What therapy is available for dissolving drusen (age-related macular degeneration deposits)?

Therapy for Dissolving Drusen

There is no proven therapy that directly dissolves drusen; instead, management focuses on preventing progression to advanced AMD through AREDS2 supplementation and risk factor modification, as drusen typically regress spontaneously through RPE atrophy rather than true "dissolution." 1, 2

Current Evidence-Based Management Approach

AREDS2 Supplementation (Primary Intervention)

For patients with intermediate AMD or large drusen (≥125 μm), the AREDS2 formulation should be prescribed to slow disease progression, not to dissolve existing drusen. 1, 2 The formulation includes:

• Vitamin C
• Vitamin E
• Zinc
• Copper
• Lutein (10 mg)
• Zeaxanthin (2 mg) 1, 2

This intervention can prevent progression to advanced AMD in over 300,000 patients if universally applied to at-risk populations, reducing the risk of progression by 27% at 10-year follow-up. 1, 3

Risk Factor Modification

Smoking cessation is critical, as cigarette smoking consistently increases AMD progression risk in a dose-dependent manner (pack-years). 1, 2 Smoking-cessation counseling should be provided at every visit. 1

Natural History of Drusen (Understanding What Happens)

Drusen do not truly "dissolve" through any current therapy. Instead, they follow one of two pathways:

• Spontaneous regression with RPE atrophy: Hard drusen can disappear as areolar atrophy of the RPE, choriocapillaris, and outer retina develops, though some regress without atrophy. 4
• Progression to advanced AMD: Soft drusen (>63 μm), particularly when confluent or numbering five or more, tend to precede RPE detachments and choroidal neovascularization. 4

Historical Context: Laser Photocoagulation

Laser photocoagulation was investigated for inducing drusen regression in adjacent areas, but this approach is not recommended as the mechanism likely involves RPE atrophy rather than true drusen dissolution, and the risk-benefit profile does not support routine use. 4 The theoretical benefit was eliminating the cleavage plane in Bruch's membrane through which choroidal neovascularization grows, but this has not translated into standard practice. 4

Monitoring Strategy

Patients with drusen should be taught to use an Amsler grid for self-monitoring of metamorphopsia (distorted vision), as early detection of progression to wet AMD is crucial for timely anti-VEGF therapy. 2 Regular comprehensive eye examinations are essential since early AMD is typically asymptomatic. 1, 2

Critical Clinical Pitfalls

• Do not promise drusen "dissolution": Patients should understand that treatment prevents progression rather than removes existing drusen. 1, 2
• Distinguish drusen types: Soft drusen (>63 μm), confluent drusen, and those with associated pigmentary changes carry higher risk for progression to advanced AMD and warrant more aggressive monitoring. 4, 5
• Beta-carotene avoidance: Former smokers should receive the AREDS2 formulation (with lutein/zeaxanthin) rather than the original AREDS formulation containing beta-carotene due to increased lung cancer risk. 2

When to Escalate Care

If drusen characteristics indicate high risk (≥5 drusen, size >63 μm, confluence, focal hyperpigmentation), or if the patient develops metamorphopsia, immediate ophthalmology referral is warranted for evaluation of possible choroidal neovascularization requiring anti-VEGF therapy. 2, 4