Macular degeneration of the retina. Age-related macular degeneration: form, age, treatment, symptoms. Age-related macular degeneration: pathophysiology of the process

With the correct functioning of the central part of the retina, a person can clearly see objects that are located very close to the eyes. He easily reads and writes and distinguishes colors. When it is damaged, macular degeneration occurs, in which the patient complains of blurred vision and finds it difficult to write or read. What is macular retinal degeneration? What are its symptoms and can this disease be treated?

Macular degeneration of the retina

Macular degeneration is a disease characterized by damage to the retina of the eye, resulting in central vision is impaired. The pathology begins with blood vessels and progresses to ischemia of the central zone of the retina, which is responsible for central vision. AMD (age-related macular degeneration) is the most common cause of blindness in people over 55 years of age. In recent years, the disease has sharply “rejuvenated”.

Women are most prone to this disease as they live longer than men. It is also transmitted hereditarily.

Age-related macular degeneration: causes

1. Lack of minerals and vitamins in the human body.
2. A diet that is high in saturated fat.
3. Age 55 years and older.
4. Smoking.
5. Duration and intensity of direct sunlight.
6. Excess body weight.
7. Eye injuries.
8. Diseases of arterial hypertension or ischemic disease.

Symptoms of age-related macular degeneration

AMD develops slowly, painlessly, but with obligatory visual impairment. In isolated cases, blindness due to macular degeneration occurs suddenly.

Types of macular degeneration

Dry AMD- forms and accumulates a yellowish coating, which has a bad effect on the photoreceptors in the macula of the retina. The disease begins to develop in one eye. About 90% of patients suffer from this type. Dry AMD is divided into three stages of development:

1. Early stage. There are no symptoms of visual impairment, but small to medium-sized drusen are noticeable in the eye.
2. Intermediate stage. One large drusen or several medium-sized ones appear. The patient has a noticeably distorted spot in the center of their field of vision and needs more light to read.
3. Expressed stage. Sensitive cells in the organ of vision are destroyed and the supporting tissue of the retina is damaged. Further, the spot in the center becomes darker and larger. Reading becomes difficult.

Wet (exudative) AMD- new blood vessels grow in the direction of the macula behind the retina. It progresses much faster than dry macula and appears in people suffering from dry macula, occurring in 10% of cases. Macular degeneration disease develops quickly and a person can completely lose vision.

Wet AMD is divided into two types:

1. Hidden. Hemorrhages are not abundant and vascular neoplasms are insignificant. Therefore, disturbances in central vision are invisible.
2. Classical. Active growth of new vessels occurs with tissue scarring.

AMD in both eyes

A person's life changes significantly. Some patients experience hallucinations, which is associated with impaired central vision. They are called hallucinations of Charles Bonnet. They appear in the form of figures, animals and human faces. Patients with macular degeneration themselves are afraid that if they talk about their visions, they may be mistaken for crazy. The cause of such hallucinations is visual impairment.

In the case of classical macular degeneration, straight lines are distorted, the patient sees them as curved or wavy.

With senile age-related macular degeneration of the retina, vision quickly begins to decline.

Diagnosis of AMD

To determine AMD, a simple Amsler test is performed. The Amsler grid looks like a regular sheet of paper. A square is drawn on a white background and divided into 400 small squares. A black dot is placed in the center of the grid, on which the patient must focus his gaze. Testing should be carried out under certain conditions:

• The test is carried out when you feel well, without fatigue. It is not recommended to carry out the test under stress, alcohol intoxication and when using certain medications, as this may affect the test results;
• Check contact lenses and glasses for clarity and cleanliness;
• In the room where the test is carried out, the lighting should be good and natural;
• You cannot tilt your head, squint your eyes, or look away from the center point of the table;
• The test is performed on the healthiest eye.

Checking your vision:

Evaluation of the result. If you saw clarity in the image, all the lines were parallel, the squares were the same, and the angles were right, this means your vision is fine and there is no AMD.

Treatment

Macular degeneration of the retina, unfortunately, cannot be completely cured. Some methods will help you achieve success in the fight:

• Laser therapy. Removes pathological blood vessels and stops their progress;
• Photodynamic laser therapy. The drug Visudin is administered intravenously to the patient, during which time a laser treatment session is performed under computer control. Pathological vessels are emptied and stick together, and therefore hemorrhages stop. The effect of the procedure lasts up to one and a half years.
• Anti-angiogenesis factors. The drugs can stop the growth of abnormal blood vessels.
• Devices for low vision. Special lenses and electronic devices.

AMD can also be treated by surgical intervention:

1. Submacular surgery. All abnormal vessels are removed.
2. Retinal translocation. Only the affected vessels are removed under the retina.

When treating dry macula, it is recommended to carry out courses of treatment with antioxidant therapy in order to normalize metabolic processes in the retina. Combination therapy reduces the development of advanced AMD and reduces the risk of loss of visual acuity. Prevention and treatment of the dry form of age-related macular degeneration must be carried out regularly, and not in courses.

In the wet form of macular degeneration, treatment suppresses the growth of abnormal blood vessels. If treatment for macular degeneration has given a positive result, it should be remembered that macular degeneration can return again. Be sure to periodically see an ophthalmologist to avoid complications of AMD.

