My Doctor Online The Permanente Medical Group

Types

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There are two basic types of macular degeneration: dry and wet. Approximately 90 percent of the cases we see are the dry type.

Dry AMD

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The dry form of AMD occurs when the central retina deteriorates with age. As it deteriorates, small yellow waste deposits, called drusen, accumulate underneath the retina. At the same time, the pigmented layer under the retina begins to break down. The loss of pigment and the build up of drusen damage your central vision.

• How much central vision you lose depends on how much drusen builds up and how much pigment has been lost.
• Dry AMD tends to progress slowly over a number of years and in many cases, people retain functional vision.
• However, sometimes the dry changes are severe or the disease will change into the wet variety without warning.

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Wet AMD

The wet type of AMD is always preceded by the dry type. It causes damage to the eye much more quickly and can cause serious vision loss within months or weeks. Approximately 10 percent of cases of dry macular degeneration progress to the wet type. In wet macular degeneration, the eye grows abnormal blood vessels that bleed and leak fluid into the macula. The fluid builds up, causing the macula to become distorted, which prevents the retina from functioning properly.

• Straight edges or objects may look wavy, because the macula is no longer smooth.
• Everything may be blurred and you may develop blind spots due to blood or fluid under the macula. 
• Eventually, without treatment, scar tissue can develop and permanently damage your central vision.
• Treatments for wet AMD have improved over the past several years and many people who were previously untreatable are now candidates for treatment.

Symptoms

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The symptoms are similar for both types of AMD. However, symptoms are more serious and develop much more quickly with wet macular degeneration. Dry macular degeneration progresses more slowly. If you think you have wet macular degeneration, contact us right away. Early detection and treatment can help you keep your central vision. Symptoms of AMD include:

• Dim or blurry central vision.
• Flat or level objects may look wavy or crooked or smaller than they really are. 
• Blurred or blind spots in the center of your visual field combined with a drop in the sharpness of your central vision. In the dry form this happens very gradually. In the wet form vision loss happens quickly.
• As the disease progresses you may not see well enough to read or drive.

Screening and Diagnosis

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We can schedule a general eye exam for you in either our Optometry or Ophthalmology departments. However, if you have sudden vision changes, especially if you have a family history of macular degeneration, contact us to schedule an urgent appointment in Ophthalmology.

A screening exam for AMD will include some or all of the following:

• Ophthalmoscopy. We use a strong light and magnifying lens to examine your retina for signs of macular degeneration. This allows us to see drusen and any blood or scarring. We may also photograph your eye during this exam.
• Visual Acuity Test. Just like a regular eye exam, this tests the strength of your central vision by requiring you to read letters on a wall chart some distance away.
• Amsler Grid. An Amsler Grid can detect wet macular generation. The grid consists of straight lines with a dot at the center. The lines near the center dot will appear wavy or curved instead of straight if you have wet macular degeneration. We may give you a grid to take with you so that you can watch for any vision changes at home.
• Fluorescein angiogram/Optical Coherence Tomography (OCT). If we suspect wet macular degeneration, we may perform some additional diagnostic tests, including a fluorescein angiogram or computerized eye scan called optical coherence tomography.

Causes and Prevention

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AMD is caused by deterioration of the central portion of the retina, called the macula. The retina is the nerve layer that lines the back of the eye and converts light into electrical signals that are sent to the brain. These signals are interpreted by the brain as images. The macula ensures that we can focus clearly, particularly when looking straight ahead. A healthy macula is important for activities like driving and reading.

AMD is associated with family history of the disease and the natural aging process. Smoking, chronic sun exposure and poor nutrition can also increase your risk of developing macular degeneration. To reduce your risk of developing AMD:

• Wear sunglasses. Sunglasses block harmful ultraviolet sunlight rays (UVA and UVB).
• Eat fresh fruits and dark green leafy vegetables. Good choices include collard greens and spinach.
• Take a vitamin supplement specifically for your eyes. For example, studies have shown that multivitamins with The Age-Related Eye Disease Study (AREDS) formula, which contain beta-carotene and zinc, may be able to slow the progression of symptoms in people with advanced macular generation. Check with us to make sure that they are appropriate for you. Some formulas, for example, are not appropriate for smokers or for ex-smokers.
• Quit smoking. Studies suggest that smoking more than doubles your risk of developing AMD.
• Maintain healthy blood pressure and cholesterol levels.  Talk to your personal physician about keeping your blood pressure and cholesterol levels under control.

Treatments

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Dry macular degeneration

There is no cure or treatment for dry macular degeneration at the moment. We recommend that you follow lifestyle and nutrition advice including wearing sunglasses, eating dark leafy vegetables and fruit, and quitting smoking.

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Wet macular degeneration

There are a number of effective treatments for wet macular degeneration, although there is no cure yet.

