Retinal Pigment Epithelial Atrophy in a 60-Year-Old Male with Myopia
Age-related macular degeneration (AMD) is the most common cause of retinal pigment epithelial (RPE) atrophy in a 60-year-old male, regardless of myopia history. 1, 2
Age as the Dominant Risk Factor
- Advanced age is the single most important risk factor for AMD, with prevalence increasing dramatically from 2.8% in those aged 40-59 years to 13.4% in those 60 years or older. 1
- At 60 years old, this patient falls squarely within the high-risk age group where AMD becomes the predominant cause of RPE atrophy. 1, 2
- The prevalence continues to escalate from 1% in those aged 65-69 years to 17% in those older than 80 years, making age the overwhelming determinant. 1
AMD Pathophysiology and RPE Atrophy
- Dry AMD accounts for approximately 85-90% of all AMD cases and is characterized by progressive deterioration of the retina with atrophy of retinal layers and RPE cells, eventually leading to geographic atrophy and central vision loss. 2
- The pathogenic sequence involves RPE dysfunction, accumulation of intracellular and extracellular material (drusen, basal laminar and linear deposits), changes in Bruch's membrane composition, and ultimately RPE atrophy followed by choriocapillaris and photoreceptor atrophy. 3
- AMD affects the RPE and Bruch's membrane in the macula, leading to secondary photoreceptor degeneration and eventual loss of central vision. 4
Clinical Implications and Diagnostic Approach
- Optical coherence tomography (OCT) should be performed to characterize drusen morphology, assess for sub-RPE deposits, and evaluate for geographic atrophy or subretinal/intraretinal fluid. 5, 2
- Look for high-risk features including bilateral soft drusen, confluent drusen, RPE clumping or atrophy, which warrant AREDS2 supplementation. 1, 2
- Fundus autofluorescence and near-infrared autofluorescence imaging can identify areas of reduced signal corresponding to RPE atrophy. 6
Important Caveats
- While myopia is mentioned in the patient's history, age-related factors overwhelmingly dominate as the cause of RPE atrophy at age 60. 1, 2
- If the patient has received anti-VEGF therapy for neovascular AMD, this treatment itself is associated with progression of atrophy, with the number of injections statistically significantly associated with atrophy progression (odds ratio 1.35). 6
- Smoking history must be assessed, as cigarette smoking is the only proven modifiable risk factor for AMD, increasing risk 2-3 times compared to non-smokers. 1, 2
- Family history should be elicited, as genetics play a significant role, particularly in younger patients, though at age 60 the age factor predominates. 1
Management Algorithm
- For intermediate AMD or advanced AMD in one eye, initiate AREDS2 supplementation immediately (vitamin C, vitamin E, zinc 25mg, copper, lutein 10mg, zeaxanthin 2mg), which reduces progression risk by up to 36% over 10 years. 2
- Mandate smoking cessation if applicable, as this is the key modifiable risk factor. 2
- Establish baseline visual function and monitor with regular comprehensive eye examinations every 6-12 months, as early AMD is typically asymptomatic. 1, 2
- Counsel patients that central vision loss is common but total blindness is extremely rare, as peripheral vision is typically preserved. 2