Retinal macular degeneration: modern approaches to classification, diagnosis and treatment. Macular degeneration of the retina: causes, symptoms and treatment

Vision is one of the greatest gifts for a person, and to lose it is a great tragedy. A person who has never seen feels much better than someone who has seen and then gone blind. Unfortunately, acquired blindness of varying severity is one of the most likely outcomes of some eye diseases. Therefore, for a disease such as macular degeneration of the retina, treatment is an opportunity to preserve a person’s vision for as long as possible.

Anatomical features of the retina

‒ this is the deepest structure of the eyeball, a light-sensitive organ containing a huge number of receptors. The well-known cones and rods are nerve cells capable of sensing light or color stimuli. A beam of light hitting the retina activates the receptors and they conduct this signal, converted into nerve impulse, through the optic nerve and subcortical structures to the main brain centers of vision.

If we roughly describe the retina, then it is a yellowish-red circle (this is how doctors see it during ophthalmoscopy). It clearly shows blood vessels, the place of penetration optic nerve, so-called disc, as well as the macular area, slightly off-center. The macula is the area in which the concentration of receptor cells is maximum. This is where they focus light rays and it is this area that is responsible for bright, clear, clear central vision.

What is macular degeneration of the retina?

Macular degeneration, macular degeneration, degeneration of the corpus luteum are all synonyms that describe a condition in which the nutrition of the macular area suffers. Central vision becomes blurry, making it impossible to distinguish small parts, people's faces, reading and watching films becomes inaccessible. Features of the disease are the possibility of hallucinations not related to mental illness and those who are not, as well as preservation of peripheral vision.

The disease is widespread throughout the world and is an age-related pathology, affecting elderly and senile people, and the incidence of the disease is directly dependent on age.

Risk factors

Despite the fact that the disease develops in many older people, it is not a necessary companion to old age. There are some factors that increase the likelihood of developing macular regeneration.

Table. List of main risk factors.

How does the disease develop?

The pathogenesis of age-related macular degeneration is not known with certainty, although a number of theories have been put forward, including oxidative stress, mitochondrial dysfunction and inflammatory processes.

An imbalance between the production of damaged cellular components and their degradation leads to the accumulation of harmful products, such as intracellular lipofuscin. Incipient atrophy is accompanied by thinning or depigmentation of the macular area. At more serious stages, new ones develop blood vessels(neovascularization), and all factors together lead to the death of photoreceptors and loss of central vision.

There are two variants of the disease - “dry” and “wet” macular degeneration. In the dry (non-exudative) form, cellular lesions called drusen accumulate between the retina and the uvea, causing retinal atrophy and scarring. In the wet (exudative) form, which is more severe, blood vessels grow from choroid(neovascularization) behind the retina, which is accompanied by exudation and can also cause hemorrhage.

Stages of disease development

Knowledge of the disease development process is important, since the treatment method will be selected depending on the stage at which the pathology is detected.

Pathology begins with deposits small size in the macular region, between the epithelium and the main choroid. In the vast majority of cases, vision does not suffer at all during this period, and it is difficult to detect an incipient pathology, and even more difficult to suspect. This period of time is not even considered the disease itself, but rather some kind of “prodromal period”.

Early stage

It is diagnosed when the formed drusen are of medium size (considered to be the approximate size of a human hair). There are no symptoms during this period either.

Intermediate stage

During this period, drusen become larger, and any abnormalities in retinal pigmentation also appear. Visual impairment is possible here, but people often attribute them to age-related hypermetropia, insufficient lighting, fatigue and other similar factors.

Late stage

When the retina is damaged significantly, there is symptomatic loss of central vision along with large size Druze It is at this stage that the disease begins to be divided into dry and wet subtypes, and it is now that the main treatment tactics are determined.

Symptoms of the disease

First of all, it should be noted that macular degeneration “does not hurt.” This is very important for differential diagnosis, and the appearance of pain is an alarm symptom that requires urgent medical intervention. Among the symptoms of macular degeneration are the following.

1. At "dry" dystrophy the predominant one is:
   1. blurred vision (cells are destroyed slowly, and central vision slowly and steadily becomes less clear);
   2. the appearance of a dark spot in the very center of the field of vision;
   3. gradually central vision completely disappears.
2. At "wet" macular degeneration:
   1. a feeling that all straight lines are becoming wavy (liquid exudate collecting under the macula raises it slightly, contributing to image distortion);
   2. the appearance of a small dark spot;
   3. gradual loss of central vision as the dark spot grows.

Other signs of macular degeneration (common to both types):

• slow recovery of visual function after exposure to bright light;
• a sharp decrease in visual acuity even in the absence of a spot in front of the eyes;
• change in color perception;
• decreased sensitivity to contrast.

Treatment of retinal macular degeneration

To date, there is no unconditionally effective therapy. Treatment largely comes down to improving the quality of life of patients; there are both conservative and surgical methods of assistance. But first of all, all patients, regardless of the form and stage of the disease, are given general recommendations.

1. Nutrition. In the presence of overweight body it needs to be adjusted by reducing the amount of calories and fats in the diet. In addition, it is necessary to monitor the amount of cholesterol, trans fats, fast carbohydrates. Suggested to consume more fish(such as salmon), which is high in omega-3 fatty acids. There should be no shortage of fresh vegetables and fruits and herbs. They contain lutein, which has a protective effect on the macula. It is important to control your sugar levels, because... joining diabetes with his retinopathy will significantly worsen the condition.
2. Active lifestyle. This is useful both for weight loss and for maintaining body tone, improving microcirculation, strengthening cordially- vascular system. Intense visual stress should be excluded, but adequate visual strain should be present.
3. Light restrictions. It is recommended to avoid ultraviolet radiation, it is necessary to use high-quality Sunglasses, visiting the solarium is prohibited.
4. Control blood pressure . This recommendation must be followed, since one of the target organs for arterial hypertension is the retina. Vascular disorders in the fundus will aggravate the situation and may cause serious complications, for example, retinal detachment and bleeding (especially important for “wet” macular degeneration).
5. Quitting smoking and alcoholism.

