Understanding Age-Related Macular Degeneration and Your Vision
Understanding AMD
The macula is a tiny area at the center of the retina, the light-sensitive tissue that lines the back of the eye. It is responsible for central vision. This is the sharp, straight-ahead vision you use for reading, driving, and seeing fine details. When the macula is damaged, central vision becomes blurred or distorted, even though side vision may remain intact.
AMD develops when aging-related changes damage the retinal pigment epithelium (RPE), a layer of cells that supports the retina by removing metabolic waste. Over time, these cells lose their ability to function properly. Waste products, lipids, and proteins accumulate and form deposits called drusen beneath the retina. Chronic inflammation, increased oxidative stress, and changes in the blood supply behind the retina all contribute to this process.
There are two types of AMD. Dry AMD, also called non-neovascular AMD, accounts for about 80 to 90 percent of cases. In dry AMD, drusen build up beneath the retina. Over time, advanced dry AMD can progress to geographic atrophy (GA), where areas of the retina waste away and cause lasting blind spots.
Wet AMD, also called neovascular AMD, affects about 10 to 20 percent of people with AMD. In wet AMD, abnormal blood vessels grow beneath the retina in a process called neovascularization. These fragile vessels can leak fluid or blood, causing rapid and severe damage to central vision. About 200,000 new cases of wet AMD are diagnosed each year in North America (Genentech, 2023).
AMD is the leading cause of significant vision loss in people over age 50 in developed countries. In 2019, an estimated 18.34 million Americans aged 40 and older were living with early-stage AMD (Rein et al., Ophthalmology, 2022). Approximately 1.49 million Americans had late-stage, vision-threatening AMD (Rein et al., Ophthalmology, 2022). Among Americans aged 80 and older, roughly 3 in 10 have early AMD, and about 1 in 10 have the late, vision-threatening form (Prevent Blindness, 2023).
Who Is Affected and Risk Factors
The greatest risk factor for AMD is age. The older a person is, the greater the chance of developing this condition. AMD is rare in people under 50 but becomes increasingly common after age 60. The risk rises sharply after age 80.
People with a family history of AMD are at higher risk. Researchers have identified genes involved in inflammation, immune response, and lipid metabolism that are linked to AMD. Two major genetic locations, known as CFH and ARMS2-HTRA1, have been consistently associated with the disease.
Cigarette smoking is the most consistently reported environmental risk factor for AMD. Current smokers face two to three times the risk of AMD compared to non-smokers. The risk increases with the number of cigarettes smoked and the number of years a person has smoked. Quitting smoking at any age can help reduce this risk.
Several additional factors may increase a person's risk of developing AMD:
- Gender: women tend to be at greater risk than men
- Race: Caucasians and people of European descent are more likely to develop vision-threatening AMD than African Americans or Asian populations
- Obesity: being significantly overweight may increase the chance of AMD progressing to a more advanced stage
- Diet and nutrition: diets low in leafy greens, fish, and certain vitamins may contribute to AMD risk
Signs and Symptoms
In its earliest stages, AMD may produce no symptoms at all. Many people do not realize they have the condition until it is detected during a routine eye exam. As dry AMD progresses, a person may notice that straight lines appear slightly wavy or distorted. Colors may seem less bright or intense than before.
When dry AMD reaches the advanced stage of geographic atrophy, areas of the central visual field may become dark or blurry. Reading small print or seeing in dim light may become noticeably more difficult. These changes tend to develop gradually over months or years.
Wet AMD often causes more sudden and noticeable vision changes. Symptoms can include a rapid decrease in the sharpness of vision, blind spots in the center of the visual field, and significant distortion of straight lines or edges. If you experience a sudden change in your central vision, see a retina specialist or go to the emergency room immediately. Prompt treatment is critical for preserving vision.
Diagnosis and Testing
A retina specialist can detect AMD during a thorough eye examination. The specialist will dilate the pupils and examine the retina using specialized lenses and lights. Drusen, pigment changes, fluid, or blood beneath the retina can often be seen during this exam.
