections?
No.
Do injections into the eye hurt?
Most people only feel slight discomfort only, because I always give local anaesthetic drops first. I also always use a very fine needle - almost as thin as a human hair - and I always inject just in to the corner of the eye.
If you have Wet ARMD you will need several injections over time, and I have never had a patient cancel an appointment because the injections hurt her - not even once.
Will I see the needle?
Only if you want to! The injection is given into the corner of the eye so no, you won't normally see the needle at all.
Do you give any anaesthetic before giving the injections?
Always. I always give eye drops into the eye to make it nice and numb before giving the injection.
Can you have cataracts and ARMD?
Yes you can. And because both conditions affect older people there are many people with both conditions. This is another reason to see an expert early if you have any trouble with your vision at all. Your vision is too precious to risk anything else.
Are you more likely to get ARMD if you have cataracts?
No. But both are common conditions and both affect the same sorts of people, so many people do have both.
Can you treat ARMD with stem cells?
Not yet. One day perhaps, but any treatment with stem cells is many years away yet.
Will taking high doses of vitamins prevent me getting ARMD?
No. We do not believe that taking high doses of vitamins will prevent ARMD.
What will happen if I have ARMD and dont get treated?
ARMD is a serious, progressive condition affecting your vision. If it is left untreated your vision will continue to deteriorate. If you go on to develop wet ARMD then your eyesight can deteriorate very quickly indeed over a matter of days or weeks, even. Its just not worth risking your eyesight at all.
How long do the injections take?
A few moments only then its all done. There really is nothing to be afraid of.
Afterword
s you will probably have realized this has been a whistle-stop summary about age-related macular degeneration - what it is, what causes it and how it is treated. I have also summarized what you can expect if you should need treatment for wet ARMD and the common questions I get asked by patients. I hope it has been useful.
As a consultant ophthalmologist I am fully trained in the management of all conditions affecting the eye, and my special expertise is in treating ARMD and cataracts.
If you have problems with your eyes and would like to see me via the NHS then have a word with your GP and ask to be referred.
If you wish to be seen privately then you do not need a GP referral and can simply contact my secretary directly.
I look forward to seeing you.
Best wishes,
Mr. J aheed Khan FRCOphth
A
How to Contact Mr. J aheed Khan rivately I practice at both Moorfields and at Harley Street either telephone or send my secretary an email. A GP referral is not necessary for Private Patients.
Moorfields Eye Hospital
Private Consulting Rooms J ohn Saunders Suite 9-11 Bath Street London EC1V 9LF