Folk remedies for the treatment of macular degeneration

Include more healthy foods in your diet. Eat more berries: blueberries, strawberries, they are able to maintain the performance of the retina of the eyes, which will prevent further development of the macula. Green vegetables are very useful in this case - spinach, dill, celery, parsley and cabbage. They contain antioxidants and vitamins A, C and E, which are so necessary for the eyes.

Prepare a carrot salad and season with vegetable oil for better absorption of vitamin A. With long-term consumption of grain crops, cholesterol and fat metabolism are normalized, cysts, fibroids, and fatty tissues resolve. The intestinal microflora is restored, bones are strengthened. A person becomes cheerful, his performance increases and he gets rid of obesity.

Use cereal decoctions and infusions.

Prevention of age-related macular degeneration

To prevent age-related macular degeneration from causing serious consequences, it is necessary to carry out its prevention.

• undergo an examination by an ophthalmologist annually;
• use sunglasses;
• quit smoking;
• adhere to proper nutrition: give up fatty foods, add fruits, vegetables and fish to your diet;
• take courses of a complex of vitamins for the eyes;
• take care of your health and lead a healthy lifestyle.

Age-related macular degeneration is a chronic disease that causes deterioration of central vision. The pathological process is based on damage to the macula, the central part of the retina. The macula contains a huge number of light-sensitive cells that provide sharp and detailed central vision. The macula is located in the posterior part of the retina and is the most sensitive part.

What it is?

Experts distinguish between dry and wet forms of AMD. The first type is quite common and is associated with the appearance of deposits on the retina. The wet form is formed due to the sweating of blood and fluid from the blood vessels.

Age-related macular degeneration significantly impairs quality of life. Patients have deteriorating vision in the central part of the visual field, and this area is responsible for many processes, including reading, recognizing faces, driving a car, and sewing.

Most often, degenerative changes in the macula appear after the age of fifty, although there are cases when the disease occurs in young patients. AMD can develop slowly, with vision remaining unchanged for a long period of time. In other cases, the pathology progresses rapidly and causes significant visual impairment in one or both eyes.

There are wet and dry forms of AMD

Provoking factors

The exact causes of degenerative changes in the macula are still not fully understood, but they occur as the eye ages. This ultimately leads to thinning and destruction of the central part of the retina.

Experts identify the following etiological theories of the occurrence of AMD:

• abnormal growth of blood vessels. Fluid leaking from abnormal vessels interferes with the normal functioning of the retina and leads to clouding of the macula. As a result, the objects you look at appear bent and misshapen;
• accumulation of fluid in the back of the eye. This causes epithelial detachment, which appears as a blister under the macula.

The dry form of age-related macular degeneration can progress and become the wet type. Experts make no guarantees as to whether such rebirth is possible or when it will happen. For some people, vision loss progresses so much that it leads to blindness.

Smoking is a provoking factor in the occurrence of the pathological process of the macula

Risks of age-related macular degeneration under the influence of the following factors:

• smoking. According to research, this bad habit doubles the risk of AMD;
• genetic predisposition;
• cardiovascular disorders;
• overweight;
• race. Europeans are more likely to be diagnosed with AMD;
• age indicators;
• poor nutrition;
• inflammatory processes;
• elevated cholesterol levels;
• surgery for lens opacity;
• prolonged exposure to an intense light source.

Experts assure that a healthy lifestyle significantly reduces the likelihood of a pathological process. Doctors recommend quitting smoking, engaging in moderate exercise, and monitoring blood pressure and cholesterol levels. An important role is played by the diet, which should include greens, vegetables, and fish.

Symptoms

Macular degeneration is characterized by the following symptoms:

• the need for brighter light for reading and working with small objects;
• poor adaptation in low light conditions;
• vagueness of the text;
• feeling that colors have become faded;
• poor face recognition;
• the appearance of haze before the eyes;
• rapid deterioration of vision;
• the appearance of a blind spot in the field of vision;
• straight lines appear curved;
• visual hallucinations. People or geometric shapes may appear.

Visual hallucinations may occur with macular degeneration

Why is macular degeneration dangerous?

As you know, the eyes are a paired organ, so the healthy organ of vision takes on the function of the affected one. For a long time, manifestations of degeneration may remain undetected. It is also worth noting the fact that with macular degeneration there may be no pain, so the patient may think that everything is normal.

The disease threatens complete blindness and loss of ability to work. Irreversible consequences can develop in just a few weeks. That is why you should contact an ophthalmologist for diagnosis as soon as possible.

The diagnosis is made on the basis of anamnestic data, visual acuity studies, angiogram and CT scan. The doctor will definitely examine the fundus of the eye.

Macular degeneration occurs when cells in the macula are destroyed.

Living with macular degeneration

If you are diagnosed with age-related macular degeneration, it means you will have to make lifestyle changes. This also applies to nutrition. Consider all these recommendations:

• eat fruits and vegetables. The antioxidants it contains are extremely important for eye health. Doctors recommend introducing spinach, beans, broccoli, and kale into your diet. These vegetables contain not only antioxidants, but also lutein and zeaxanthin, which are so necessary in the fight against macular degeneration;
• eat fats. We are talking about healthy unsaturated fats, which are, for example, found in olive oil. At the same time, you should limit your intake of saturated fats. They are found in butter, fast foods;
• replace flour with whole grain products;
• eat fish. Omega-3 fatty acids included in the product reduce the risk of vision loss.

