Special Senses Patient B

The following is a description of a 76 year old patient that was presented in the Journal of the American Medical Association 2008;300(1):91-92.

Patient's Comments:

My vision is much worse. The best corrected vision in my left eye is 20/50 and I need a +5 lens for reading. I can't use standard bifocals because the lower half of the lens is a +5-diopter lens and if I look down I will trip, since I have no depth perception. I have arranged for my optician to make me a special lens using an 8-mm strip of corrected glass with +5-diopter correction in the mid portion of the left lens transversely, and that would give me an 8-mm-wide corrected lens for reading. I�ve tried not to let the macular degeneration interfere with my quality of life. I�m pretty much the same except I get upset and I get angry. Reading was always a very important part of my life, and now I get very frustrated because I read slowly, and I can't scan. I have tried books on tape, but I fall asleep. Music has always been a major part of my life as well. One of the real deprivations is that I can't play the piano because I can't read the music at the same time that I see the keyboard. But I can still simply listen to music, which is a great form of enjoyment for me. I take all the supplements that people say will prevent macular degeneration: ....... I am still working as the director of a small plastic surgery residency training program, and I take that very seriously. The residents are very supportive; they read the charts to me outside the patient's room, and then I go in the room with them and the patient is never the wiser of my inability to read or to write notes. I can't write notes in the charts because I can't follow the lines and I usually write the second line over the first line. It's not a happy situation. I�m more depressed than ever. My internist has recommended that I go talk to a psychiatrist about it. Talk is not going to solve my problems. And even though I have a great deal of respect for psychiatrists, you can't talk yourself into seeing.

Doctor's Comments

The discussion centered on Dr G, a 76-year-old semiretired surgeon devastated by the loss of depth perception in his right eye because it prevented him from continuing to practice surgery. Three years prior to the conference, Dr G noticed subtle vision changes, which progressed, resulting in a diagnosis of AMD.

Although our ability to treat AMD has made steady progress over the past 2 years, it is clear from the frustration expressed by patients like Dr G and their treating physicians that the road ahead will be both long and challenging. I hope that as our understanding of the underlying pathophysiology of AMD improves, we will continue to make significant inroads into both the prevention and treatment of this disease. The vision in Dr G's better eye with dry AMD has dropped from 20/30 2 years ago to 20/50 despite best correction. Unfortunately, simple visual acuity is a relatively poor measure of overall visual function in patients with AMD like Dr G, given the common loss of pericentral vision due to parafoveal chorioretinal atrophy.

Patient B: Treatment

After the diagnosis, Dr G received photodynamic therapy to the right eye 5 times, twice with the experimental addition of intraocular triamcinolone. Despite these treatments, Dr G lost vision in his right eye. At the time of the conference, Dr G was primarily concerned with protecting the vision in his left eye, allowing him to maintain autonomy and function with general ease. Dr Arroyo suggested that Dr G meet with a visual rehabilitation specialist to discuss strategies to help him overcome the functional limitations of his vision loss. Dr Arroyo also advised Dr G to adhere to a diet high in fruits, vegetables, fish, and nuts and to take a daily Age-Related Eye Disease Study (AREDS)�recommended antioxidant and zinc formulation. Finally, Dr Arroyo recommended that Dr G's depressive symptoms be addressed and treatment provided if necessary.

We know from the results of the AREDS randomized controlled trial that patients with moderate and advanced AMD who took 500 mg of vitamin C, 400 IU of vitamin E, 15 mg of beta carotene, 80 mg of zinc oxide, and 2 mg of cupric oxide per day had an approximate 25% reduction in their risk of progression to advanced AMD and visual acuity loss.

(This discussion is from 2008. Since then AREDS II formulation has been introduced.

QUESTION: The left eye has "dry macular degeneration" What is meant by the "dry"?


QUESTION: How do you know the right eye, which has the worst vision, has "wet macular degeneration"?


QUESTION: What is photodynamic therapy?


QUESTION: What is another substance used more commonly for "wet macular degeneration"?


QUESTION: What is the point of the triamcinolone?