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Macular Dystrophies Mimicking Age-Related Macular Degeneration

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Macular Dystrophies Mimicking Age-Related Macular Degeneration Progress in Retinal and Eye Research 39 (2014) 23e57 Contents lists available at ScienceDirect Progress in Retinal and Eye Research journal homepage: www.elsevier.com/locate/prer Macular dystrophies mimicking age-related macular degeneration Nicole T.M. Saksens a,1,2,7, Monika Fleckenstein b,1,3,7, Steffen Schmitz-Valckenberg b,4,7, Frank G. Holz b,3,7, Anneke I. den Hollander a,5,7, Jan E.E. Keunen a,5,7, Camiel J.F. Boon a,c,d,5,6,7, Carel B. Hoyng a,*,7 a Department of Ophthalmology, Radboud University Medical Centre, Philips van Leydenlaan 15, 6525 EX Nijmegen, The Netherlands b Department of Ophthalmology, University of Bonn, Ernst-Abbe-Str. 2, Bonn, Germany c Oxford Eye Hospital and Nuffield Laboratory of Ophthalmology, John Radcliffe Hospital, University of Oxford, West Wing, Headley Way, Oxford OX3 9DU, United Kingdom d Department of Ophthalmology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands article info abstract Article history: Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in the elderly Available online 28 November 2013 population in the Western world. AMD is a clinically heterogeneous disease presenting with drusen, pigmentary changes, geographic atrophy and/or choroidal neovascularization. Due to its heterogeneous Keywords: presentation, it can be challenging to distinguish AMD from several macular diseases that can mimic the Age-related macular degeneration features of AMD. This clinical overlap may potentially lead to misdiagnosis. In this review, we discuss the AMD characteristics of AMD and the macular dystrophies that can mimic AMD. The appropriate use of clinical Macular dystrophy and genetic analysis can aid the clinician to establish the correct diagnosis, and to provide the patient Differential diagnosis Retina with the appropriate prognostic information. An overview is presented of overlapping and distinguishing Clinical characteristics clinical features. Ó 2013 Elsevier Ltd. All rights reserved. Contents 1. Introduction . ..................................................24 1.1. AMD.........................................................................................................................24 1.2. Differentiating macular dystrophies from AMD: difficulties and relevance . .. ........................25 2. Fundoscopic findings in AMD and macular dystrophies . .................................... 25 2.1. Drusen and ‘drusen-like lesions’ .................................................... ............................................25 2.2. Pigmentary changes . ........................29 2.3. Geographic atrophy . ........................29 2.4. Choroidal neovascularization . ........................29 3. Differential diagnostic tools . .................................................31 3.1. Symptoms and fundoscopy . ........................31 3.2. Fundus autofluorescence . ........................31 3.3. Fluorescein angiography . ........................32 * Corresponding author. Tel.: þ31 24 36 144 48; fax: þ31 24 35 405 22. E-mail addresses: [email protected] (N.T.M. Saksens), [email protected] (M. Fleckenstein), [email protected] bonn.de (S. Schmitz-Valckenberg), [email protected] (F.G. Holz), [email protected] (A.I. den Hollander), [email protected] (J.E. E. Keunen), [email protected] (C.J.F. Boon), [email protected] (C.B. Hoyng). 1 Shared first authors. 2 Tel.: þ31 24 36 102 41; fax: þ31 24 35 405 22. 3 Tel.: þ49 228 287 15647; fax: þ49 228 287 15603. 4 Tel.: þ49 228 287 16826; fax: þ49 228 287 11470. 5 Tel.: þ31 24 36 144 48; fax: þ31 24 35 405 22. 6 Camiel J.F. Boon was supported by a Niels Stensen Fellowship Award. 7 Percentage of work contributed by each author in the production of the manuscript is as follows: Nicole Saksens, 35%; Monika Fleckenstein 25%; Steffen Schmitz- Valkenberg 5%; Camiel Boon 15%; Anneke den Hollander 5%; Holz 5%; Keunen 5%; Hoyng 5%. 