The following tips will help you adapt to changes in vision:

• try to select glasses as accurately as possible;
• use a magnifying glass to work with small objects;
• On electronic devices, select the desired font size and image contrast. There are special computer programs designed for the visually impaired. You can install a program with which the text will be produced in mp3 format;
• brighten your home;
• If you are allowed to drive, do so with great care;
• Don’t isolate yourself, seek help from your loved ones. You may need the help of a psychologist or psychotherapist.

Spend more time with your family, loved ones will provide invaluable support

Wet macular degeneration

The pathological process is based on the growth of pathological vessels under the macula on the posterior side of the retina. These abnormal blood vessels are fragile enough to allow blood and fluid to leak through them, elevating the macula from its natural position. The wet form develops quickly and is characterized by rapid deterioration of vision.

Important! In ninety percent of cases, it is wet macular degeneration that causes blindness.

Treatment of age-related macular degeneration includes conservative therapy. Patients are prescribed dedystrophic drugs, antioxidants and immunomodulators. Also useful for retinal degeneration are lutein and zeaxanthin. Although they cannot restore vision, they are quite capable of stopping the progression of the pathological process.

Currently, methods are used whose effectiveness has been clinically proven:

• photodynamic therapy. This is a relatively new treatment method. Abnormal vessels are exposed to photochemical effects. Using a weak laser effect, a special substance is activated, which is first administered intravenously. As a result, abnormal blood vessels are blocked and swelling is relieved;
• angiogenesis inhibitors: Avastin, Eilia, Lucentis. These drugs quickly relieve swelling and return normal vision. The products are injected directly into the eye using a very thin needle. This procedure is absolutely painless.

With wet AMD, fluid and blood leak from pathological vessels

Dry macular degeneration

It is characterized by atrophic changes, which result in thinning of the macular tissue. First, the pathological process affects one eye, after which the second organ of vision is also involved.

A characteristic symptom of the dry form is the formation of drusen. They are deposits under the retina. Drusen themselves do not cause vision impairment.

The disease occurs in three main stages:

• Early stage. It is characterized by the appearance of several small drusen. As a rule, there are no clinical manifestations.
• Intermediate stage. There are a large number of medium-sized drusen and a few large ones. There may be no symptoms. In some cases, clouding of the central part of the visual field appears. A person needs more time to go into a dark room and brighter lighting to read.
• Late stage. Large drusen appear. Macular cells are destroyed. Significant deterioration of vision.

Treatment for dry macular degeneration includes the following:

• timeliness of treatment measures;
• impact on the mechanism of development of the pathological process;
• comparative analysis of AMD with other pathologies;
• lifelong treatment, including lifestyle changes;
• the use of medication, laser and surgical treatment.

Summary

Age-related macular degeneration is a serious pathological process that most often occurs in people after fifty years of age. The disease threatens irreversible changes, including loss of vision. Macular degeneration can be dry or wet. Depending on the form of the disease, appropriate treatment is selected. Early diagnosis, timely treatment and following medical recommendations will help prevent the development of dangerous complications and restore vision.

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 of pathological changes in the eye begin to be felt by the age of 55. In old age and old age, the disease progresses to such an extent that a person may completely lose the ability to see.

Age-related macular degeneration of the retina is a common disease. Often this pathology becomes the cause of 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 the implementation of 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. The causes of dystrophic changes in the macula of the retina can 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. The presence 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 provides laser treatment for macular degeneration. It may vary. The choice of method depends on the stage of AMD and the manifestations of the pathology. The following methods of surgical correction are distinguished:

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

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.

The disease is detected by ophthalmoscopy. Treatment is carried out using intravitreal injections of a VEGF inhibitor, laser photocoagulation, photodynamic therapy, selection of optical devices and nutritional supplements.

AMD is the most common cause of permanent vision loss among... It is more common among the Caucasian population.

Age-related macular degeneration (AMD) is a chronic degenerative (dystrophic) disease involving the central zone of the retina that affects the pigment epithelium, the choriocapillaris layer in the central zone of the retina.

Pathophysiology of age-related macular degeneration

There are two types of AMD:

• dry (atrophic) - in 90% of cases;
• wet (exudative, or neovascular) - in 10% of cases.

90% of all cases of blindness in patients with AMD occur in the wet form.

As a result of the dry form of AMD, retinal pigmentation disorders, round yellow lesions (drusen), and areas of chorioretinal atrophy (so-called geographic retinal atrophy) develop. In this case, scarring and swelling of the retina, hemorrhages or exudation in the retina are not observed.

Wet AMD (WAMD) begins in the same way as dry AMD. Choroidal neovascularization then begins beneath the retina. Swelling of the optic nerve head (OND) or local hemorrhage in this area can lead to its elevation and local detachment of the retinal pigment epithelium (RPE). Ultimately, neovascularization leads to elevation and scarring of the optic disc.

