What is the best achievable vision with macular degeneration?

Vision Outcomes in Macular Degeneration

Patients with age-related macular degeneration can be reassured that while central visual loss is common, total visual loss is extremely rare. 1

Understanding Visual Prognosis

The visual outcomes in AMD vary dramatically depending on disease type, stage, and treatment:

Wet (Neovascular) AMD with Treatment

Anti-VEGF therapy has revolutionized visual outcomes in wet AMD, with many patients achieving substantial vision gains when treated early. 2

• In clinical trials, 37-40% of patients gained ≥15 letters (3 lines) of vision at 3 months with ranibizumab treatment for neovascular disease. 3
• The mean visual acuity improvement was approximately +12 letters (2.4 lines) at 3 months in treated patients. 3
• Early treatment within 2 years of diagnosis significantly reduces legal blindness and visual impairment. 4
• Without treatment, wet AMD progresses rapidly with severe vision loss, but with modern anti-VEGF therapy, many patients maintain or improve functional vision. 5, 2

Dry (Non-Neovascular) AMD

Dry AMD progresses more slowly than wet AMD but can eventually lead to geographic atrophy and central vision loss. 4

• Dry AMD accounts for approximately 85-90% of all AMD cases and has a slower progression pattern. 4
• With AREDS2 supplementation, progression risk can be reduced by up to 36% over 10 years in patients with intermediate or advanced dry AMD. 4
• Visual acuity outcomes are more variable and depend on the extent of geographic atrophy and whether the foveal center is involved. 1

Functional Vision Expectations

What Patients Can Expect

The characteristic visual impairment in both forms of AMD is loss of central vision (central scotoma), resulting in severe difficulties with reading that may be only partly compensated by magnifying devices. 6

• Peripheral vision is typically preserved, meaning patients do not experience total blindness. 1
• Central visual acuity may range from near-normal (20/40-20/60) in early disease to severe impairment (20/200-20/400) in advanced disease. 1
• Patients with severe visual loss related to AMD often have unrealistic expectations about vision rehabilitation, which optimizes existing visual function rather than restoring lost vision. 1

Vision Rehabilitation Potential

Vision rehabilitation can help patients maximize their remaining vision and adapt to activities of daily living, with electronic magnification providing acuity reserve enabling reading skills for almost all levels of visual acuity. 6

• Special optical or electronic magnifying lenses, bright lights, and electronic reading aids may help patients read more effectively, but not as well as before AMD onset. 1
• Magnifying optical lenses and electronic magnification preserve binocularity even at high levels of visual disparity between eyes. 6
• Prescription filters reduce short-wavelength light to reduce glare and improve apparent contrast sensitivity and visual acuity. 6

Critical Clinical Considerations

Disease-Specific Outcomes

For patients with wet AMD in one eye, the fellow eye remains at exceptionally high risk and should be monitored every 6-12 months even without symptoms to detect asymptomatic CNV at a treatable stage. 1, 7

• Patients with advanced AMD in one eye and large drusen with RPE changes in the fellow eye represent the highest risk group. 1
• Loss of visual acuity increases the risk of frequent falls, and depression frequently accompanies severe central vision loss. 1
• Charles Bonnet syndrome (visual hallucinations) frequently accompanies severe central vision loss but does not represent psychosis or mental deterioration. 1

Setting Realistic Expectations

Patients should understand that central vision loss is common but total blindness is extremely rare, and vision rehabilitation optimizes existing function rather than restoring lost vision. 7

• With progressive central visual loss, patients lose their ability to perform more complex activities of daily living. 6
• The loss of central vision has a profound impact on patient quality of life, with patients reporting substantial decline and increased need for assistance with daily activities as visual acuity worsens. 4
• Acceptance of the disease improves with better corrected visual acuity and contrast sensitivity values after treatment. 8