Specific treatment

Both conservative and surgical treatment should depend on the stage of the disease and its type.

Early macular degeneration

At the stage of early macular degeneration of the retina, treatment is usually not carried out, if only because it is almost impossible to “catch” the disease during this period. But even if the diagnosis was made at the very beginning of the disease, specific method there is no treatment. During this period, it is necessary to adjust risk factors as much as possible, and you can also resort to some conservative therapy:

• B vitamins, vitamin A, vitamin E;
• microcirculatory protectors;
• antioxidants.

It is important to undergo timely examinations with an ophthalmologist, especially for people over the age of 50, so as not to miss the disease at more serious stages.

Transitional and severe macular degeneration

Dry macular degeneration is very difficult to treat. The laser correction method is used, which is based on the removal of overgrown drusen. But at the same time, photoreceptor cells cannot be restored, and therefore vision cannot be restored. Wet dystrophy is slightly more treatable. But this does not mean that you can completely stop the process - it is only possible to slow it down as much as possible in order to delay blindness. The main direction is to stop neoangiogenesis.

1. Injections of narcotic analgesics into the eyes.
2. One of the progressive directions is biological therapy- administration of vascular endothelial factor inhibitors. These are substances released during the formation of blood vessels. These inhibitors (for example, bevacizumab, ranibizumab, lapatinib and others) block the growth of new blood vessels, which contributes to a significant inhibition of degradation processes. Inhibitors are administered by injection, usually requiring several injections.
3. Photodynamic therapy. The drug verteporfin is injected intravenously, and then a laser effect is added, aimed at the abnormal vessels. The laser activates the injected substance, and it begins to destroy the newly formed vessels.
4. surgical methods . A high-intensity laser beam is aimed at the abnormal blood vessels. This method can be used when there are still few new vessels and they are located in a strictly delimited area.

Application of adaptive devices

Since it is impossible to completely restore vision, but at the same time, absolute blindness does not occur, palliative methods of correcting the condition take place. Macular degeneration does not affect peripheral vision, so patients can learn to use this part of visual functions to a greater extent than ordinary people. Special devices are used to help patients:

• magnifying glasses, spectacle lenses;
• special screen reading devices that can expand certain sections of text or pictures;
• voice guidance for computers (screen reading), voice control.

Thus, Macular degeneration of the retina is a serious disabling disease. It is completely impossible to cure it, and all treatment methods are aimed only at improving people’s living standards. However, many adapt to new conditions, actively use adaptive devices and lead an active lifestyle.

Video - Macular degeneration of the retina

According to the World Health Organization, age-related macular degeneration is one of the most common reasons blindness and low vision in people of the older age group. Age-related macular degeneration is a chronic degenerative disorder that most often affects people over 50 years of age. According to official materials from the WHO Center for the Prevention of Avoidable Blindness, the prevalence of this pathology in terms of appeal in the world is 300 per 100 thousand population. In economically developed countries of the world, AMD as a cause of low vision ranks third in the structure ocular pathology after glaucoma and diabetic retinopathy. In the United States, 10% of people aged 65 to 75 years and 30% over 75 years have central vision loss due to AMD. Terminal stage AMD (blindness) occurs in 1.7% of the total population over 50 years of age and about 18% of the population over 85 years of age. In Russia, the incidence of AMD is 15 per 1000 population.

AMD is characterized by progressive deterioration of central vision and irreversible damage to the macular area. Macular degeneration is a bilateral disease (in approximately 60% of cases, both eyes are affected), however, as a rule, the lesion is more pronounced and develops faster in one eye; in the other eye, AMD can begin to develop after 5-8 years. Often, the patient does not immediately notice problems with vision, since at the initial stage the better seeing eye takes on all the visual load.

IMPORTANT! When visual acuity decreases both at distance and at close range; difficulties encountered when reading and writing; the need for stronger lighting; If a translucent fixed spot appears before the eye, as well as distortion of the contours of objects, their color and contrast, you should immediately consult an ophthalmologist. The diagnosis of macular degeneration can only be made by a medical specialist. However, self-monitoring of the visual functions of each eye separately is highly informative. using the Amsler test.

Mechanism of development and forms of age-related macular degeneration (AMD)

• The macula is made up of several layers of special cells. A layer of photoreceptors is located above the layer of retinal pigment epithelial cells, and below is a thin Bruch's membrane, separating the upper layers from the network of blood vessels (choriocapillaris), which provide the macula with oxygen and nutrients.

• As the eye ages, waste products from cell metabolism accumulate, forming so-called “drusen” - yellowish thickenings under the retinal pigment epithelium. The presence of many small drusen or one (or several) large drusen is considered the first sign of an early stage "dry" forms of AMD. The “dry” (non-exudative) form is the most common (in approximately 90% of cases).

• As drusen accumulate, they can cause inflammation by triggering the release of Vascular Endothelial Growth Factor (VEGF), a protein that promotes the growth of new blood vessels in the eye. The growth of new pathological blood vessels begins, this process is called angiogenesis.

• New blood vessels grow through Bruch's membrane. Since newly formed vessels are pathological in nature, blood plasma and even blood pass through their walls and enter the layers of the macula.

• From this moment on, AMD begins to progress, moving into another, more aggressive form - "wet".Fluid accumulates between Bruch's membrane and the photoreceptor layer, affecting the vulnerable nerves that provide healthy vision. If this process is not stopped, hemorrhages will lead to detachments and the formation of scar tissue, which threatens irreparable loss of central vision.
  The “wet” (exudative) form is much less common than the “dry” form (in approximately one or two cases out of 10), but is more dangerous - rapid progression occurs and vision deteriorates very quickly.

Symptoms of the “wet” form of AMD

• A sharp decrease in visual acuity, inability to improve vision with glasses correction.
• Blurred vision, decreased contrast sensitivity.
• Dropout of individual letters or crooked lines when reading.
• Distortion of objects (metamorphopsia).
• The appearance of a dark spot in front of the eye (scotoma).