Symptoms and signs of age-related macular degeneration

Dry AMD (SVMD). A decrease in CV usually develops slowly, is not accompanied by painful sensations and, as a rule, is not sharply expressed. In later stages, central blind spots (scotomas) may occur and may become quite large. The defeat is usually bilateral.

• retinal pigmentation disorder
• Druze,
• zones of chorioretinal atrophy.

VVMD. The wet form of AMD is characterized by rapid loss of vision. At the onset of the disease, disturbances such as central blind spots (scotomas) and impaired perception of the shape and size of objects (metamorphopsia) are usually observed. Peripheral and color vision are usually not affected, but without timely treatment, the patient may develop complete blindness in one or both eyes (vision ability less than 20/200). IVMD usually affects only one eye, so clinical manifestations are usually unilateral.

Ophthalmoscopy reveals the following:

• subretinal hemorrhage in or near the optic disc;
• local elevation of the RPE;
• retinal swelling;
• discoloration of the pigment epithelium;
• exudates in or around the optic disc;
• RPE detachment.

This disease is usually divided into “dry” and “wet” forms. The “dry” (non-exudative) form is most common. This term most often refers to early manifestations of the process - the formation of drusen, pigmentation disorders (hypo- and hyperpigmentation). The early stage is characterized by small drusen, pigmentation changes are insignificant. Visual acuity is most often not reduced. In the intermediate stage, drusen become large, confluent, and so-called soft drusen may predominate. Vision deteriorates. It is this clinical picture that indicates the possibility of transition to a late stage. Late stage of AMD - geographic atrophy (which is also referred to as the “dry” form) and choroidal neovascularization.

The “wet” form of AMD, with a small share in the structure of this pathology, is relatively small (less than 20%), and leads to a sharp decrease in visual functions: up to 90% of cases of decreased visual acuity due to AMD are caused precisely by manifestations of the exudative form. At the same time, the quality of life of patients deteriorates significantly, in particular, the ability to read is lost.

During the initial examination with suspected AMD and during dynamic monitoring of such patients, in addition to the best corrected visual acuity and binocular examination of the fundus with a wide pupil, OCT is mandatory. If the presence of a “wet” form is suspected or if its progression is suspected, fluorescein angiography should be performed. Sometimes the latter study is supplemented with indocyanine green angiography, which makes it possible to differentiate pathological changes in the choroid. In case of geographic atrophy, the progression or stabilization of the process can be determined by the study of fundus autofluorescence. If necessary, documenting the condition of the retina can be supplemented with examination by photographing the fundus using a fundus camera.

Diagnosis of age-related macular degeneration

Ophthalmoscopy can detect both forms of the disease. Fluorescence tomography is performed if IVMD is suspected. Angiography can identify areas of geographic retinal atrophy.

Treatment of age-related macular degeneration

Nutritional supplements for the treatment of dry or unilateral ARMD.

• Intravitreal injections of a VEGF inhibitor.
• Symptomatic therapy.

SVMD. The changes that occur with dry AMD are irreversible, but daily use of the drugs leads to significant improvement among patients with large drusen, retinal pigmentation disorders, and geographic atrophy.

VVMD. For unilateral IVMD, the treatment used for dry AMD is effective. The choice of treatment tactics depends on the size, location and type of neovascularization. Intravitreal injections (ranibizumab, bevacizumab, and sometimes pegaptanib) improve near vision in a third of patients. Sometimes, along with these drugs, an intraocular injection of corticosteroids (for example, triamcinolone) is given.

Laser photocoagulation of pathological vessels outside the fovea can prevent significant vision loss. In some cases, photodynamic therapy, a type of laser therapy, is effective. Other treatments, such as transpupillary thermotherapy and macular translocation, are rarely used.

Symptomatic therapy. For patients with a severe decrease in central vision, the use of magnifying glasses, corrective reading glasses, wide computer monitors and telescopic lenses is recommended. There are also special computer programs that can increase the font size or read the text out loud.

In early-stage AMD, the use of a combination of antioxidant vitamins and minerals has not been shown to reduce the rate of progression to intermediate stages.

In intermediate-stage AMD, the AREDS study demonstrated a beneficial effect of antioxidant supplementation. Thus, it has been shown that combination therapy with antioxidant vitamins, zinc and copper preparations reduces the development of AMD. This combination therapy also reduces the risk of vision loss by 19%. However, monotherapy with zinc preparations or antioxidants leads to a statistically significant reduction in the risk of developing late stage AMD. In this study, a formula for a vitamin-mineral complex was developed for use in the intermediate stage of AMD. In the subsequent AREDS 2 study, this formula was adjusted: it was proven that β-carotene can be replaced with the carotenoids lutein and zeaxanthin, which turned out to be even more effective. Combination therapy with antioxidant vitamins, carotenoids and microelements is effective. Repeated examination after initiation of therapy is indicated after 6-24 months in the absence of symptoms; If new symptoms indicating CNV appear, immediate examination is necessary.

Treatment of exudative age-related macular degeneration

The first choice drugs for the treatment of exudative (neovascular) AMD are antiangiogenic agents (VEGF inhibitors). The only representative of the class of VEGF inhibitors registered in Russia is ranibizumab (Lucentis), which is used in the form of intravitreal injections.