Optical coherence tomography, commonly called OCT, is a non-invasive imaging test that creates detailed cross-sectional pictures of the retina. OCT allows a retina specialist to see drusen, fluid, swelling, or thinning of the retinal layers with great precision. This test is used to diagnose AMD and to monitor it over time.
Fluorescein angiography is an imaging test in which a yellow dye is injected into a vein in the arm. As the dye travels through the blood vessels in the retina, a special camera captures images. This test helps identify leaking or abnormal blood vessels associated with wet AMD.
The Amsler grid is a simple tool that looks like a sheet of graph paper with a dot in the center. A retina specialist may ask you to look at this grid one eye at a time. This checks for distortion or missing areas in your central vision. Many patients are given an Amsler grid to use at home for ongoing self-monitoring between appointments.
Treatment Options
The primary treatment for wet AMD is anti-VEGF therapy. VEGF, or vascular endothelial growth factor, is a protein that triggers the growth of abnormal blood vessels in the eye. Anti-VEGF medications are injected directly into the eye in a procedure called an intravitreal injection. This blocks the protein and reduces vessel leakage.
FDA-approved anti-VEGF therapies for wet AMD include:
- Lucentis (ranibizumab), approved in 2006, typically given every 4 weeks
- Eylea (aflibercept), approved in 2011, typically given every 4 to 8 weeks after initial loading doses
- Beovu (brolucizumab), approved in 2019, given every 8 to 12 weeks after loading doses
- Vabysmo (faricimab), approved in 2022, a bispecific antibody targeting both VEGF-A and angiopoietin-2, given every 4 to 16 weeks
- Eylea HD (high-dose aflibercept), offering four times the dose of conventional Eylea, allowing extended intervals of 8 to 16 weeks after loading
Avastin (bevacizumab) is FDA-approved for cancer treatment but is widely used off-label by retina specialists to treat wet AMD. Studies have shown it to be effective and safe for this purpose.
The Age-Related Eye Disease Studies (AREDS and AREDS2) found that a specific combination of vitamins and minerals may help slow the progression of intermediate dry AMD. The AREDS2 formula includes vitamin C, vitamin E, lutein, zeaxanthin, zinc, and copper. A retina specialist can advise whether this supplement is appropriate based on the stage of your AMD. Supplements do not reverse existing damage, but they may help reduce the risk of progression to more advanced disease.
Geographic atrophy, the advanced form of dry AMD, now has two FDA-approved treatments. Syfovre (pegcetacoplan), a complement inhibitor, and Izervay (avacincaptad pegol), also a complement inhibitor, are both given as intravitreal injections. These medications work by targeting the complement system, a part of the immune system involved in the inflammation that drives geographic atrophy. These treatments are specifically for geographic atrophy and are not used for wet AMD.
Research into AMD treatments continues to advance. Susvimo (ranibizumab injection via ocular implant) was approved by the FDA in October 2021 as a refillable port delivery system. This implant can deliver medication for months, reducing the number of required office visits. RGX-314, a gene therapy approach to anti-VEGF treatment, is currently in phase III clinical trials. This therapy has the potential to block VEGF for years following a single surgical procedure.
What to Expect
An intravitreal injection is performed in the retina specialist's office. The eye is numbed with anesthetic drops, and the injection itself takes only a few seconds. Most people feel a sensation of pressure rather than sharp pain. Some mild discomfort, redness, or a gritty feeling is common afterward and usually resolves within a day or two.
Wet AMD typically requires ongoing treatment. Many patients begin with a series of monthly injections, called loading doses, followed by injections at longer intervals. The treatment schedule is tailored to each person based on how the eye responds. Consistent follow-up appointments are essential for monitoring and adjusting treatment.
Anti-VEGF treatment has been a significant advancement for wet AMD. Many patients experience stabilized vision, and some gain back a portion of lost central vision. However, outcomes vary from person to person. The earlier wet AMD is detected and treated, the better the chance of preserving vision. Treatment does not restore vision that has already been lost.
