Age-Related Macular Degeneration – Sight Threat To Elderly

Age-Related Macular Degeneration – Sight Threat To Elderly

Age-Related Macular Degeneration (ARMD) is a progressive central retinal disorder and a third major cause of vision loss globally. With early detection, diagnosis, and advanced treatment methods, it is possible not just to prevent further vision loss but also to maintain the residual vision required for daily living activities. The use of modern technology and devices, making appropriate low vision rehabilitation services available, and improving communication between patients, families, and vision care professionals, can also contribute significantly towards mitigating the disease's effects on quality of life.

As we marked Age-Related Macular Degeneration Awareness Month, panellists at the India Vision Institute (IVI) - VisionPlus Magazine hosted ‘Age-Related Macular Degeneration – Sight Threat to Elderly’ panel discussion on February 17 shared their knowledge, ideas, and experiences in an engaging talk on a vision health challenge that adversely impacts the quality of life for the elderly. Moderated by IVI’s CEO, Vinod Daniel, the panel at the discussion comprised Dr Manisha Agarwal, Head, Vitreoretinal Services, Dr Shroff's Charity Eye Hospital, Dr Beula Christy, Associate Director/Head of Services, Institute of Vision Rehabilitation LV Prasad Eye Institute, Ms Sarika Gopalakrishnan, Senior Optometrist/Head, Low Vision Care Clinic, Sankara Nethralaya, and Ms Soniya Srivastava, Senior Faculty/ Optometrist Incharge, Vision Enhancement Center & Clinical Training, Dr Shroff's Charity Eye Hospital.

In his introductory remarks, Mr Daniel observed that ARMD is the third largest cause of vision loss globally and that worldwide, approximately 8.1 million people have lost vision due to ARMD. Citing WHO data, Ms Sarika Gopalakrishnan said there are 39 million blind people worldwide, with 8 million in India. “ARMD accounts for 8.7% of total blindness globally,” she noted.

While not much is known about the exact pathogenesis of ARMD, it is clear that ageing plays the primary role in the pathology of the disease. Genetic factors and lifestyle choices such as diet and smoking can also lead to macular degeneration. Since the disease affects the central part of the retina, it impairs a person’s ability to read and write properly. It also reduces a patient’s ability to perform other essential daily tasks. As Dr Manisha Agarwal said, “The elderly are often restricted to sedentary activities such as reading, writing, knitting, and doing household chores. ARMD damages the central retina, which is the part of the eye that is important for activities such as reading and writing. This causes elderly patients to feel extremely handicapped. It makes them feel depressed and demotivates them from leading near-normal lives.” 

Noting that ageing is the key cause of ARMD, Mr Daniel requested the panellists to talk about symptoms of the disease. There are two varieties of ARMD – Dry ARMD and Wet ARMD, that can affect an individual. Dry  ARMD happens when there are metabolic deposits in the retina called the drusen. “This is an early stage of ARMD, and at this stage, a patient may be mostly asymptomatic except for feeling a slight decrease in contrast sensitivity. Since symptoms are very mild, the patients can be quite oblivious to their condition at this stage,” Dr Agarwal observed. In Wet  ARMD, new blood vessels are formed in the central part of the retina known as the macula, and these new blood vessels create a new membrane known as the choroidal neovascular membrane. These blood vessels are very fragile and leak a lot of fluid in the central part of the retina. Patients with this type of ARMD will start seeing a stationary central black spot (scotoma) in their field of vision.

Optometrists, being the first contact individual with patients, need to be mindful of these ARMD symptoms. Early diagnosis is essential for timely intervention. It is recommended that an Amsler grid charting be conducted on a patient with mild symptoms of ARMD,  before carrying out a dilated fundus evaluation. The optical coherence tomography (OCT) angiography is a test that may be very useful when dealing with elderly patients because it is non-invasive. Optometrists should ideally refer such patients to retina specialists for consultations because a specialist would be best-placed to recommend the ideal course of treatment. Unlike in the past, when treatment options were limited, treatment methods available today have made recovering from ARMD a genuine possibility.

Mr Daniel highlighted the importance of modern technology in diagnosing ARMD and asked the panellists how technology, even in remote and rural parts of the country, can help people with ARMD maintain a good quality of life. Despite not being universally available, contemporary technologies and quality services are accessible, even in some rural areas of India. Private sector-owned primary, secondary and tertiary-level vision health centres in rural parts of the country offer state-of-the-art technology to diagnose ARMD and provide care. Tools such as mobile diagnostic vehicles and portable diagnostic equipment available today have made it easier to access remote areas. Low vision optical devices such as magnifiers and spectacle-mounted telescopic systems and electronic devices like mouse model CCTV, desktop CCTV, and pocket magnifiers can assist ARMD patients in leading near-normal lives.

Despite the availability of technology, access in remote areas is often hindered by a lack of awareness. “It depends on the willingness of the person affected to come forward and receive the services and support on offer. A lot needs to be done to create awareness and educate the community,” said Dr Beula Christy. Lack of awareness is a major impediment that creates an access gap in rural areas, even when the best technology and services may be available.

People with ARMD need to be given holistic care. In addition to early diagnosis and treatment, the availability of low vision rehabilitation services can be vital. Low vision intervention involves making the most of a person's residual vision, making the individual independent in carrying out daily living activities. Low vision services can reduce symptoms of psychological depression among patients by significantly improving reading, access to information, emotional well-being, and overall quality of life.

The families of ARMD patients can also help their elderly cope with the challenges of vision loss. “There is no technology or device that can solve all the problems associated with ARMD. Families can assist by making environmental adjustments to facilitate easy living for their visually impaired relatives. For example, you can observe the daily routine of your elders and make changes such as improving the lighting in parts of the house that require attention,” Ms Soniya Srivastava suggests. Every person is unique, and communication between patients and their families can do wonders in providing low vision care. This is because it may not always be possible for vision care professionals alone to identify all the problems a patient faces. Giving moral support, enabling access to counselling services and paying attention to daily needs are ways in which a family can stand behind its elderly and do its best to protect the older generation.