What is the recommended treatment and management plan for an older adult patient with a history of vision problems diagnosed with Macular Degeneration?

Treatment and Management of Age-Related Macular Degeneration

For an older adult with macular degeneration, immediately determine whether the disease is wet (neovascular) or dry (non-exudative), as wet AMD requires urgent intravitreal anti-VEGF therapy within days of diagnosis, while dry AMD requires AREDS2 supplementation and risk factor modification. 1

Immediate Diagnostic Classification

The first critical step is optical coherence tomography (OCT) to identify subretinal fluid, intraretinal fluid (indicating wet AMD), or geographic atrophy (indicating advanced dry AMD). 1 This distinction determines the entire treatment pathway and urgency of intervention.

Treatment Algorithm for Wet (Neovascular) AMD

If wet AMD is confirmed, initiate intravitreal anti-VEGF therapy immediately—treatment within 2 years of diagnosis significantly reduces legal blindness and visual impairment. 1

Loading Phase Protocol

• Administer three loading doses at exactly 4-week intervals using aflibercept, ranibizumab, or bevacizumab 1, 2
• Perform OCT imaging at each visit to assess for persistent subretinal or intraretinal fluid 1
• Biomicroscopic fundus examination is required at every injection visit 1

Maintenance Phase Options

After completing the loading phase, choose from evidence-based maintenance regimens: 1

• Aflibercept every 8 weeks (comparable efficacy to monthly dosing in first year) 1
• Treat-and-extend protocol (adjust intervals based on disease activity) 1
• PRN (as-needed) dosing with monthly monitoring 1
• Monthly injections if disease remains active 1

Critical pitfall: Avoid arbitrary dosing intervals (such as every 6 weeks) that lack clinical trial support—stick to established protocols of 4-week or 8-week intervals. 1

Monitoring Requirements

• OCT at every visit to detect recurrent fluid 1
• If disease activity recurs before the 8-week interval, increase frequency to every 4 weeks until stabilization 1
• Patients must report symptoms of endophthalmitis, retinal detachment, or decreased vision immediately 1

Treatment Algorithm for Dry (Non-Exudative) AMD

For intermediate or advanced dry AMD, prescribe AREDS2 supplementation immediately—this reduces progression risk by up to 36% over 10 years. 1

AREDS2 Formulation Components

The specific formulation includes: 1

• Vitamin C
• Vitamin E
• Zinc 25mg (not 80mg—lower dose has equivalent efficacy with fewer genitourinary complications) 1
• Copper (essential to prevent copper-deficiency anemia from zinc) 1
• Lutein 10mg 1
• Zeaxanthin 2mg 1

Critical safety consideration: Beta-carotene was eliminated from AREDS2 due to 18% increased cumulative incidence of lung cancer in current and former smokers (relative risk 1.28). 1 Never prescribe beta-carotene-containing formulations to smokers.

Coordination with Primary Care

Coordinate with the patient's primary care physician before initiating long-term AREDS2 supplementation due to potential adverse effects, particularly increased genitourinary hospitalizations with zinc. 1 This is non-negotiable for patient safety.

Risk Factor Modification (All AMD Types)

Smoking Cessation—Non-Negotiable Priority

Cigarette smoking is the only proven modifiable risk factor and must be addressed aggressively in all AMD patients. 3 Current smokers face 2-3 times higher AMD risk, with risk increasing proportionally to pack-years smoked. 3 Smoking cessation is mandatory and the key modifiable risk factor. 1

Additional Modifiable Factors

• Address elevated body mass index 3
• Manage cardiovascular disease and hyperlipidemia 3
• Encourage dietary intake of antioxidants and carotenoids 4

Patient Education and Counseling

Visual Prognosis

Reassure patients that while central visual loss is common, total blindness is extremely rare—peripheral vision is typically preserved. 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

Fellow Eye Monitoring

For patients with wet AMD in one eye, the fellow eye remains at exceptionally high risk and requires monitoring every 6-12 months even without symptoms. 1 Patients with advanced AMD in one eye and large drusen with retinal pigment epithelial changes in the fellow eye represent the highest risk group. 1

Home Monitoring

Provide an Amsler grid for daily self-monitoring—patients should look at the central dot and evaluate if any grid lines appear wavy or distorted (metamorphopsia). 1 Instruct patients to return immediately with any new visual symptoms in the unaffected eye. 1

Vision Rehabilitation Referral

Refer patients with reduced visual function to vision rehabilitation services immediately, including: 1

• Optical or electronic magnifying devices 1
• Bright lights and enhanced lighting 1
• Electronic reading aids 1

Important counseling point: Vision rehabilitation optimizes existing visual function rather than restoring lost vision—patients often have unrealistic expectations about this. 1

Psychosocial Considerations

• Loss of visual acuity increases risk of frequent falls 1
• Depression frequently accompanies severe central vision loss and should be screened for 1
• Charles Bonnet syndrome (visual hallucinations) frequently accompanies severe central vision loss but does not represent psychosis or mental deterioration—counsel patients about this benign phenomenon 1

Follow-Up Schedule

For Wet AMD

• Monthly visits during loading phase 1
• Every 8 weeks during maintenance (if stable on aflibercept) 1
• More frequent if disease activity recurs 1

For Dry AMD

• Regular comprehensive eye examinations for early detection of progression 1
• Monitor fellow eye every 6-12 months if unilateral advanced disease 1
• Annual examinations if bilateral early/intermediate disease 1

What NOT to Do

• Do not delay anti-VEGF therapy in wet AMD—early treatment within 2 years significantly reduces blindness 1
• Do not use beta-carotene formulations in current or former smokers 1
• Do not use 80mg zinc when 25mg provides equivalent efficacy with better safety 1
• Do not prescribe AREDS2 supplements as a substitute for anti-VEGF therapy in wet AMD 1
• Do not use arbitrary injection intervals lacking clinical trial support 1