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DOCTOR AT THE DESK

The M.D. is in!

"Macular degeneration, that is."
By: Marc Evans Abat, MD, FPCP, FPCGMThe M.D. is in!

Those going through medical school dream of eventually passing the board exams and getting the M.D. initials next to their name. However, as one gets older, one might find that he can get an M.D. even without studying! This M.D. will not give you the license to cure people but instead will leave you groping in the dark.  We are talking about macular degeneration.

Someone with macular degeneration may experience blurring of vision in the central part of the visual field. Over time, this area can expand or there may be dark spots in the center of vision.  Other complaints may include the following:

  • Straight lines appearing wavy
  • Trouble seeing distant objects
  • Problems seeing colors
  • Problems seeing details in faces or words

Age is the major risk for developing macular degeneration. This disease is more common for those 60 years old and above but in some situations, it may occur in younger persons.  Other risk factors may include:

  • Smoking
  • A family history of macular degeneration – the risk is 3-fold higher with a 1st-degree relative having the condition
  • Being female and Caucasian
  • Have a history of hypertension or high blood pressure
  • Obesity

There are generally 2 types of macular degeneration:

  • Dry type: This accounts for about 90% of all cases of macular degeneration.  It happens when deposits called drusen develop in the macula. Small amounts of drusen do not cause any problems but as it increases in size and number, it starts causing damage leading to the mentioned symptoms.  Later, these can lead to thinning of the layers of light-sensitive cells in the macula.
  • Wet type: In this type, blood vessels form underneath the macula, in the choroid layer.  These blood vessels then start either leaking fluid or bleed into the macula. In the long run, these blood vessels, with the fluid and blood, lead to scarring of the macula

So, how does one know if he has M.D.? Of course, the most obvious answer is to see and M.D., in particular, an ophthalmologist, for a thorough eye examination. An Amsler grid may be used to identify areas in your visual field that may be distorted (e.g. wavy or even missing).  Fundoscopy is done using a variety of instruments, but commonly using an ophthalmoscope, to look inside the eye, particularly on the surface of the retina, to look for changes related to macular degeneration. The eye doctor may also order fluorescein angiography, wherein a dye is injected into a vein in the arm, then a special light is shown through the eyes to check for abnormal blood vessels and leakage of the dye in the retina.Optical coherence tomography is a specialized technique wherein a detailed cross-sectional image of the retina and any relevant structures is obtained.

Ok so now you know you have M.D., what can be done about it? There is really no cure for macular degeneration. Currently available modalities aim to decrease the amount of vision that may be lost. This is especially through for the wet type since this is more likely to cause visual impairment.

A study published in 2001 revealed that the use of antioxidant supplements (particularly containing vitamins E and C, beta-carotene and zinc) reduced risk of progression to advanced dry macular degeneration by 25% in 5 years. The caveat here is that the high dose of beta carotene also increased the risk for lung cancer. A follow-up study published with 2013 where beta carotene was replaced by omega-3 fatty acids and lutein + zeaxanthin, showed that lutein + zeaxanthin may substitute for beta carotene. The dose preparation of the antioxidants in these studies are much higher than ones commercially available in multivitamin preparations.  Whether or not the results of the studies are robust and the possibility of side effects remain to be studied further.

The wet form of macular degeneration can be managed using several modalities. 

  • Laser therapy: The laser destroys the abnormal blood vessels and prevents new ones from growing. This will help reduce visual loss in the early stages.  However, the procedure causes scar formation at the site of treatment, hence there may be some treatment-related visual loss. This is however accepted to prevent further spread of the blood vessels
  • Photodynamic therapy: This involves an injection of a drug that is light-activated. Once injected into the veins, a specialized laser is then used to activate the drug, closing the abnormal blood vessels while leaving the retina intact.
  • Anti-vascular endothelial growth factor (anti-VEGF) medications can be injected directly into the eye to prevent the abnormal growth of the blood vessels. The drugs are injected using a very fine needle, under strict sterile techniques, by a trained ophthalmologist.

And there you have it! Whenever you start seeing “weird” or distorted images, go to your eye M.D. and have yourself checked for M.D.

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