Randomized clinical trials have also been conducted to study the effectiveness of intravitreal administration of glucocorticoids or antiangiogenic drugs in various combinations with photodynamic therapy. The results of a 12-month follow-up within the DENALI and MONT BLANC CTs showed no advantage of combination therapy with verteporfin and ranibizumab compared to ranibizumab monotherapy. In our country, photodynamic therapy is currently not performed due to the lack of registration of verteporfin.

Naturally, we must not forget about the use of laser technologies in the treatment of macular edema caused by AMD, diabetes, impaired retinal vein patency and other diseases. However, discussion of these important issues is beyond the scope of this guide.

Patients should undergo fundus biomicroscopy regularly. Patients following ranibizumab injections should be evaluated after approximately 4 weeks. Further observation depends on the clinical manifestations and the opinion of the treating ophthalmologist.

Ranibizumab injections can lead to complications, the frequency of which is low: the development of endophthalmitis (<1,0% за 2 года в исследовании MARINA; <1,0% за 1 год в исследовании ANCHOR), отслойке сетчатки (<0,1 %), травматическому повреждению хрусталика (0,1% случаев за первый год после лечения).

Typical mistakes in the treatment of age-related macular degeneration

• According to the AREDS and AREDS 2 CTs, the use of a combination of antioxidant vitamins, carotenoids and microelements does not reduce the rate of progression of early stages to intermediate stages of AMD. Therefore, their use is not advisable in the early stages of AMD.
• In case of geographic atrophy or in the presence of a disc-shaped scar, the use of such drugs will also not be effective.
• When prescribing drugs that meet AREDS guidelines, the risk of increased side effects must be assessed. Thus, it is advisable for smokers to avoid taking β-carotene (due to existing evidence of an increased incidence of lung cancer in smokers or even former smokers). It is more advisable to prescribe combination drugs that contain lutein and zeaxanthin instead of β-carotene (confirmed by AREDS 2).
• For exudative AMD, the modern “gold standard” is the prescription of VEGF inhibitors; laser and combination treatment is also possible. It is a mistake to reject modern pathogenetic therapy and carry out “palliative therapy” with drugs, the use of which is not justified due to the lack of evidence.
• Patients with wet AMD receiving treatment with VEGF inhibitors should undergo monthly monitoring of visual acuity and retinal condition according to biomicroophthalmoscopy and OCT. Monthly injections should be resumed if there are signs of CNV activity. An unjustified increase in the interval between follow-up visits is associated with an increased risk of permanent decline in central vision in this category of patients.

The invention relates to medicine, namely to ophthalmology, and can be used to treat patients with the “dry” form of age-related macular degeneration. Lutein-containing antioxidants and carotenoids are used orally for a year at intervals of 2-3 months. Additionally, fenofibrate (Traykor 145) is used for a time sufficient to normalize the lipid profile and maintain these indicators at the achieved level. Vitrum Vision Forte or Nutrof Total are used as lutein-containing antioxidants and carotenoids. The invention ensures that the progression of the “dry” form of AMD is stopped. 1 salary, 1 pr.

The present invention relates to ophthalmology and is intended for the treatment of patients with the “dry” form of age-related macular degeneration (AMD). According to statistics, the “dry” form of AMD occurs in 90% of cases, the “wet” form - in 10%. The “dry” form of AMD is characterized by: a bilateral process and chronic slow progression from insignificant in the early stages to low vision and blindness in the later stages of the disease, for this reason the disease ranks third among the causes of blindness in the second half of life after glaucoma and diabetic retinopathy.

Research in this area is highly relevant given the loss of general ability to work due to AMD by people of working age. In this category of patients, lipid metabolism disorders lead to a sharp imbalance in the oxidative processes of the body's vascular system (oxidative stress), causing damage to both large and small vessels. This category includes microvessels that supply photoreceptors in the macular area. Numerous studies confirm that the primary influence on the development of AMD is atherosclerotic changes in the vessels of the choriocapillaris layer of the eyeball. Ophthalmoscopic changes in “dry” AMD manifest themselves in the form of drusen and varying degrees of destruction of the retinal pigment epithelium in the macula.

Considering that in AMD, atherosclerotic changes occur at the level of small and minute vessels of the body, the drugs used in the treatment of this disease must also be appropriate for their intended purpose and affect the improvement of the condition of the microvascular system of the eye. Therefore, this category of patients must, simultaneously with treatment by an ophthalmologist, be under the supervision of a therapist or cardiologist in order to strictly compensate for blood pressure and also control and normalize lipid profile parameters.

