Retina / AMD

The retina, medically called the retina, performs the imaging function in the eye – similar to the film in a camera. It is best to imagine the eye as a spherical organ enclosed by a protective layer, the sclera. Where light enters the eye – in the area of the pupil – this protective layer is transparent. This transparent window is the cornea of the eye. The inner lining, the layer on the rear inner wall of the eye, is the retina. It is a highly complex nerve tissue with a thickness of 1/10 to 1/3 of a millimeter. It serves as the projection surface for all perceived images and transmits them via the optic nerve to the brain, where the impressions are processed.

The macula is the area for the sharpest vision. Macula means “spot,” specifically the spot of sharpest vision. It is often referred to as the yellow spot of the retina, as the yellow protective pigments are only present in the macula. The macula plays a major role when we want to fixate on something precisely, for example when reading or when we want to recognize faces.

Macular Disorders

Macular disorders manifest through reduced visual acuity and typically through distortions in perception. Letters or parts of words may drop out while reading, sometimes letters appear to jump, faces appear distorted and difficult to recognize, while lines and edges may appear wavy or warped. In cases of severe changes, reading may even become impossible.

Since in most cases of macular diseases the remaining retina continues to function, affected individuals can still see in the peripheral visual field. In this area, they can perceive many things, which enables, for example, orientation in rooms or recognition of smaller objects in the peripheral visual field. However, when the affected person tries to fixate precisely on an object, it disappears because the image falls on the diseased macula.

This particular visual experience can cause confusion in the immediate social environment. People might react with irritation when the affected person says they cannot see anything while still noticing a spot on the floor. Therefore, it is important that family members also understand how vision can change during the course of a macular disease and that the visual impairment is not questioned.

Macular Diseases

AMD, DME, CME (Vascular Occlusions, Uveitis)

The macula lutea, also known as the yellow spot of the retina, is the site of sharpest vision and is located precisely in the center of the retina on the optical axis of the eye. Diseases of this region of the retina can therefore lead to significant impairment of visual acuity.

Macular diseases can already occur in adolescents, for example in the context of juvenile macular degeneration. These degenerations have genetic causes, and currently no effective therapies are available.

The most commonly occurring form of macular degeneration is age-related macular degeneration (AMD for short), which occurs with increasing age.

Age-related macular degeneration (AMD) manifests in two main forms:

Dry macular degeneration shows deposits in the layer beneath the retina in its early stages. These deposits are detectable in very early stages through special photographic procedures. As the condition progresses, spot-like changes known as drusen become visible during fundus examination. In the further course, there may be loss of the pigment layer beneath the retina and damage to the sensory cells of the retina. This condition often leads to impairment of visual acuity.
Wet macular degeneration is characterized by the uncontrolled formation of blood vessels beneath the retina. These abnormal vessels can cause hemorrhages or fluid accumulation in the macula, severely impairing retinal function. In advanced stages, patients frequently suffer from a distorted visual field and reduced visual acuity, especially as the macula increasingly scars.

Causes of Age-Related Macular Degeneration (AMD)

The disease primarily affects people over the age of 50, which is why it is called age-related macular degeneration. The exact causes of macular degeneration are not yet fully known. There are indications that the light we are exposed to throughout our lives plays a significant role. When light hits tissue, aggressive oxygen atoms called radicals can be created through photo-oxidation, which can cause cell damage. For this reason, dark-skinned individuals, who have more protective pigment, may be less susceptible to AMD than light-skinned individuals.

Hereditary factors may also play a certain role. Nevertheless, it is not necessarily the case that children will also develop AMD if this disease occurs in their parents.

Large studies have shown a connection with smoking. It was found that smokers are more likely to develop AMD than non-smokers.

Current findings suggest that cataract surgery does not appear to influence the course of AMD. For a long time, it was suspected that cataract surgery could worsen AMD, but there is no clear evidence for this.

Symptoms of Age-Related Macular Degeneration (AMD)

Early signs of AMD may manifest as disturbances while reading. Individual letters or parts of words may drop out. Occasionally, a dark spot may be perceived, especially in the morning after waking up or after looking at a bright surface. Bends or waves may appear at lines, door edges, or window frames. Over time, it becomes more difficult to fixate precisely on objects. Contrasts lose sharpness and colors lose intensity.

Symptoms at a glance:

Gray spot or blank areas while reading
Imprecise vision, especially in the fixated area
Distorted lines
Decreasing contrast sharpness
Reduced color intensity

Course

During the course of AMD, it is crucial to identify the potential transition from the dry to the wet form in a timely manner. For this case, effective treatment methods are available today. With the help of modern diagnostic procedures such as Optical Coherence Tomography (OCT) or Fluorescein Angiography, it is possible to detect wet AMD quickly and precisely.

In Our Own Right

A focus of our practice lies in the individualized treatment of AMD conditions. Prof. Dr. Koss is an internationally sought-after expert and is therefore currently the youngest professor in German ophthalmology due to his contributions to AMD therapy. He is a sought-after consultant in the introduction of the Faricimab (Vabysmo) antibody for the treatment of wet AMD and diabetic macular edema, having been involved in the development of the medication since 2011 (as a co-author). Prof. Dr. Koss is also a close consultant on photobiomodulation and the drug Pegcetacoplan, both strategies for treating dry AMD.

Diagnostics

For the diagnosis of AMD, all necessary diagnostic devices are available to us.