Decreased visual acuity	Reduced contrast sensitivity
Central scotoma	Metamorphopsia - perception of objects in a distorted form

Goal of treatment for age-related macular degeneration

Age-related macular degeneration is treatable. However, not so long ago there was only one way to stop the “leaking” of blood vessels in wet AMD - laser coagulation. But this method did not eliminate the cause of the appearance of pathological vessels, and was only a temporary measure.

In the early 2000s, a more effective treatment called targeted therapy was developed. This method is based on the impact of special substances specifically on the VEGF protein.

Currently, so-called anti-VEGF therapy has completely changed approaches to the treatment of AMD, allowing one to preserve vision and maintain the quality of life of millions of people around the world. Anti-VEGF therapy can not only reduce the progression of AMD, but in some cases even improve vision. Treatment is effective, but only if it is carried out before scar tissue forms and permanent vision loss occurs.

Intravitreal injections of drugs - Anti-VEGF therapy

In order for drugs that counteract the development of new blood vessels to effectively act on the macula, it is necessary to inject directly into the vitreous body of the eye. The procedure is performed in a sterile operating room by a qualified ophthalmologist.

The procedure for administering the drug takes only a few minutes and does not cause any pain. As the anti-VEGF drug penetrates the macula tissue, it reduces the level of activity of the protein, which stops the growth of abnormal blood vessels, after which these vessels begin to disintegrate and regress, and with continued treatment, the abnormal fluid also resolves.

Controlling angiogenesis and associated swelling stabilizes visual function and prevents further damage to the macula. According to clinical studies, approximately 30% of patients receiving anti-VEGF therapy for wet AMD recover some of the vision lost due to this disease.

Drugs for the treatment of age-related macular degeneration - LUCENTIS and Eylea

The first drug for anti-VEGF therapy in the form of intravitreal injections, certified in Russia for use in ophthalmology, was LUCENTIS, which has made a real revolution in the treatment of AMD and has become the “gold standard”. In June 2006, it was approved by the American Drug Control Agency (FDA) as unique remedy for the treatment of age-related macular degeneration, and in 2008 it was registered in Russia. Since 2009, EXCIMER ophthalmological clinics have been using the drug LUCENTIS in clinical practice.

Scientists continued their research to create a drug with a more prolonged action, not inferior in quality results to LUCENTIS. In November 2011, a new drug was approved in the United States for the treatment of wet age-related macular degeneration of the retina. EILEA. Since March 2016, the drug has been registered in Russia and began to be used in Excimer ophthalmology clinics.

Why are LUCENTIS AND EYLEA effective?

Before the advent of these drugs, anti-VEGF therapy used drugs created for the treatment of cancer. LUCENTIS (and subsequently EYLEA) were specifically developed for use in ophthalmology, which ensures their higher effectiveness and safety.

The composition of the drug LUCENTIS molecules included active substance— ranibizumab, which reduces excessive stimulation of angiogenesis (growth of pathological vessels) in age-related macular degeneration and normalizes retinal thickness. LUCENTIS quickly and completely penetrates all layers of the retina, reduces macular edema and prevents an increase in the size of the lesion, the progression of the formation and sprouting of blood vessels and new hemorrhages.

EILEA- a drug containing the active substance - aflibercept, the molecules of which act as a “trap”, merging with the molecules of not only vascular endothelial growth factor (VEGF), but also placental growth factor (PIFG). EYLEA is characterized by a longer intraocular effect, which allows injections to be performed less frequently. In addition, this drug can be used not only for the “wet” form of age-related macular degeneration, but also in cases of visual impairment caused by diabetic macular edema and macular edema due to retinal vein occlusion.

What does scientific research show?

The clinical activity and safety of the drugs have been proven in a number of large international trials. The results are truly impressive - the majority of patients not only stopped the progression of the disease and maintained visual acuity, but this indicator significantly improved.

Central retinal thickness before and after treatment

• Compared to laser treatment ( photodynamic therapy) anti-VEGF therapy drugs significantly surpassed the results in terms of visual acuity obtained: by 6 months of treatment, injection therapy gave ~8.5-11.4 letters (on the ETDRS scale), whereas in the group laser treatment- 2.5 letters. By week 52, the anti-VEGF groups had gained 9.7–13.1 letters, whereas the laser group had lost 1 letter.
• After 52 weeks of treatment, the proportions of patients maintaining visual acuity in the LUCENTIS and EYLEA groups were 94.4% and 95.3%, respectively.
• The proportions of patients with an increase in visual acuity of ≥15 letters on the ETDRS scale - with EYLEA - 30.6%, with LUCENTIS - 30.9%, and the average value of improvement in visual acuity was 7.9 letters and 8.1 letters when treated with EYLEA and LUCENTIS.
• The average change in the thickness of the central zone of the retina: -128.5 µm (EYLEA) and -116.8 µm (LUCENTIS).

Frequency of administration and dosage

A drug LUCENTIS is injected into the vitreous body in a dose of 0.5 mg (0.05 ml). First, 3 consecutive monthly injections of Lucentis are carried out (the “stabilization” phase), then the number of injections is recommended by the doctor depending on the state of visual functions and the degree of the disease (the “maintenance” phase). The interval between doses is at least 1 month. After the stabilization phase, treatment with the drug is suspended, but 2-3 times a year patients need to be screened for the condition of the visual system.

Treatment with the drug EILEA start with three consecutive injections into the vitreous at a dose of 2 mg, then perform one injection every 2 months, with no additional follow-up examinations between injections required. After reaching the “stabilization” phase, the interval between injections can be increased by the attending physician based on the results of changes in visual acuity and anatomical parameters.

Cost of basic services

Our task is to save your vision!

Age-related macular degeneration (AMD) is the leading cause of blindness in people over 50! According to WHO, more than 45 million people in the world currently suffer from this disease.

Preventing blindness and restoring vision is our core philosophy when working with patients suffering from age-related macular degeneration. In our clinic we use modern and effective developments in the diagnosis and treatment of this disease. Timely treatment started together with the use of anti-VEGF therapy gives reliable results!

Important to remember, what's the most reliable way Diagnosis of macular degeneration is a preventive visit to an ophthalmologist and a targeted examination of the fundus with a wide pupil during an ophthalmological examination!