State of the art

In the treatment of the “dry” form of AMD, the effectiveness of drugs has not yet been confirmed by multicenter randomized placebo-controlled studies. Therefore, in the vast majority of domestic hospitals in patients with “dry” forms of AMD, the effectiveness of parenteral use of drugs has not yet been confirmed. It is mandatory to prescribe vasoprotectors, nootropics, vitamins, coenzymes and retinoprotectors (sermion, phosphaden, cytoflavin, cytochrome C, Cavinton). These drugs have virtually no effect on the process in the fundus, possibly causing only some positive temporary effect on the general condition of patients. In recent years, peptide bioregulators (retinolamine for topical use and cortexin for intramuscular use) have been used in the treatment of patients with “dry” forms of AMD. Retinolamine is a complex of low molecular weight polypeptides with a molecular weight of 1000 to 10,000 daltons, sufficient to pass through the blood-ophthalmic barrier. One of the disadvantages of the drug is severe pain during subconjunctival and parabulbar administration. The drug is used for numerous eye diseases of the retina and optic nerve, but hopes for a lasting therapeutic effect have not been obtained for any disease. Cortexin in patients with “dry” forms of AMD is used as a means of correcting the functional state of the central nervous system, improving intellectual functions and psycho-emotional state, and also having antioxidant activity (Boiko E.V., Zhuravleva L.V., Sosnovsky S.B. Methodological recommendations - “Age-related macular degeneration” (risk factors, classification, diagnosis, prevention, treatment). 2010). Thus, the effect of this drug has a somewhat indirect function, without directly affecting the disease process.

A more targeted approach to the pathological processes occurring in the macular area in the “dry” form of AMD is the use of drugs that provide antioxidant protection to the body. The main recognized antioxidants today are: vitamin C (ascorbic acid), vitamin E (dl-alpha tocopherol acetate), vitamin zinc (zinc oxide), vitamin B 2 (riboflavin), selenium (selenium chelate amino acid complex), rutin, extract blueberries However, these drugs are essentially a favorable base, included in one dose or another in the composition of these vitamin complexes. The main components of these drugs are carotenoids (lutein and zeaxanthin), which have a positive effect on the condition of macular pigments. The mechanism of the protective action of carotenoids is based on their ability to absorb light (especially in the short-wave spectrum) and on their increased antioxidant activity, due to which damaging photo-oxidative processes directly in the central region of the retina are slowed down. Clinical studies have confirmed that long-term use of complexes including carotenoids ensures the delivery of lutein and zeaxanthin directly to the macular area, therefore, the quality of drugs is currently assessed depending on the quantitative content of zeaxanthin, and, in particular, lutein.

In recent years, many lutein-containing preparations, both domestic and imported, have appeared.

The closest analogue of the proposed invention is a method for the same purpose, involving the oral use of the drug Nutrof total (Bausch & Lomb company), which, along with antioxidants and carotenoids (lutein 10 mg, zeaxanthin 2 mg), includes an anti-cholesterol drug - OMEGA-3, covering at the recommended dosage - 1 tablet per day, 50% of the daily requirement required by an adult (P.A. Bezdetko // Ways to optimize the prevention and treatment of age-related macular degeneration. // - Health of Ukraine, No. 23-24, December 2008 , pp. 74-75.)

Recently, much attention has been paid to the positive pharmacological effect of OMEGA-3 PUFAs (polyunsaturated fatty acids) on the pigment epithelium and vascular endothelium. Reliable clinical studies AREDS 2 (Age-Related Eye Disease Study Group) (2007-2009) consisted of using a combination of lutein 10 mg and zeaxanthin 2 mg with the inclusion of OMEGA-3 (polyunsaturated fatty acids - 1 g - docosahexaenoic and eicosapentaenoic acid) in patients with the “dry” form of AMD. The results of this study concluded that the risk of early AMD was lower in people with higher intakes of omega-3 fatty acids (PUFAs) compared to those who did not consume them or consumed lower amounts. With the recommended use of the drug for 1 to 3 months, cases of stabilization and suspension of the progression of the “dry” form of AMD have been described. Numerous clinical studies have shown that OMEGA-3 polyunsaturated fatty acids are the basis of a healthy diet to support the functioning of the heart and have a positive effect on the reduction of low-density lipoproteins and normalize the ratio of cholesterol and triglycerides in the blood. OMEGA-3 polyunsaturated fatty acids inhibit the processes of thrombus formation, ensure the maintenance of the body's immune status, normalize cerebral circulation, increasing the stability of cerebral vessels during hypoxia and a drop in blood pressure. Important representatives of a number of OMEGA-3 polyunsaturated fatty acids are eicosapentaenoic acid and docosahexaenoic acid. The drug prevents the deposition of cholesterol in the walls of blood vessels, provides cell protection, and protects the heart from damage associated with magnesium deficiency or lack of oxygen. However, to date there is no evidence base regarding the specific effect of the OMEGA-3 drug on microvessels and their blood flow. OMEGA-3 also does not have the property of “building up” high-density lipoproteins, which is very important not only in relation to atherogenic protection of the vascular system, but in relation to microvascular protection.

Almost the majority of patients with the “dry” form of AMD suffer from vascular diseases (hypertension, coronary heart disease), and in some patients AMD develops against the background of type 2 diabetes mellitus. When studying the lipid spectrum in these patients, disturbances of this type of metabolism are almost always revealed with an increased coefficient of atherogenicity, which is associated with the threat of serious vascular accidents (heart attacks, strokes, thrombosis). On the other hand, the drug Nutrof Total, which includes OMEGA-3, is used for a limited time (1-3 months) with subsequent replacement of lutein-containing drugs or a pause in the prescription of drugs of this type. However, this category of patients requires constant microvascular antilipid protection against the background of periodic intake of antioxidants and carotenoids.