Optical Coherence Tomography (OCT)

Optical Coherence Tomography (OCT) has become the worldwide standard in the diagnosis of retinal diseases, especially of the macula, as well as optic nerve diseases such as glaucoma.

It has become an indispensable instrument for evaluating AMD, macular edema, macular holes, or so-called macular puckers.

The principle is based on measuring the reflected light beam in the eye and converting it into an image visible to the human eye using digital technology. The resolution is 10 micrometers. The procedure is painless and completely harmless.

It is important to note that OCT is not covered by statutory health insurance and must therefore be billed as a private medical service.

Fluorescein Angiography (FLA)

Fluorescein angiography enables the visualization of the retinal vascular system. This examination may be necessary in various macular diseases, inflammations, retinal circulatory disorders (e.g., due to thrombosis), diabetes, age-related macular degeneration (AMD), and in cases of suspected tumors.

A dye is injected into an arm vein and made visible in the eye’s blood vessels through a special photographic technique. Based on the distribution pattern in the eye, conclusions can be drawn about underlying changes.

Temporary yellowish skin discoloration from the dye may occur but disappears quickly. After 4–6 hours, the dye is excreted through the kidneys. Allergic reactions are possible but rare. Nevertheless, appropriate treatment measures are available to immediately address any reactions.

Important to note: For several years now, we have been offering so-called OCT angiography. Here, the blood flow of the macular retinal layers can be visualized without the use of dye.

Treatment

Individualized Intravitreal Injection

Treatment of Wet Age-Related Macular Degeneration

Unlike dry AMD, the wet form can be effectively treated in many, but not all, cases. In this therapy, effective medications are introduced into the eye under sterile surgical conditions. This procedure is called IVOM, an abbreviation for intravitreal operative medication administration.

This procedure is also used in other conditions such as:

Macular edema caused by retinal diseases such as vascular occlusions or diabetic retinopathy. Edema in the macula can also occur after cataract surgery.
Neovascularization resulting from rare eye diseases.
Uveitis, an inflammation of the middle layer of the eye, namely the choroid.
Symptomatic vitreomacular adhesions, referring to attachments and traction effects of the vitreous body on the macula.

IVOM is a procedure for treating specific macular diseases. The medication is introduced into the vitreous cavity. Available medications include VABYSMO®, LUCENTIS®, AVASTIN®, EYLEA®, JETREA®, and steroids such as OZURDEX®.

Procedure of Intravitreal Medication Administration (IVOM)

IVOM is a brief procedure usually performed under local, often only superficial, anesthesia. The surgeon introduces the active substance through a fine cannula into the vitreous body. The injection site closes on its own. After the injection, ointment is applied to the eye. A bandage is rarely required.

The procedure requires sterile surgical conditions to avoid infections. Should pain or visual impairment occur in the first days after the injection, an immediate ophthalmological examination is necessary. Fortunately, infections are extremely rare. However, cases of retinal tears, retinal detachments, lens injuries, or hemorrhages have been described in the literature. For this reason, the procedure may only be performed by specially trained physicians. An initial ophthalmological check-up in the first few days is crucial to detect possible signs of inflammation early.

Important to know! Thanks to the efficient organization of our practice, we can often perform an IVOM on the same day as diagnosis, so that a return visit or hospital stay with corresponding waiting times can be avoided.

Treatment of Dry Age-Related Macular Degeneration

The exact cause of both wet and dry AMD is unknown to this day. Age, as the name suggests, is the main factor, alongside nicotine consumption, which has been identified as the only clear risk factor. Research into genetic diagnostics aims to identify additional risk factors, particularly in the immunological complement system – however, neither age nor the immune system can be changed!

As with many other diseases, a healthy diet rich in raw foods and low in meat, with plenty of green leafy vegetables, fruit, and occasional fish, as well as avoidance of nicotine consumption (smoking), form the basis of all recommendations.

The following treatment options are available to you at our center.

Valeda

Over the course of life, eye cells can become diseased, leading to loss of function and cell death. Valeda uses photobiomodulation by applying specific light wavelengths to the eye. Photobiomodulation uses low-level light to stimulate cell function and improve cell survival. Healthy cells are crucial for good eye health. Currently, photobiomodulation is being used as a therapy for various conditions, and Valeda is the first device specifically developed for the treatment of dry (non-exudative) age-related macular degeneration (AMD).

Patient Advisory Services for AMD

The Eye Center Nymphenburger Höfe offers its patients, in addition to diagnostic and therapeutic services, comprehensive consultation for visual rehabilitation. Prof. Dr. rer. biol. hum. Werner Eisenbarth, specialist in LowVision rehabilitation, examines and advises patients with AMD, diabetic retinopathy, and other eye diseases individually.

This consultation is a supplementary option alongside ophthalmological diagnostics and therapy. It aims to show you all rehabilitation options for your specific eye condition. Our shared goal is to make the best possible use of and improve your visual ability. We want to help you maintain your independence in everyday activities, especially reading.

What Does the Advisory Service Include?

Detailed medical history including needs analysis
Optometric examination (review of existing visual aids, macular mapping, contrast sensitivity, magnification requirements, lighting requirements, etc.)
Quantification of reading performance
Consultation on innovative therapy options – including for dry AMD, magnifying visual aids, and training possibilities
Duration: approx. 1 hour