WHAT IS AMD?

Age-related macular degeneration (AMD) is a pathological process in the central (macular) region of the retina, leading to a pronounced decrease in visual function. The macular area of ​​the retina is responsible for central visual acuity, and when it is damaged, the objects in question first become distorted and straight lines appear curved, then an opaque spot appears in the central area of ​​vision. As a result, patients experience severe problems with facial recognition, reading, driving, it becomes difficult to navigate in space, and the risk of injury (falls, bruises, fractures) increases. In general, the quality of normal life activities of any person deteriorates, which leads to social isolation and clinical depression.

The chronic degenerative process in the central zone of the retina occurs due to age-related changes in metabolism and the vascular system. As a result, retinal nutrition is disrupted, which leads to damage to the choriocapillaris layer, Bruch's membrane and retinal pigment epithelium. According to statistics, this pathology is the leading cause of loss of central vision up to blindness in patients over the age of 50 years. The severity of the disease is determined by the central localization of the process and, as a rule, bilateral eye damage.

With macular degeneration, photoreceptors are affected - the cells responsible for object vision, giving us the ability to read, see distant objects and distinguish colors.

FORMS OF MACULAR DYSTROPHY

There are two forms of age-related macular degeneration – dry and wet.

DRY FORM OF AMD (AGE-AGE MACULOUS DYSTROPHY)

Dry AMD is the most common form of the disease and develops in several stages. In the early stages of dry AMD, yellow deposits known as drusen form and begin to accumulate in the layers of the retina. Drusen can vary in both size and number, and are considered part of the natural process of age-related changes in the eyes. Loss of vision at this stage is felt insignificantly, especially with unilateral lesions.

Over time, the disease progresses to advanced dry AMD and may eventually transform into the wet form. In the advanced stage of dry AMD, in addition to an increase in the number and size of drusen, patients experience destruction of light-sensitive cells and tissues surrounding the macula. This already causes significant vision problems.

Dry AMD can affect one or both eyes. When a patient has only one eye affected, it is more difficult to detect early changes in vision due to the fact that the healthy eye works harder to compensate for the lack of vision due to the affected eye. Therefore, it is very important to regularly visit an ophthalmologist to check the visual acuity of both eyes and other preventive tests.

WET FORM OF AMD (AGE-AGE MACLODYSTROPHY)

Wet AMD, also known as neovascular macular degeneration or exudative form AMD is the most serious and aggressive form of age-related macular degeneration. In approximately 15-20% of patients, dry AMD turns into a wet form.

In wet AMD, new abnormal blood vessels begin to form in the choriocapillaris layer under the macula, a process called neoangiogenesis. Fluid and blood leak through these defective pathological vessels, which can cause blister-shaped recesses under the macula. It is these bubble-shaped notches that distort vision in the affected eye, causing straight lines to appear wavy. The patient can see dark spot or various spots in the center of the visual field. This occurs due to the accumulation of blood or fluid under the macula.

Unlike dry AMD, which can develop slowly, wet AMD develops quite quickly and damages the macular area, which soon leads to severe loss of central vision and blindness. Therefore, it is very important for patients at risk of developing wet AMD to have their vision checked periodically by an ophthalmologist. If wet AMD is not treated promptly, bleeding in the eye can cause scar tissue to form, leading to permanent vision loss.

WHAT ARE THE RISK FACTORS AND CAUSES OF AMD?

Age-related macular degeneration is a multifactorial, polymorphic disease of the central zone of the retina and choroid. The influence of the following factors on the body several times increases the risk of developing AMD and the aggressive progression of this disease:

• Age over 50 years.
• Family predisposition and genetic factors.
• Floor. Women are twice as likely to develop AMD as men.
• Overweight and obesity.
• Smoking.
• Prolonged and intense insolation.
• The presence of chronic diseases such as:
  • hypertonic disease;
  • atherosclerosis;
  • systemic diseases;
  • diabetes mellitus and other diseases.
• Occupational hazards (laser, ionizing radiation).
• Bad ecology.

Other causes may include injury, infection or inflammatory diseases eye, high myopia.

WHAT ARE THE MAIN SYMPTOMS OF AMD?

In the early stages, AMD may not be accompanied by any noticeable symptoms. Over time, patients notice a loss of brightness and contrast in colors, blurred, unclear images, and it becomes difficult for them to see the details of objects, both near and far. Straight lines are perceived as wavy or partially broken mainly in the central parts of the visual field. The perception of familiar objects changes, for example, a doorway seems skewed.

• First a blurry, then a dark spot appears in the center of the visual field.
• It becomes difficult to distinguish colors.
• Blurred vision.
• Contrast sensitivity decreases.
• Vision decreases when moving from bright to dim lighting.
• Spatial vision is impaired.
• Increased sensitivity to bright light.
• Visual functions improve at night.
• Faces become blurry.
• It becomes impossible to do work that requires close vision, for example, it becomes almost impossible to thread a needle.

If you notice such symptoms, you should immediately undergo an examination by an ophthalmologist!

CAN VISION LOSS CAUSED BY WET AMD BE REVERSED?

Undoubtedly. Clinically proven that timely diagnosis and specific progressive therapies help restore patients' vision.

HOW IS AMD DIAGNOSED?

Changes in vision can be determined at home independently by simple test, for which the Amsler lattice is used. This test is intended both to identify diseases of the central retina and to monitor the dynamics of treatment for existing pathology of the central retina. The Amsler test should be placed at a distance of 30 cm from the eye, and the other eye should be covered with your hand, then focus on the bold dot in the center of the test. If you find any changes, mark them on the Amsler test or sketch how you see them, and take them with you to an appointment with an ophthalmologist.

WHAT DIAGNOSTIC EXAMINATION FOR AMD IS CARRIED OUT IN THE CLINIC?

In addition to routine diagnostic examination methods for retinal dystrophy, such as determining visual acuity, biomicroscopy, examination of the fundus (ophthalmoscopy), determination of visual fields (perimetry), we use modern computerized methods diagnostic study retina of the eye. Among them, the most informative for AMD is optical coherence tomography. This study allows us to identify the earliest changes that appear in macular degeneration of the retina. Optical coherence tomography (OCT) allows you to identify changes within the tissue structures of the retina and determine the form of macular degeneration.