The technical result of the proposed invention is to ensure that the progression of the “dry” form of AMD is stopped.

The technical result is ensured due to complete microvascular antilipid protection against the background of taking lutein-containing antioxidants and carotenoids orally using fenofibrate (Traykor 145) for a time sufficient to normalize the lipid profile and maintain these indicators at the achieved level. Lutein-containing drugs are prescribed in repeated courses for 2-3 months with breaks of 1-2 months.

The lipidogram, as is known, reflects the values ​​of the cholesterol profile: these are indicators of total cholesterol, triglycerides, low-density lipoproteins (LDL), high-density lipoproteins (HDL), very low-density lipoproteins (VLDL). The relationship between these indicators is very important, as they reflect the coefficient of atherogenicity - the threat of the development of vascular accidents in the body.

Pathogenetically targeted treatment - anticholesterol, which provides microvascular protection, and antioxidant, which has a positive effect on damaging photo-oxidative processes directly in the central region of the retina.

The proposed method of treating the “dry” form of AMD differs significantly from its analogue in that it provides complete long-term microvascular protection of the patient due to a significant decrease in lipid profile parameters and equalization of their relationships. Thus, Traikor 145, unlike OMEGA-3, is capable of “increasing” HDL, which plays an important role in achieving an atherogenic coefficient that is safe for the patient. This effect is achieved by long-term administration of the drug Traykor 145 with monthly monitoring of the patient’s blood lipid profile. Unlike OMEGA-3, the positive effect of Traykor on the cholesterol profile of patients appears within 3-4 weeks and, usually, the indicators of several fractions improve simultaneously.

Traykor 145 belongs to the class of fibrate derivatives of fibric acid, used since the late 50s in the treatment of vascular diseases accompanied by increased levels of cholesterol and its fractions (coronary heart disease). However, it later became clear that these drugs thoroughly provide microvascular protection and only partially affect atherosclerotic changes in large vessels in coronary artery disease. The currently used fenofibrate (Traykor 145) is already a 3rd generation drug and at the moment it is the most studied, safe and proven by use in domestic and foreign clinical practice. The drug appeared in Russia in September 2008. Currently, it is supplied by Abbott Products in the form of a special form of nanoparticles obtained using the Nano Cristall technology in the Irish city of Cork. Currently, this is the only drug obtained in this way, which provides: 1. minimal doses when taken; 2. maximum bioavailability; 3.maximum safety; 4. complete absorption from the gastrointestinal tract; 5. independence from food intake; 6. take 1 tablet per day at any time of the day; 7. no need for special selection of drug doses. Trikor is prescribed in one dosage of 145 mg once a day for all patients, regardless of age, duration of the disease and severity of complications. It has been studied that Traykor is well tolerated by patients, which is confirmed by extensive clinical experience of its use abroad, where more than 36 million patients with diabetic retinopathy take it.

The mechanism of action of fenofibrate - Traikor 145 is explained by its ability to stimulate a certain fraction of alpha receptors, which are responsible for lipid metabolism in liver cells. These receptors play a dominant role in the intracellular regulation of the transfer and rewriting of DNA genomes responsible for the levels of lipid metabolism and inflammatory cytokines. Activation of receptors occurs as a result of their binding to Traikor 145 through complex biochemical processes leading to stimulation of the lipase enzymatic system. This process is accompanied by a decrease in the concentration of triglycerides, normalization of the particle sizes of low-density lipoproteins (LDL) - from small, dense and atherogenic to larger, buoyant and less atherogenic particles, an increase in the levels of high-density lipoproteins (HDL), which is collectively manifested by a decrease in the atherogenicity of the blood lipid spectrum .

In addition, Traikor 145 has a non-lipid pleiotropic effect, which explains the positive effect of Traikor 145 on the retina of a patient with a “dry” form of macular degeneration in conditions of a normal lipid profile. This effect not only helps to slow down the progression of microvascular changes in the retina, its positive effect also extends to the progression of atherosclerosis and cardiovascular events in this category of patients.

In clinical studies, we selected regimens for the use of the drug Traikor 145 against the background of periodic intake of lutein-containing antioxidants in patients with the “dry” form of macular degeneration. The most optimal regimen was selected, the purpose of which was to: 1. Bring the results of the study of the patient’s lipid metabolism to normal or close to the physiological norm and maintain it at this level in order to eliminate the main pathogenetic cause of the disease. 2. Improve metabolic functions in the body as a whole by taking broad-spectrum antioxidants included in lutein-containing preparations in order to prevent antioxidant stress in the vascular system and in the retina. 3. Slow down or completely stop the progression of the “dry” form of AMD using the complex of drugs described above.

The method is carried out as follows.

Therapy with Traykor 145 is prescribed after examining the patient’s fundus, obtaining the results of the lipid profile, as well as computed tomography data. The drug is prescribed in 1 tablet. 1 time per day for continuous use. Simultaneously with Traikor 145, any lutein-containing antioxidant drug (mainly with the largest amount of lutein in its composition) is prescribed. Currently, these drugs are Vitrum Vision Forte and Nutrof Total. These drugs are prescribed with a break of 2-3 months throughout the year. Vitrum Vision Forte and Nutrof Total are somewhat different in their composition, so their perception by patients is also different. Depending on individual preferences, patients report that one of the drugs seems more effective to them. It is recommended that they take this drug. Every 3 months, the patient’s lipid profile is examined, and visual functions are also examined.

