AMD milestones mark a new age of insight

New Orleans-Continued efforts in the areas of treatment, prevention trials, and understanding the pathogenesis of age-related macular degeneration (AMD) has helped "move AMD from the rear balcony to center stage," according to Stuart L. Fine, MD, department chairman, professor of ophthalmology, and director of the Scheie Eye Institute at the University of Pennsylvania School of Medicine, Philadelphia.

AMD is a major cause of severe and irreversible vision loss in the United States, currently affecting 1.75 million Americans aged 40 and older. By 2020, this number is expected to reach almost 3 million with the aging of the U.S. population.

Researchers have come a long way over the last 3 decades in terms of identifying important risk factors and in evaluating treatments for the disease.

During his 35-year ophthalmologic career, Dr. Fine has focused his clinical research on the area of macular degeneration.

He began his residency in ophthalmology at the University of Florida College of Medicine, Gainesville, in 1969 where he first heard the term, "senile macular degeneration," from his mentor, Melvin L. Rubin, MD.

Dr. Fine was a National Institutes of Health (NIH) Special Fellow from 1972 to 1973 at the Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, and joined the Johns Hopkins faculty in 1973. From 1979 to 1990, he was director of the Retinal Vascular Center at the Wilmer Eye Institute and became professor of ophthalmology in 1982.

In 1991, Dr. Fine became affiliated with the Scheie Eye Institute.

The first era: 1969 to 1979 During the first era, with the advent of fluorescein fundus photography, researchers were able to demonstrate that abnormal choroidal vessel leakage was responsible for exudative manifestations of AMD, as reported in the 1967 issue of the American Journal of Ophthalmology, he said.

"However, in the early 1970s, there were relatively few centers equipped to perform fluorescein fundus photography and the quality of the angiograms generally was quite poor," Dr. Fine explained.

As far as treatment of AMD was concerned, a multivitamin was the most common option. A few reports in the literature discussed photocoagulation, although there was no specific protocol for its performance or evaluation that researchers agreed upon, he said.

"There was little information with regard to AMD risk factors apart from age and family history, as initially presented in the 1980 Framingham Eye Study monograph, which first identified AMD as a major cause of blindness in the United States," said Dr. Fine. Risk factors for AMD, such as smoking, cardiovascular disease, dietary history, UV exposure, and others were studied and reported in the literature over the next 10 years, he continued.

"Even the name [of the disease] was different. Until the mid-1980s, the condition was called senile macular degeneration," he said.

In 1976, the benefit of panretinal photocoagulation (PRP) for proliferative and severe non-proliferative diabetic retinopathy was reported in the American Journal of Ophthalmology, considered a major breakthrough, Dr. Fine noted.

"In addition to documenting the substantial benefits of PRP, the report provided a second lesson of equal importance," he said. "It demonstrated again the power of the randomized clinical trial in the assessment of new treatments."

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