A 72-year-old man comes to the office for a regular visit. His vision has been deteriorating gradually for the past year. The patient has been having difficulty reading the newspaper and has been using reading glasses more frequently to read small print. Lately, he has also had difficulty driving and now drives only during the daytime. The patient has a history of hypertension and osteoarthritis. He has smoked a pack of cigarettes daily for 38 years.
His blood pressure is 155/77 mm Hg and pulse is 76/min. BMI is 31 kg/m². Ocular examination shows no visible abnormalities of the cornea or lens, and the pupils are round and reactive. Visual acuity is diminished in both eyes, the left eye more than the right. Funduscopic examination shows mottling of sub-retinal pigments and bright yellow drusen deposits in the macular area of the left retina. Cardiopulmonary and neurologic examination is unremarkable.
Which of the following is the best initial management of this patient's vision problems?

Question

Quizplus · Accepted Answer

This patient likely has age-related macular degeneration (AMD), the leading cause of blindness in industrialized countries. The condition likely results from chronic oxidative damage to the retinal pigment epithelium and choriocapillaris. Major risk factors include advanced age, smoking, and family history. AMD is classified into dry and wet subtypes. This patient's gradual vision loss in both eyes and difficulty with reading and driving at night is characteristic of dry AMD. Funduscopy classically shows subretinal drusen deposits with pigment abnormalities. Dry AMD can progress to wet AMD, which presents with acute vision loss (days to weeks) and metamorphopsia (distortion of straight lines) due to subretinal hemorrhage or fluid accumulation. Funduscopy can show a grayish-green subretinal discoloration with adjacent fluid or hemorrhage. drusen deposits hemorrhage Smokers with AMD should receive smoking cessation counseling as it is one of the most important interventions to prevent disease progression. Patients with moderate to severe AMD (dry or wet) should also receive daily antioxidant vitamins and zinc as these may reduce the risk of progression to severe AMD and lower the likelihood of developing vision loss in the good eye. Wet AMD usually requires specific treatment with vascular endothelial growth factor (VEGF) inhibitors (eg, ranibizumab, bevacizumab) to stabilize/reverse vision loss. (Choices A and E) Although physical activity can decrease the risk of developing AMD, the relationship of AMD, hypertension, and elevated BMI is conflicting. In addition, aggressive hypertension control in the elderly can increase the risk of orthostatic hypotension and falls. (Choice B) Observational studies have shown that regular use of aspirin may be associated with an increased risk of dry and wet AMD. (Choice D) Laser photocoagulation can be considered in select patients with wet AMD; however, it has not been shown to reduce the risk of vision loss in patients with dry AMD and may be associated with an increased rate of choroidal neovascularization in these patients. Educational objective: Dry macular degeneration typically presents in older adults with progressive vision loss in one or both eyes and subretinal drusen deposits with pigment abnormalities on funduscopy. Smoking cessation and daily antioxidant vitamins with zinc can reduce the risk of disease progression. __________ References: Recent developments in the management of dry age-related macular degeneration. (http://www.ncbi.nlm.nih.gov/pubmed/25878491) Cigarette smoking and the natural history of age-related macular degeneration: the Beaver Dam Eye Study. (http://www.ncbi.nlm.nih.gov/pubmed/24953792)

A 72-Year-Old Man Comes to the Office for a Regular