Example: Patient A., 62 years old. Age-related macular degeneration (AMD) is a “dry” form of both eyes. Related: Coronary heart disease. Hypertonic disease. Complaints about a gradual (over 2 years) decrease in vision in both eyes, “blurring” of the image in the center, interfering with reading. She contacted the institute on 02/09/2011. Before that, she was observed in a clinic at her place of residence, where she was treated mainly with vasodilators and nootropic drugs (Cavinton, Afobazole, Sermion) locally with a combination of hard and soft drusen - installation of emoxypine.

Visual acuity of the right eye = 0.3 s +2.0D = 0.3-0.4; Visual acuity of the left eye = 0.4 s + 2.5 D = 0.6. The Amsler test is negative - there are no distortions. The perimetry study did not reveal any pathology. According to OCT (optical coherence perimetry), the presence of drusen is indicated by the wavy contour of the pigment epithelium layer. At the same time, the epithelium retains its thickness; no changes in photoreceptors were detected.

The retina is thinned, the optical density of the underlying tissues is increased. Due to coronary heart disease, FA study was not performed. The fundus of both eyes is almost identical during ophthalmobiomicroscopy: The optic disc is pink, the boundaries are clear, the veins are somewhat dilated, congested, the arteries are tortuous, their walls are compacted and sclerotic. The Salus 1-11 symptom is noted, which indicates the hypertensive nature of vascular damage. In the macular and paramacular zones of both eyes there are many hard and soft drusen, partially confluent.

The patient was recommended: 1. Control and compensation of blood pressure. 2. Study of the lipid profile, which revealed a significant significant increase in the values ​​of total cholesterol (up to 6.9 with reference values ​​of 3.1-5.2) and low-density lipoproteins (up to 4.56 with reference values ​​of 1.5-3.50), other lipid profile parameters were at the upper limit of normal. The patient was prescribed: 1. Traykor 145, 1 tablet once a day. Duration of treatment is at least 8 months. 2. Vitrum vision forte 1 tablet each. 2 times a day orally for a year, with an interval of 2-3 months.

After 3 months: visual acuity and the condition of the fundus without negative dynamics, however, the patient notes an improvement in the comfort of vision, the feeling of “blurring” of the image in the center when reading appears much less frequently. OCT data without negative dynamics. Blood pressure is normalized by regular use of antihypertensive drugs. When studying the lipid profile - a decrease in the levels of total cholesterol to 4.8 and low-density lipoproteins to 3.2. The use of Traikor 145, 1 tablet 1 time per day, continued. Vitrum Vision Forte was resumed after 2 months.

After 3 months of follow-up, visual acuity: right eye = 0.3 s +2.0D = 0.4. Visual acuity of the left eye = 0.4 s +2.5D = 0.5-0.6. The feeling of “blurring” of the image in the center disappeared completely.

An examination of the fundus showed some restoration of the caliber and a decrease in the tension of the veins, and the condition of the arteries was at the same level. The number of drusen has not increased, there is no calcification, and there is no increase in the number of confluent drusen, which indicates the absence of negative dynamics. OCT without deterioration. When studying the lipid profile, total cholesterol = 4.2, low-density lipoproteins at 2.4. It is recommended to continue taking Traikor 145 as before. It is recommended to repeat the course of Vitrum Vision Forte after 3 months.

After the next 3 months (with a total observation period = 12 months). Visual acuity of the right eye = 0.3-0.4 s +2.0D = 0.4-0.5. Visual acuity of the left eye = 0.4 s +2.5D = 0.5-0.6. Reading comfort has increased, and blurriness has not returned. Blood pressure remains compensated by taking antihypertensive drugs. There are no negative changes in the fundus compared to the previous examination. Lipid profile indicators: total cholesterol = 4.0; low density lipoproteins at level 2.2. The remaining indicators of the lipid profile are also at the level of reference values. Since the patient noted that while taking Traikor her general condition had significantly improved with some improvement in visual functions, she was asked to continue taking Traikor 145 against the backdrop of periodic courses of Vitrum Vision Forte.

The proposed method of treatment, including the administration of Traykor 145 and lutein-containing antioxidants, has so far been used in 26 patients with the “dry” form of AMD, in all cases a positive result was obtained, in not a single case was progression of the disease observed over a significant period of observation, not a single patient no side effects or complications were identified.

Thus, the proposed method of treating the “dry” form of AMD makes it possible to improve the quality of life of patients against the background of stabilization or some improvement not only in visual functions, but also in their general condition, and to avoid serious vascular accidents that occur when the blood lipid profile is disturbed.

1. A method of treating patients with the “dry” form of age-related macular degeneration, including the oral use of lutein-containing antioxidants and carotenoids, characterized in that they are used throughout the year with an interval of 2-3 months and additionally use fenofibrate for a time sufficient to normalize the lipid profile and maintaining these indicators at the achieved level.

2. The method according to claim 1, characterized in that Vitrum Vision Forte or Nutrof Total are used as lutein-containing antioxidants and carotenoids.

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