Particular importance is attached to OCT in cases where there is a discrepancy between visual acuity and the fundus picture obtained with conventional ophthalmoscopic examination. In addition, this study is prescribed to monitor the effectiveness of the treatment. In addition to OCT, in some cases we prescribe fluorescein angiography of the retina (FAG) - this allows us to use intravenous dye (fluorescein) to diagnose changes in the structure of retinal vessels, which is necessary to identify the source of edema when prescribing laser coagulation of the retina. All these studies make it possible to clarify the diagnosis, stage of the disease, and choose the right treatment tactics.

MODERN TREATMENT OF WET AMD

Currently, a number of effective methods for treating wet AMD are used. These treatments aim to stop angiogenesis (the formation of new, defective blood vessels) in the eye and are called "anti-angiogenic", "anti-proliferative" therapies or "anti-VEGF" therapies. The VEGF (vascular endothelial growth factor) family of proteins potentiates the growth of new defective blood vessels. Anti-VEGF therapy aims to slow the progression of wet AMD and, in some cases, improve your vision. This therapy is especially effective if used before the scarring stage, which is when treatment can preserve vision.

WHAT ARE ANTI-VEGF THERAPY DRUGS?

There are several main drugs that are VEGF inhibitors; they are most effective for treating wet AMD:

Macugen (Pegaptanib) is a VEGF inhibitor and has been recommended for the treatment of wet AMD. Macugen acts directly on VEGF and thereby helps slow down vision loss. This drug is administered directly into the eye as an endovitreal injection. This therapy requires repeated injections every five to six weeks. Macugen stabilizes vision in approximately 65% ​​of patients.

Lucentis (Ranibizumab) is a highly effective treatment for wet AMD. Lucentis is a type of anti-VEGF drug called a monoclonal antibody fragment that was developed to treat retinal diseases. It is injected directly into the eye as an endovitral injection and can stabilize vision and even reverse vision loss.

Our clinical observations show that the best results are observed if the drug is administered several times monthly. Data from clinical studies also showed that after two years of treatment with monthly Lucentis injections, vision stabilized in approximately 90% of patients, which is a significant rate of vision recovery.

Eylea (Aflibercept) is also a highly effective drug for the treatment of wet AMD, prescribed at a lower frequency of administration. Eylea is a type of anti-VEGF drug known as a fusion protein that is injected directly endovitrially into a patient's eye to treat wet AMD. Eylea targets VEGF directly, as well as another protein called placental growth factor (PGF), which has also been found in excess in the retinas of patients with wet macular degeneration. After the first 3 injections at monthly intervals and subsequent injections every two months, Eylea demonstrates the same effectiveness as monthly injections of Lucentis.

A clinical trial in patients with wet age-related macular degeneration compared monthly Lucentis injections with Eylea injections given regularly for three months and then every other month. After the first year of treatment, it was demonstrated that injections of Eylea once every two months improved or maintained vision in patients suffering from AMD at a level comparable to that achieved with Lucentis. The safety of both drugs is also similar. Overall, patients treated with Eylea required fewer injections to achieve the same effectiveness as monthly Lucentis injections.

Avastin (Bevacizumab) - antitumor drug with high anti-VEGF activity, which is prescribed by ophthalmologists as an off-label therapy for the treatment of wet age-related macular degeneration. Avastin is a type of anti-VEGF drug called a monoclonal antibody that was developed to treat cancer (the progression of which also depends on angiogenesis). Avastin is similar in structure to the drug Lucentis. Some ophthalmologists prescribe Avastin to patients suffering from wet AMD, after repackaging the drug so that it can be injected directly into the eye.

Because Avastin injections have been shown to be similar to Lucentis in treating wet macular degeneration, some ophthalmologists use Avastin because it is significantly cheaper than Lucentis. Avastin injections can be given monthly or less frequently on a schedule determined by your doctor.

All anti-VEGF drugs for the wet form of macular degeneration are injected directly endovitrally into the eye only by an ophthalmologist. Vitreoretinologists (retina specialists) are specially trained to perform this endovittrial injection safely and painlessly. The frequency of injections is determined by the ophthalmologist depending on the severity of the patient’s condition. In addition to anti-VEGF, dehydration therapy and laser coagulation of the retina are used for wet AMD. It is also necessary to know that all drugs used have risks associated with their use, which must be considered in relation to the benefits that such drugs bring. With regard to anti-VEGF therapy itself, such risks may include eye infection, increased intraocular pressure, retinal detachment, local inflammation, temporary blurred vision, hemorrhage under the conjunctiva, eye irritation and eye pain, which go away on their own over time.

Getting old is very difficult. Often, in old age, the ability to see is gradually lost. This is due to the fact that all human organs begin to “wear out” over time. One of the first tissues to suffer is the eye tissue. It is believed that vision deteriorates from the age of 40-45. This happens even in cases where a person has not previously had problems with vision during his life. Vision deterioration occurs gradually. Most people are concerned about “farsightedness,” that is, the inability to see objects that are close. Sometimes, more serious problems develop. These include pathologies such as cataracts, glaucoma, etc. Another common disease is age-related macular degeneration. This disease is dangerous because it can lead to loss of vision.

Concept of age-related retinal degeneration

Age-related macular degeneration (AMD) is a pathology that develops due to degenerative processes in the retina of the eye. This area is directly connected to the brain (it is a peripheral analyzer). With the help of the retina, the perception of information and its transformation into visual images is formed. On the surface of the peripheral analyzer there is a zone that contains many receptors - rods and cones. It is called the macula (yellow spot). The receptors that make up the center of the retina provide color vision in humans. In addition, it is in the macula that light is focused. Thanks to this function, human vision is sharp and clear. Age-related macular degeneration of the retina leads to degeneration of the macular tissue. Not only the pigment layer undergoes changes, but also the vessels feeding this area. Although the disease is called “age-related macular degeneration,” it does not only affect older people. Often the first symptoms pathological changes in the eye they begin to be felt by the age of 55. To the elderly and old age the disease progresses to such an extent that the person may lose the ability to see completely.

