AMD - Posterior Segment & Ocular Disease Spring 2026

Leading cause of blindness in individuals >50yo?

AMD

Do more people have dry or wet AMD?

dry AMD

Do males or females have higher prevalence for AMD?

No

Risk for African Americans vs White/Hispanic for AMD

Risk is lower in African Americans

EXAM QUESTION: If you are unsure whether there are changes in the macula (from clinical exam, reduced acuity, or both) you must do what?

1) Run an OCT

2) Refer to Ophthalmology

3) Or BOTH

EXAM QUESTION: What is the primary problem in macular degeneration (AMD)?

poor vascular supply to RPE/photoreceptors

EXAM QUESTION: What is an additional problem besides poor vascular supply to RPE/photoreceptors in AMD?

Breakdown of cell membranes d/t oxidative stress

EXAM QUESTION: What are the major risk factors for AMD?

-age

-smoking

-race

-genetics

What is the biggest contributor to the risk factors for AMD?

Age

Are there many genes that are related to AMD?

Yes -- there are 103(ish)

What are the OTHER (besides the major ones) that are risk factors for AMD development?

1) Lower intake of dietary anti-oxidants and omega-3 fatty acids

2) High body mass index/waist circumference

3) CV disease

4) UV exposure

5) Baseline levels of serum cystatin C (kidney function)

6) Blue iris>green iris

7) Divorced > married

8) Hyperopia

EXAM QUESTION: If you see macular degeneration in younger patients, you should think of what?

Inflammation from infections, autoimmune disorders, white dot syndromes

Central serous

Inherited disorders (Stargardt disease, pattern dystrophy)

Trauma

EXAM QUESTION: Many practitioners will not use AMD diagnosis until when?

until drusen are apparent

What are the classic signs of dry AMD?

RPE dropout

Pigment clumping

Drusen

What is RPE dropout? What color?

RPE pigmentary change; dull yellow

What is pigment clumping? What color?

RPE pigmentary change & hyperplasia; black

What can drusen progress to long-term?

Geographic atrophy long-term

Severe loss of vision

What color are drusen?

Dull yellow

What characterizes wet AMD? (five things)

Choroidal neovasc (CNVM or MNV)

RPE hyperplasia

Old blood (yellow/red)

Hard exudates

Sub-RPE hemorrhage is green-black; subretinal heme is red

What are serous RPE detachment, pigment epithelial detachment (PED), localized retinal detachment all signs of?

Could be a sign of either wet or dry AMD

How could dry AMD lead to a serous RPE/retinal detachment?

fluid leaks from the choriocapillaris and detaches RPE and/or the retina from Bruchs membrane

How could wet AMD lead to a serous RPE/retinal detachment?

fluid leaks from a choroidal neovascular membrane

If you have a serous retinal detachment, the fluid will be assumed to be from what origin?

choriodal neovasc

What color is a serous RPE/retinal detachment d/t dry AMD?

yellow/orange

What color is a serous RPE/retinal detachment d/t wet AMD?

yellow, orange, red

Can non-exudative macular neovascularization (nonexudative MNV) leak?

yes -- it may ultimately leak

What can non-exudative macular neovascularization (nonexudative MNV) be protective against?

geographic atrophy

Why is non-exudative macular neovascularization (nonexudative MNV) protective against geographic atrophy?

Alleviates some of the hypoxic stress if these vessels are not leaky and provide more profusion

RPE Detachment w/ Flow Overlay d/t Vessels (Pic)

RPE Detachment w/ Flow Overlay d/t Vessels (Pic)

What happens when OCT-A image looks like this and you do a FA?

it WILL NOT leak

Will non-exudative MNV eventually leak?

Yes

Small drusen size

<63 microns

**A retinal vessel is about 125 microns in diameter so it’s roughly less than half a retinal vessel diameter

Small drusen name

Drupelet

Medium drusen size

64-125 microns

**A retinal vein is about 125 microns in diameter

Large drusen size

>125 microns

**A retinal vein is about 125 microns in diameter

Dry AMD (Pic)

Dry AMD (Pic)

Are small drusen usually a problem?

usually not

Are large drusen a problem?

Yes -- this is worrisome

Why are you concerned about large drusen?

Concerned about possibility of choroidal neovascularization

What are drusen composed of?

protein/fat

If drusen start to coalesce with poorly defined borders, what is this referred to as?

soft drusen

What should you do on this patient?

OCT -- to look for neovasc

Calcific drusen (Pic)

Calcific drusen (Pic)

What do calcific drusen look like?

hard exudate

What color are calcific drusen?

-yellow, not very shiny

-well defined

What does calcific drusen indicate?

These patients have had AMD for a long time

What does this patient have?

a lot of soft drusen (coalesced drusen)

Drusen on an OCT (Pic)

Drusen on an OCT (Pic)

Dry AMD -- Early Macular Mottling with RPE Clumping (Pic)

Dry AMD -- Early Macular Mottling with RPE Clumping (Pic)

Can you get these pigmentary changes from other diseases besides AMD?

Yes

Does drusen ONLY happen in AMD?

Yes

Dry AMD -- Areas of RPE Dropout/RPE Window Defects (Pic)

Dry AMD -- Areas of RPE Dropout/RPE Window Defects (Pic)

What color is RPE Window Defect & RPE loss?

dull yellow or orange

If RPE dropout is orange, why?

