Professor Wu Chunrong, PLA 306 Hospital, Department of Ophthalmology
The macula is a tissue about 2 mm in size located between the upper and lower blood vessel arches at the posterior pole of the retina, rich in lutein, hence the name macula. The macular fovea has only a cone cell layer, which is the most important structure of the retina and is fine vision. Lesions in the macular area directly affect the patient's central vision, resulting in significant visual dysfunction. In the past, due to the limitations of technology, equipment and understanding, macular degeneration lacked effective diagnosis and treatment methods, and most patients with macular degeneration had a poor prognosis. In recent years, with the emergence of a series of examination and treatment technologies such as OCT examination, ICG angiography, vitrectomy, photodynamic therapy and vitreous injection, the diagnosis and treatment of macular diseases are undergoing leapfrog development. The diagnosis and treatment of common macular degeneration in the elderly are mainly introduced here.
1. Senile macular degeneration
Age-related macular degeneration (AMD), also known as Age–related macular degeneration (AMD), is a degenerative lesion that occurs in the choroid, vitreous membrane, and retinal pigment epithelium in the macula. According to us research data, the prevalence rate is 9% at the age of 45 to 64 years, 10% at the age of 65 to 74 years, and 30% at the age of 75 years. The prevalence of senile macular degeneration in people aged 50-59, 60-69 years and over 70 years in China was 5.5%, 7.7% and 15.3%, respectively.
Clinical manifestations: The clinical classification of senile macular degeneration is divided into two types: atrophic (dry) and exudative (wet). Atrophic senile macular degeneration is characterized by progressive retinal pigment epithelial atrophy, photoreceptor degeneration, causing central vision loss, simultaneous publication of both eyes, and slow loss of vision. Exudative elderly macular degeneration is characterized by subretinal neovascularization (CNV) formation, which causes a series of fundus changes such as hemorrhage, edema, exudation, and scarring in the macular area. Early on, it can manifest as blurred objects and distorted vision. When there is bleeding and exudation, central vision can be drastically reduced. Advanced lesions end with scarring and loss of vision in the patient's center.
Diagnosis: Diagnosis of macular degeneration in old age is based on fundus examination, fluorescein fundus angiography (FA), choroidal angiography, and OCT. Atrophic age-type macular degenerated fundus is manifested by vitreous membrane warts, atrophic changes in the retinal pigment epithelium. FA, ICG, and OCT tests are free of CNV formation, exudation, edema, and bleeding changes. Bleeding and exudation of the fundus macula of exudative elderly macular degeneration may be seen. CNVs are visible in FA, ICG, and OCT. Atrophic elderly macular degeneration can develop into exudative macular degeneration. With the Amsler table, patients can perform self-examination to detect the progression of fundus lesions in a timely manner.
Treatment: treatment for age-related macular degeneration depends on the type. The main goal of treatment for exudative age-related macular degeneration is to control CNV, causing it to atrophy and resolve. The biggest difficulty in treatment is not to damage the healthy tissue of the macular fovea. At present, the treatment method is mainly photodynamic therapy. Photodynamic therapy is highly selective, has little damage to the normal retina, can control the growth of CNV, and is a safe and effective treatment. However, a photodynamic therapy can not completely cure exudative elderly macular degeneration, generally require multiple treatments, so that the lesion is in a relatively stable state, the cost is expensive is its disadvantage. Vitreous injection of antivascular endothelial growth factor (VEGF) is a new technique for the treatment of exudative elderly macular degeneration. Clinical studies have shown that this method can reduce macular edema, control cnV development, and improve vision in some patients. At present, experts and scholars of fundus diseases at home and abroad are discussing photodynamic therapy combined with vitreous injection of anti-VEGF for the treatment of senile macular degeneration, and preliminary clinical studies have shown good prospects. Macular retinal flap rotation and pigment epithelial grafting are one of the surgical methods for the treatment of exudative macular degeneration. Because of its technical difficulty and limited visual effect, it has not been popularized. Laser retinal photocoagulation therapy is only suitable for a small number of cases where the lesion is outside the fovea. There is no specific treatment for atrophic macular degeneration in the elderly, and antioxidants such as vitamin C, vitamin E, as well as zinc preparations and lutein can generally be taken. In recent years, the development of antioxidants, zinc and lutein recurrence compounds has helped to delay the development of lesions.
2. Idiopathic macular fissures
Macular clefts can occur at any age and can be secondary to a variety of fundus lesions such as high myopia, trauma, and long-term macular edema. Idiopathic macular fissures refer to macular fissures that appear without obvious causes and check for fundus problems themselves, accounting for most of the macular fissures. In recent years, it has been believed that vitreous concentration and condensation at the level of the central concave tangent line of the macula are important causes of macular pit formation.
Clinical manifestations: Clinical highlights of macular pits are central vision loss, visual distortion and self-conscious central scotoma. The degree of vision loss depends on the size and location of the hole. According to the process of tear occurrence, the clinic is divided into stages I-IV, early holes, the patient's vision is mildly reduced, and if a full-layer hole is formed, the central vision is sharply reduced, usually around 0.1.
Diagnosis: fundus examination of the macula center may reveal sharp holes with round or oval edges. OCT examination may reveal a defect in the neuroepithelial layer of the central retinal region of the macula. FFA angiography can reveal translucent fluorescence.
Treatment: Macular schizophorus treatment is mainly based on vitrectomy surgery. By removing the vitreous body, the inner boundary membrane of the retina is removed, and the retinal tangential traction is released, and the healing of the hole is promoted. Clinical phases II-III are suitable for surgical treatment. Stage I macular cleavage requires clinical observation, and stage IV macular cleavage generally does not require surgery if retinal detachment does not occur due to no chance of healing.
3. Premacular retina
The anterior macular retina is a fibrous proliferative membrane that grows on the inner surface of the retina and can be secondary to a variety of fundus lesions or occur independently called idiopathic prevascular membrane. Idiopathic macular pretinal membrane is more common in the elderly, with a prevalence of 3.5 to 5.5% in elderly patients. In recent years, due to the emergence of OCT examination technology, the level of early diagnosis of the premacular retina has been improved.
Clinical manifestations and diagnosis: retinal folds and edema due to the proliferation and contraction of the pretinal retina lead to traction of the retina. In the early stage of the disease, the anterior retinal membrane is thinner, the pulling force of the retina is weaker, the patient has no obvious self-conscious symptoms, and the severe disease may have symptoms such as obvious vision loss and visual deformation. Fundus examination and OCT can confirm the diagnosis. OCT examination can show the relationship and degree of traction of the anterior macular membrane to the retina in the retinal section, which can help determine the condition and guide treatment.
Treatment: mild macular retinal membrane can be clinically observed. Severe patients require vitrectomy surgery. Surgical removal of the anterior retinal membrane improves retinal deformation and improves the patient's vision.