Age-related macular degeneration of the retina is a common disease. Often this pathology causes loss of ability to work and disability. It is widespread in America, Asia and Europe. Unfortunately, the disease is often diagnosed in late stages. In these cases, it is necessary to resort to surgical treatment. However, with timely therapeutic treatment, as well as preventive measures, it is possible to avoid surgical intervention and complications of pathology (blindness).

Causes of development of age-related macular degeneration

Like all degenerative processes, this disease tends to be slow and progressive. Causes dystrophic changes V macula retina may be different. The main one is considered to be the involution of eye tissue. However, in some people, dystrophic changes occur more quickly, while in others, more slowly. Therefore, there is an opinion that age-related macular degeneration is inherited (genetically), and also predominates in people of European nationality. Other risk factors include: smoking, arterial hypertension, frequent exposure to the sun. Based on this, the causes of macular degeneration can be identified. These include:

1. Vascular lesions. Atherosclerosis of small arteries is considered one of the risk factors. Impaired oxygen delivery to eye tissues is one of the main mechanisms for the development of degeneration.
2. Excess body weight.
3. Lack of vitamins and some microelements. Among the substances necessary to maintain retinal tissue are lutein and zeaxanthin.
4. Availability of a large number of free radicals" They increase the risk of developing organ degeneration several times.
5. Ethnic characteristics. The disease is more common in people with light-colored eyes. The fact is that representatives of the Caucasian race have a low density of pigment contained in the retina. For this reason, degenerative processes develop faster, as do the symptoms of the disease.
6. Poor nutrition.
7. Exposure to direct sunlight without protective glasses.

Pathology often develops in people with a burdened hereditary history (presence of the disease in parents or grandmothers). In most cases, the disease is diagnosed in the female population.

Age-related macular degeneration: pathophysiology of the process

Surgical treatment of retinal degeneration

Drug therapy alone is not enough if the patient is diagnosed with age-related macular degeneration. Treatment of the pathology must be combined with surgical correction. This is especially true for the wet form of AMD. Currently, almost every ophthalmology clinic Laser treatment for macular degeneration is performed. It may vary. The choice of method depends on the stage of AMD and the manifestations of the pathology. Highlight following methods surgical correction:

1. Laser coagulation of neovascular membrane.
2. Photodynamic therapy with Visudin.
3. Transpupillary laser thermal correction.

If possible and there are no contraindications, pigment epithelium transplantation and vitrectomy (in case of hemorrhage into the vitreous body of the eye) are performed.

Prevention of age-related retinal degeneration

TO preventive measures include: dieting, weight loss. In case of vascular lesions, smoking cessation is recommended. People with light-colored eyes should also avoid direct exposure to sunlight. In addition, prevention includes the use of vitamins to strengthen vision and microelements.

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The retina is a specific structural and functional unit of the eyeball, necessary for capturing the image of the surrounding space and transmitting it to the brain. From an anatomical point of view, the retina is a thin layer of nerve cells thanks to which a person sees, since it is on them that the image is projected and transmitted along the optic nerve to the brain, where the “picture” is processed. The retina of the eye is formed by light-sensitive cells, which are called photoreceptors, since they are able to capture all the details of the surrounding “picture” that appears in the field of vision.

Depending on which area of ​​the retina is affected, they are divided into three large groups:
1. Generalized retinal dystrophies;
2. Central retinal dystrophies;
3. Peripheral retinal dystrophies.

With central dystrophy, only the central part of the entire retina of the eye is affected. Since this central part of the retina is called macula, then the term is often used to denote dystrophy of the corresponding localization macular. Therefore, a synonym for the term “central retinal dystrophy” is the concept of “macular retinal dystrophy”.

In peripheral dystrophy, the edges of the retina are affected, while the central areas remain undamaged. With generalized retinal dystrophy, all parts of the retina are affected - both central and peripheral. A special case is age-related (senile) retinal dystrophy, which develops against the background of senile changes in the structure of microvessels. According to the location of the lesion, senile retinal dystrophy is central (macular).

Depending on the characteristics of tissue damage and the characteristics of the course of the disease, central, peripheral and generalized retinal dystrophies are divided into numerous varieties, which will be discussed separately.

Central retinal dystrophy - classification and brief description of varieties

• Stargardt's macular dystrophy;
• Yellow-spotted fundus (Franceschetti's disease);
• Best's vitelline (vitelliform) macular degeneration;
• Congenital cone retinal dystrophy;
• Colloid retinal dystrophy Doina;
• Age-related retinal degeneration (dry or wet macular degeneration);
• Central serous choriopathy.

Central chorioretinal retinal dystrophy

Due to the presence of effusion under the retina, a characteristic symptom of this dystrophy is a decrease in visual acuity and the appearance of wave-like curvatures of the image, as if a person is looking through a layer of water.

Macular (age-related) retinal degeneration

Both forms of macular degeneration of the retina develop in people over 50–60 years of age against the background of senile changes in the structure of the walls of microvessels. Against the background of age-related dystrophy, damage occurs to the vessels of the central part of the retina, the so-called macula, which provides high resolution, that is, allows a person to see and distinguish the smallest details of objects and the environment at close range. However, even with severe age-related dystrophy, complete blindness occurs extremely rarely, since the peripheral parts of the retina remain intact and allow a person to partially see. Preserved peripheral parts of the retina allow a person to navigate normally in his usual environment. In the most severe course of age-related retinal dystrophy, a person loses the ability to read and write.

Dry (non-exudative) age-related macular degeneration The retina is characterized by the accumulation of waste products of cells between the blood vessels and the retina itself. These waste products are not removed in a timely manner due to disruption of the structure and function of the microvessels of the eye. Waste products are chemical substances that are deposited in the tissues under the retina and look like small tubercles yellow color. These yellow tubercles are called Druze.

