Neovascular age-related macular degeneration (NVAMD) is a leading cause of irreversible visual impairment in older individuals in the United States. In NVAMD, there is choroidal neovascularization (CNV) which can result in leakage of fluid, retinal pigment epithelial detachment, and hemorrhage. Though the wet form is less common than the dry form, it accounts for 90% of the cases of acute vision loss due to AMD.
27.1.1 Common Symptoms
Symptoms include metamorphopsia, scotomata, and blurry vision. If the fellow eye has good visual acuity, the disease may seem asymptomatic due to compensation from the fellow eye.
27.1.2 Exam Findings
Drusen are an early characteristic finding of both types of AMD. In addition, NVAMD often have findings related to the presence of CNV, including intraretinal fluid, subretinal fluid, intraretinal hemorrhage, subretinal hemorrhage, and pigment epithelial detachments (▶ Fig. 27.1, ▶ Fig. 27.2). The CNV may be visible as a gray/green subretinal lesion. End-stage NVAMD is frequently characterized by subretinal fibrosis and disciform scarring.
Fig. 27.1 Color fundus photo of new-onset neovascular age-related macular degeneration with retinal hemorrhage and scattered macular drusen.
Fig. 27.2 (a) Ultra-widefield fundus photo with extensive subretinal hemorrhage and significant vision loss due to neovascular age-related macular degeneration. (b) Optical coherence tomography demonstrates retinal irregularity and subretinal hyperreflective material consistent with hemorrhage overlying a prominent hemorrhagic pigment epithelial detachment.
27.2 Key Diagnostic Tests and Findings
27.2.1 Optical Coherence Tomography
Optical coherence tomography (OCT) has become the gold standard for the detection of exudative activity due to NVAMD. Intraretinal (i.e., hyporeflective intraretinal cystic changes) and/or subretinal fluid (i.e., hyporeflective subretinal space between retina and retinal pigment epithelium [RPE]) are frequently present (▶ Fig. 27.3, ▶ Fig. 27.4). Additional OCT findings may include outer retinal/ellipsoid zone attenuation, subretinal hyperreflective material, increased outer retinal reflectivity, and sub-RPE fluid/pigment epithelial detachments (▶ Fig. 27.2). RPE tears may also be visualized on OCT (▶ Fig. 27.5).
Fig. 27.3 (a) Spectral domain optical coherence tomography at initial presentation with nonneovascular age-related macular degeneration with moderate drusen and no evidence of exudation. (b) Conversion to neovascular age-related macular degeneration with new-onset vision loss, large pigment epithelial detachment, and subretinal fluid.
Fig. 27.4 Optical coherence tomography (OCT) with recent conversion to neovascular age-related macular degeneration exhibiting drusen, trace subretinal fluid, and intraretinal fluid. (a) Focal subretinal pigment epithelial hyporeflective material is present, likely reflecting type 1 choroidal neovascularization. (b) Following anti-vascular endothelial growth factor therapy, OCT demonstrates complete resolution of intraretinal and subretinal fluid.