We will usually refer you to one of our retina vitreous specialists who can recommend the best approach to treating your wet AMD. This may include a combination of treatments or one specific treatment. Sometimes treatment can't restore good central vision, but can slow the vision loss. Response to treatment varies from patient to patient and can even vary between each of your eyes. We will consider treatments such as:

• Traditional argon laser. During this procedure we use a precise laser to seal the abnormal blood vessels that are leaking into the macula. The procedure can be performed in our Ophthalmology clinic, with local anesthetic; it only takes a few minutes.  
• Photodynamic therapy (PDT) laser. Photodynamic therapy combines laser treatment with a medicine called verteporfin which is activated by light. At the beginning of the procedure we inject verteporfin into the bloodstream. When the medicine reaches the abnormal blood vessels under the macula, we use the light from the laser to activate the drug, which then forms blood clots that seal the abnormal blood vessels. This slows down the buildup of fluid under the retina, the growth of scar tissue and subsequent vision loss.  Photodynamic therapy is performed in our Ophthalmology clinic.
• Anti-VEGF injections. We may recommend injecting anti-vascular endothelial growth factor (VEGF) medicines directly in to your eye. VEGF is a protein that supports the growth of abnormal blood vessels into the macula. These abnormal blood vessels leak into the macula and cause wet macular degeneration. By blocking the effects of VEGF, anti-VEGF drugs can stop the growth of new abnormal blood vessels, reduce fluid leakage and slow further vision loss.

Lifestyle Changes and Management

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Enhance your vision

If you have already lost vision, it's important to adjust your lifestyle to maximize the eyesight that you have:

• Choose large print books and magazines.
• Use magnifiers or low vision aides.
• Position lighting so that it is aimed at what you want to see and away from your eyes. Add extra table lamps and floor lamps where more lighting is needed.
• Make sure entry areas and stairs are well lit to avoid falls. Mark these areas with contrasting paint or tape so you can easily see them.
• Use bold lettering and high color contrast materials to make labels and mark switches.
• Talk to us about a referral to a low vision specialist. They can give you further advice on how to adapt your home and lifestyle according to the vision you have.
• Realize that you are not alone. This is a common disease. There is hope that advancements in research will continue to improve our ability to treat this condition.

Consider taking multivitamin supplements

Scientists are still debating whether taking vitamin and/or mineral supplements could help prevent, treat or cure certain eye conditions. Some early scientific studies seemed to show that supplements had the potential to prevent or slow the progression of cataract and AMD. One such study is The Age-Related Eye Disease Study (AREDS), sponsored by the National Eye Institute (NEI), one of the Federal government's National Institutes of Health. If you are interested in considering multivitamin supplements:

• Review a summary about AREDS' findings.
• Talk to us before taking supplements and follow our dosage recommendations carefully. Some supplements may interfere with each other or other medications.
• Smokers and ex-smokers probably should not take beta-carotene, as studies have shown a link between beta-carotene use and lung cancer among smokers.

Monitor your vision with an Amsler grid

The Amsler grid is a screening test that is used to assess your macula (the center of your retina). You should print a copy of the Amsler grid and administer the test at home.

The grid has horizontal and vertical lines, with a dot in the center, printed on black or white paper. While staring at the dot, you should look for wavy lines and missing areas of the grid. We are interested in tracking the following:

• Are you able to see the corners and sides of the square?
• Do you see any wavy lines?
• Are there any holes or missing areas?

If the lines of the grid do not appear straight and parallel or there are missing areas, we will examine the back of your eye (macula) very closely. If you notice any sudden vision change, such as flashing lights or floaters, you should come in for a dilated eye exam, even if the Amsler grid looks normal.

Your Care with Me

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If your optometrist sees signs of macular degeneration during your regular eye exam, he or she will make an appointment for you to see me or one of my colleagues in the Ophthalmology department. If you are not scheduled for a regular eye exam, and you notice symptoms of macular degeneration such as dim or blurry central vision or a blind spot, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

Your first appointment is likely to take at least 1 hour and possibly longer. During your office visit, we will discuss your medical and family history and I will perform a comprehensive eye exam and some diagnostic tests.

I may administer eyedrops to dilate your pupils so that I can clearly see the structures of your eyes. Your pupils will remain dilated for several hours, so you may wish to bring someone who can drive you home after your exam.

I will explain the findings of your exam and answer any questions or concerns you may have. I will also give you an Amsler grid to use at home to monitor your symptoms. If you notice any new changes, please let me know.

If we decide that you need further evaluation, or further treatment or surgery, I will discuss the treatment options that are available, and together we will create a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line, available 24 hours a day, 7 days a week. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the "After Visit Summary" that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

If surgery or a procedure is a treatment option

I will recommend you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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