Dry retinal dystrophy accounts for up to 90% of cases of all macular degeneration and is a relatively benign form, since its course is slow, and therefore the decrease in visual acuity is also gradual. Non-exudative macular degeneration usually occurs in three successive stages:
1. The early stage of dry age-related macular degeneration of the retina is characterized by the presence of small drusen. At this stage, the person still sees well and is not bothered by any visual impairment;
2. The intermediate stage is characterized by the presence of either one large drusen or several small ones localized in the central part of the retina. These drusen reduce a person's field of vision, as a result of which he sometimes sees a spot in front of his eyes. The only symptom at this stage of age-related macular degeneration is the need for bright light for reading or writing;
3. The pronounced stage is characterized by the appearance of a spot in the field of vision, which is dark in color and big size. This spot does not allow a person to see most of the surrounding picture.

Wet macular degeneration of the retina occurs in 10% of cases and has an unfavorable prognosis, since against its background, firstly, there is a very high risk of developing retinal detachment, and secondly, vision loss occurs very quickly. With this form of dystrophy, new blood vessels, which are normally absent, begin to actively grow under the retina of the eye. These vessels have a structure that is not typical for the eye, and therefore their membrane is easily damaged, and fluid and blood begin to leak through it, accumulating under the retina. This effusion is called exudate. As a result, exudate accumulates under the retina, which puts pressure on it and gradually peels off. That is why wet macular degeneration is dangerous due to retinal detachment.

With wet macular degeneration of the retina, a sharp and unexpected decrease in visual acuity occurs. If treatment is not started immediately, the onset of complete blindness against the background of retinal detachment.

Peripheral retinal dystrophy - classification and general characteristics of types

Peripheral retinal dystrophies are often caused by changes in the length of the eye against the background of progressive myopia and deterioration of blood circulation in this area. As peripheral dystrophies progress, the retina becomes thinner, resulting in the formation of so-called tractions (areas of excessive tension). These tractions, if they exist for a long time, create the preconditions for a tear in the retina, through which the liquid part of the vitreous seeps under it, lifts it and gradually peels off.

Depending on the degree of danger of retinal detachment, as well as on the type of morphological changes, peripheral dystrophies are divided into the following types:

• Lattice retinal dystrophy;
• Retinal degeneration of the “snail traces” type;
• Frost-like degeneration of the retina;
• Cobblestone retinal degeneration;
• Small cystic degeneration of Blessin-Ivanov;
• Retinal pigmentary dystrophy;
• Pediatric Leber's taperetinal amaurosis;
• X-chromosomal juvenile retinoschisis.

Lattice retinal dystrophy

Most often (in 2/3 of cases) lattice retinal dystrophy is detected in men over 20 years of age, which indicates its hereditary nature. Lattice dystrophy affects one or both eyes with approximately equal frequency and then progresses slowly and gradually throughout a person's life.

With lattice dystrophy, white, narrow, wavy stripes are visible on the fundus, forming lattices or rope ladders. These stripes are formed by collapsed and hyaline-filled blood vessels. Between the collapsed vessels, areas of thinning of the retina are formed, which have the characteristic appearance of pinkish or red lesions. In these areas of the thinned retina, cysts or tears can form, leading to detachment. The vitreous body in the area adjacent to the area of ​​the retina with dystrophic changes is liquefied. And at the edges of the area of ​​dystrophy, the vitreous body, on the contrary, is very tightly fused to the retina. Because of this, areas of excessive tension on the retina (traction) arise, where small tears are formed that look like valves. It is through these valves that the liquid part of the vitreous penetrates under the retina and provokes its detachment.

Peripheral retinal dystrophy of the “snail traces” type

Frost-like retinal dystrophy

Retinal dystrophy "cobblestone"

Small cystic retinal dystrophy Blessin–Ivanov

Retinal pigmentary dystrophy

Pediatric Leber's taperetinal amaurosis

X-chromosomal juvenile retinoschisis

Congenital retinal dystrophy

• Pigmentary dystrophy;
• Leber's amaurosis;
• Nyctalopia (lack of night vision);
• Cone dysfunction syndrome, in which color perception is impaired or complete color blindness is present (a person sees everything as gray or black and white).

• Stargardt's disease;
• Best's disease;
• Age-related macular degeneration.

• X-chromosomal juvenile retinoschisis;
• Wagner's disease;
• Goldman-Favre disease.

Retinal dystrophy during pregnancy

If a woman had any eye diseases before pregnancy, for example, myopia, hemeralopia and others, this significantly increases the risk of developing retinal dystrophy during pregnancy. Since various eye diseases are widespread in the population, the development of retinal dystrophy in pregnant women is not uncommon. It is precisely because of the risk of dystrophy with subsequent retinal detachment that gynecologists refer pregnant women for consultation with an ophthalmologist. And for the same reason, women suffering from myopia need permission from an ophthalmologist to give birth naturally. If the ophthalmologist considers the risk of fulminant dystrophy and retinal detachment during childbirth to be too high, he will recommend a cesarean section.

Retinal dystrophy - causes

To the locals causal factors and retinal dystrophy include the following:

• Hereditary predisposition;
• Myopia of any severity;
• Inflammatory eye diseases;
• Previous eye surgeries.

• Hypertonic disease;
• Diabetes;
• Past viral infections;
• Intoxication of any nature (poisoning with poisons, alcohol, tobacco, bacterial toxins, etc.);
• Increased blood cholesterol levels;
• Deficiency of vitamins and minerals entering the body with food;
• Chronic diseases (heart, thyroid, etc.);
• Age-related changes in the structure of blood vessels;
• Frequent exposure to direct sunlight on the eyes;
• White skin and blue eyes.

Retinal dystrophy - symptoms and signs

• Decreased visual acuity in one or both eyes (the need for bright light for reading or writing is also a sign of decreased visual acuity);
• Narrowing of the field of view;
• The appearance of scotoma (spot or sensation of a curtain, fog or obstruction in front of the eyes);
• A distorted, wave-like image before the eyes, as if a person is looking through a layer of water;
• Poor vision in darkness or twilight (nyctalopia);
• Impaired color discrimination (colors are perceived as different, not corresponding to reality, for example, blue is seen as green, etc.);
• Periodic appearance of “floaters” or flashes before the eyes;
• Metamorphopsia (incorrect perception of everything related to the shape, color and location in space of a real object);
• Inability to correctly distinguish a moving object from a stationary one.