For people with early or intermediate dry AMD, regular monitoring is key. A retina specialist will schedule periodic exams and OCT scans to watch for signs of progression. Between appointments, using an Amsler grid at home can help detect new distortion or changes in central vision. Any new or worsening symptoms should be reported to a retina specialist right away.
Living with AMD
Many people with AMD continue to live full, active lives. Adjustments can help make daily tasks easier. Brighter lighting for reading and close work, magnifying devices, large-print books and screens, and high-contrast settings on electronic devices can all be helpful. A low vision rehabilitation specialist can suggest tools and strategies tailored to your needs.
Several habits may help slow the progression of AMD or protect your remaining vision:
- Do not smoke, and if you currently smoke, seek help to quit
- Eat a diet rich in leafy green vegetables, fish, and fruits
- Maintain a healthy weight and exercise regularly
- Wear sunglasses that block ultraviolet light when outdoors
- Take AREDS2 supplements if recommended by your retina specialist
A diagnosis of AMD can bring feelings of worry or frustration. It is normal to feel concerned about the future of your vision. Support groups, low vision counseling, and occupational therapy can provide practical help and emotional encouragement. Many communities and organizations offer resources specifically for people living with vision loss from AMD.
When to See a Retina Specialist
Adults over age 50 should have regular comprehensive eye exams that include a dilated retinal evaluation. If you have risk factors for AMD, such as a family history, a history of smoking, or if you are over 60, your eye care provider may recommend more frequent screenings. An optometrist or primary care eye doctor can screen for AMD and refer you to a retina specialist if signs of the disease are found.
Certain symptoms require immediate attention. If you experience any of the following, see a retina specialist or go to the emergency room right away:
- A sudden decrease in the sharpness of your vision
- New distortion of straight lines, such as door frames or telephone poles appearing wavy
- A dark or blank spot in the center of your vision
- A sudden change in the appearance of colors
Prompt evaluation can make a meaningful difference in outcomes, especially when wet AMD is suspected. Early treatment offers the best chance to preserve vision.
Questions and Answers
There is no certain way to prevent AMD. However, certain steps may lower your risk or slow its progression. Not smoking, eating a diet rich in leafy greens and fish, maintaining a healthy weight, and protecting your eyes from ultraviolet light are all associated with reduced risk. If you have intermediate dry AMD, taking AREDS2 supplements as recommended by a retina specialist may help delay progression.
Most people with AMD do not go completely blind. AMD affects central vision, but it typically does not damage peripheral, or side, vision. This means that even with advanced AMD, most people retain enough vision to navigate their surroundings and remain independent. However, the loss of central vision can make detailed tasks like reading and driving very difficult. Treatment and low vision aids can help maintain quality of life.
The frequency of anti-VEGF injections depends on how your eye responds to treatment. Most patients begin with a series of injections given every four weeks for the first few months. After this initial phase, many patients can extend the time between injections. Intervals of every 8, 12, or even 16 weeks are possible, depending on the medication used and individual response. Your retina specialist will monitor your condition closely and adjust the schedule to find the right interval for you.
The original AREDS formula included beta-carotene, which was later found to increase the risk of lung cancer in current and former smokers. The AREDS2 formula replaced beta-carotene with lutein and zeaxanthin. These are considered safer and equally effective. The AREDS2 formula is now the recommended version. Over-the-counter AREDS2 supplements are widely available, but you should consult your retina specialist before starting any supplement to confirm it is appropriate for your stage of AMD.
Yes. Dry AMD can progress to wet AMD at any stage. This is one of the reasons regular monitoring is so important. Not all cases of dry AMD will convert to wet AMD, but the risk increases as the disease advances. Using an Amsler grid at home and keeping up with scheduled retinal exams can help detect the conversion early. If you notice any sudden changes in your vision, contact a retina specialist promptly.