RPE and retina loss

Dry AMD -- RPE Clumping and RPE Dropout in Fundus Photo and FA (Pic)

Dry AMD -- RPE Clumping and RPE Dropout in Fundus Photo and FA (Pic)

RPE Clumping will be (hyper/hypo) fluorescent on FA

hypo -- RPE pigment clumps will block

RPE Window defect will be (hyper/hypo) fluorescent on FA

hyperfluorescent -- no pigment to block

Dry AMD -- Drusen, RPE Clumping, Orange Areas are Window Defects with Effacement (Pic)

Dry AMD -- Drusen, RPE Clumping, Orange Areas are Window Defects with Effacement (Pic)

What size are the drusen in this pic? (see pic)

Large

What are effaced areas?

areas of missing RPE and retina (photoreceptors)

What color are effaced areas of AMD?

orange

What is the end stage of Dry AMD?

Geographic atrophy

What are characteristics of geographic atrophy?

choroidal BVs are showing through the RPE window defect & outer retina (possibly inner retina?)

Is vision good in this patient? (see pic)

No, the fovea is involved and VA will be terrible (20/400ish)

Whitening of BVs d/t what in geographic atrophy?

sclerosis

OCT and AMD -- RPE Atrophy and RPE Window Defects (Pic)

A RPE Window defect will be (hyper/hypo)reflective on OCT

hyper

Drusen will be (hyper/hypo)reflective on OCT

hyper

Is the RPE very thick in this patient? (see pic)

No -- reflectance off sclerosed vessels

What is present in this patient? (see pic)

Geographic atrophy -- coalesced window defects, shown by extra reflectivity in the choroid from missing RPE

EXAM QUESTION: Changes of dry macular degeneration summary?

RPE clumping

RPE Dropout/Window Defects

Drusen

Geographic atrophy

REVIEW: What color is RPE clumping?

dark pigment

REVIEW: What color is RPE dropout?

yellow or orange if effaced

REVIEW: What color is drusen?

dull yellow

REVIEW: Small, well defined drusen are (hard/soft) drusen

hard drusen

REVIEW: large, more poorly defined drusen are (hard/soft) drusen

soft

RPE/Retinal Detachment -- Serous Elevation from Choroidal Neovasc (Wet AMD) or Serous Fluid from Choriocapillaris (Dry AMD)

RPE/Retinal Detachment -- Serous Elevation from Choroidal Neovasc (Wet AMD) or Serous Fluid from Choriocapillaris (Dry AMD)

Is there fluid present in this retina? (see pic)

Yes -- blister like appearance

WET AMD Source of Serous Fluid

choroidal neovasc

DRY AMD Source of Serous Fluid

from choriocapillaris

Serous RPE Detachment (PED) with Small Serous Retinal Detachment (Pic)

Serous RPE Detachment (PED) with Small Serous Retinal Detachment (Pic)

Where is the RPE Detachment in this pic?

See pic

Where is the serous retinal detachment in this pic?

See pic

What is the extra hyper-reflectivity in this pic near the RPE?

-RPE hyperplasia and scarring (result of choroidal neovasc)

-Choroidal neovasc membrane itself that has broken through the retina

If you did an OCT-A of this patient in the outer retina, what would you see?

Choroidal neovasc

Wet AMD w/ Subretinal Hemorrhage (Bright Red) & Sub-RPE Hemorrhage (Darker) (Pic)

Wet AMD w/ Subretinal Hemorrhage (Bright Red) & Sub-RPE Hemorrhage (Darker) (Pic)

How do we want to catch edema in the macula?

with OCT or Amsler grid

Blood in the retina leads to (better/worse) prognosis

worse

Darker blood in Wet AMD is indicative of a (subretinal heme/sub-RPE heme)

sub-RPE heme

Brighter blood in Wet AMD is indicative of a (subretinal heme/sub-RPE heme)

subretinal heme

Wet AMD (Pic)

Wet AMD (Pic)

Choroidal Neovasc will be (hyper/hypo) fluorescent on FA

hyper

Choroidal Neovasc will be (hyper/hypo)reflective on OCT

hyper

Choroidal Neovasc presentation on OCT-A?

Neovasc vessels present in the choroidal OCT-A Slab

Classifications of Classic Choroidal Neovasc Membrane (CNVM) OR Type 1 Choroidal Neovascularization

-Well demarcated hyperfluorescence on FANG

-Subretinal Neovasc

Classifications of Occult Choroidal Neovasc Membrane (CNVM) OR Type 2 Choroidal Neovascularization

-Not well demarcated on FANG (diffuse fluorescence)

-Sub-RPE Neovasc

Classifications of Type 3 Choroidal Neovascularization

Starts in the retina and grows into the choroid

Classic vs Occult Choroidal Neovasc (Pic)

Classic vs Occult Choroidal Neovasc (Pic)

What does Classic (Type 1) Choroidal Neovasc Membrane look like on FA?

-hyperfluorescent

-well demarcated

What does Occult (Type 2) Choroidal Neovasc Membrane look like on FA?

-hyperfluorescent

-not well demarcated