In addition to the listed clinical symptoms, retinal dystrophy is characterized by the following signs, identified during objective examinations and various tests:
1. Distortion of lines on Amsler test. This test consists in the fact that a person alternately looks with each eye at a point located in the center of a grid drawn on a sheet of paper. First, the paper is placed at a distance arm's length away from the eye and then slowly brought closer. If the lines are distorted, this is a sign of macular degeneration of the retina (see Figure 1);


Figure 1 – Amsler test. At the top right is the picture that a person with normal vision. At the top and bottom left is the image that a person sees with retinal dystrophy.
2. Characteristic changes on the fundus (for example, drusen, cysts, etc.).
3. Reduced electroretinography readings.

Retinal dystrophy - photo

This photograph shows retinal dystrophy of the “cobblestone” type.

This photograph shows dry age-related macular degeneration of the retina.

Retinal dystrophy - treatment

General principles of treatment of various types of retinal dystrophy

Drug therapy for retinal dystrophy involves the use of the following groups of drugs:
1. Antiplatelet agents– drugs that reduce thrombus formation in blood vessels (for example, Ticlopidine, Clopidogrel, acetylsalicylic acid). These drugs are taken orally in tablet form or administered intravenously;
2. Vasodilators And angioprotectors – drugs that dilate and strengthen blood vessels (for example, No-shpa, Papaverine, Ascorutin, Complamin, etc.). The drugs are taken orally or administered intravenously;
3. Lipid-lowering drugs – drugs that lower blood cholesterol levels, for example, Methionine, Simvastatin, Atorvastatin, etc. The drugs are used only in people suffering from atherosclerosis;
4. Vitamin complexes , which contain elements important for the normal functioning of the eyes, for example, Okyuvit-lutein, Blueberry-forte, etc.;
5. B vitamins ;
6. Drugs that improve microcirculation , for example, Pentoxifylline. Typically, drugs are injected directly into the structures of the eye;
7. Polypeptides, obtained from the retina of cattle (the drug Retinolamine). The drug is injected into the structures of the eye;
8. Eye drops containing vitamins and biological substances, promoting repair and improvement of metabolism, for example, Taufon, Emoxipin, Ophthalm-Katachrome, etc.;
9. Lucentis– a remedy that prevents the growth of pathological blood vessels. Used for the treatment of age-related macular degeneration of the retina.

The medications listed above are taken in courses, several times (at least twice) throughout the year.

In addition, for wet macular degeneration, Dexamethasone is injected into the eye, and Furosemide is administered intravenously. When hemorrhages develop in the eye, heparin, Etamsylate, aminocaproic acid or Prourokinase are administered intravenously in order to quickly resolve and stop it. To relieve swelling in any form of retinal dystrophy, Triamcinolone is injected directly into the eye.

Also used in courses for the treatment of retinal dystrophies following methods physiotherapy:

• Electrophoresis with heparin, No-shpa and nicotinic acid;
• Photostimulation of the retina;
• Stimulation of the retina with low-energy laser radiation;
• Electrical stimulation of the retina;
• Intravenous laser irradiation blood (ILBI).

• Laser coagulation of the retina;
• Vitrectomy;
• Vaso-reconstructive operations (crossing the superficial temporal artery);
• Revascularization operations.

Approaches to the treatment of macular degeneration of the retina

If macular degeneration is in a more severe stage, then along with drug treatment, physiotherapy methods are used, such as:

• Magnetic stimulation of the retina;
• Retinal photostimulation;
• Laser stimulation retina;
• Electrical stimulation of the retina;
• Intravenous laser blood irradiation (ILBI);
• Surgeries to restore normal blood flow in the retina.

If a person has wet dystrophy, then first of all laser coagulation of sprouting, abnormal vessels is performed. During this procedure, a laser beam is directed to the affected areas of the retina, and under the influence of its powerful energy, blood vessels are sealed. As a result, fluid and blood stop sweating under the retina and peeling it off, which stops the progression of the disease. Laser coagulation of blood vessels is short in duration and completely painless procedure, which can be performed in a clinic setting.

After laser coagulation, it is necessary to take drugs from the group of angiogenesis inhibitors, for example, Lucentis, which will inhibit active growth new, abnormal vessels, thereby stopping the progression of wet retinal macular degeneration. Lucentis should be taken continuously, and other medications should be taken in courses several times a year, as with dry macular degeneration.

Principles of treatment of peripheral retinal dystrophy

Retinal dystrophy - laser treatment

Examples therapeutic treatment laser dystrophy - is stimulation of the retina, during which the affected areas are irradiated in order to activate metabolic processes in them. Laser stimulation of the retina in most cases gives an excellent effect and allows you to stop the progression of the disease for a long time. An example of surgical laser treatment for dystrophy is coagulation of blood vessels or delimitation of the affected area of ​​the retina. IN in this case The laser beam is directed to the affected areas of the retina and, under the influence of the released thermal energy, literally glues and seals the tissue and, thereby, delimits the treated area. As a result, the area of ​​the retina affected by dystrophy is isolated from other parts, which also makes it possible to stop the progression of the disease.

Retinal dystrophy - surgical treatment (operation)

Vitamins for retinal dystrophy

Vitamins for retinal dystrophy must be taken in two forms - in special tablets or multivitamin complexes, as well as in the form of food products rich in them. Fresh vegetables and fruits, cereals, nuts, etc. are richest in vitamins A, E and group B. Therefore, these products must be consumed by people suffering from retinal dystrophy, since they are sources of vitamins that improve the nutrition and functioning of the eyes.

Prevention of retinal dystrophy

• Do not overstrain your eyes, always give them rest;
• Do not work without eye protection from various harmful radiation;
• Do eye exercises;
• Eat well, including fresh vegetables and fruits, as they contain a large number of vitamins and microelements necessary for the normal functioning of the eye;
• Take vitamins A, E and group B;
• Take zinc supplements.

Retinal dystrophy - folk remedies