1350-9462/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.preteyeres.2013.11.001 24 N.T.M. Saksens et al. / Progress in Retinal and Eye Research 39 (2014) 23e57 3.4. Optical coherence tomography . ........................................32 3.5. Psychophysical and electrophysiological testing . ......................................33 3.6. Genetics . ...................................................33 4. Macular dystrophies mimicking AMD . ......................35 4.1. Drusen and ‘drusen-like deposits’ ...............................................................................................35 4.1.1. Malattia leventinese . ........................................35 4.1.2. Sorsby fundus Dystrophy . ........................................36 4.1.3. North Carolina macular dystrophy . ........................................37 4.1.4. Late-onset retinal degeneration . ........................................38 4.2. Irregular yellowish flecks . ........................................39 4.2.1. Late-onset Stargardt disease . ........................................39 4.2.2. Pattern dystrophies . ........................................40 4.3. Vitelliform lesions . ........................................41 4.3.1. Adult-onset foveomacular vitelliform dystrophy . ............................41 4.3.2. Best vitelliform macular dystrophy . ........................................41 4.4. Miscellaneous . ...................................................42 4.4.1. Central areolar choroidal dystrophy . .........................................42 4.4.2. Late-onset cone dystrophy . ........................................43 4.4.3. Central serous chorioretinopathy . ........................................44 4.4.4. Macular telangiectasia . ........................................44 4.5. Dystrophies associated with a syndrome or systemic disease . ............................47 4.5.1. Mitochondrial retinal dystrophy associated with the m.3243A > G mutation (maternally inherited diabetes and deafness and MELAS syndrome) . ........................................47 4.5.2. Dystrophies with angioid streaks . ........................................48 4.5.3. Cuticular drusen in membranoproliferative glomerulonephritis II . .............................49 4.5.4. Maculopathy in myotonic dystrophy . .......................................50 5. Conclusions and future directions . ..................... 50 References . ...................................................51 1. Introduction visual acuity from AMD is caused by these advanced forms of the disease. In addition, psychophysical studies have demonstrated that 1.1. AMD several parameters of visual function, in particular contrast sensi- tivity, visual adaptation, central visual field, and colour discrimina- Age-related macular degeneration (AMD) is a progressive chronic tion, deteriorate already in the early stages of AMD (Neelam et al., disease of the central retina and the leading cause of irreversible 2009). Since the disturbance in psychophysical function in AMD is blindness in the elderly population in industrialized countries (Lim not limited to the macular region, but extends well into the retinal et al., 2012). Based on a meta-analysis of studies in white people periphery, it appears that there is a global impairment of retinal aged 40 years and older, the prevalence of early AMD is estimated to function (Ronan et al., 2006; Walter et al., 1999). be 6.8% and the late stages to be 1.5% (Smith et al., 2001). The prev- The pathogenesis of AMD is incompletely understood. As a alence of AMD increases exponentially with age (Rudnicka et al., complex, multifactorial disease, it is thought to involve variations in 2012). In the Beaver Dam Eye Study that includes predominantly a number of genetic, systemic and environmental factors. Ageing white participants, individuals of age 75 years and older, the fifteen itself appears to be the major risk factor that renders the retina year cumulative incidence of early AMD was 24.4% and of late AMD more susceptible to environmental effects (Boulton, 2013). was 7.6% (Klein et al., 2007). The prevalence of AMD, however, differs Biochemical, histological and genetic studies have indicated in ethnic groups. The Baltimore Eye Study has shown that late stage several pathways in AMD pathogenesis, including excessive accu- AMD was nine to ten times more prevalent in the white as compared mulation of lipofuscin, oxidative damage, malfunctioning of the to the black participants (Friedman et al., 1999). In the Asian popu- complement system, and chronic low-grade inflammation and lation, the prevalence of late stage AMD appears to be largely similar possible sequences of events have been proposed. to that in white people (Kawasaki et al., 2010). Lipofuscin accumulates in postmitotic RPE cells with age Different cell layers are involved in the disease process: the apparently due to incomplete lysosomal degradation of photore- photoreceptors, the retinal pigment epithelium (RPE), Bruch’s ceptor outer segments (reviewed by Boulton (2013)). Lipofuscin membrane and the choriocapillaris. consists of a multitude of molecules including the dominant fluo- Different stages and phenotypic manifestations of AMD have been rophore N-retinyl-N-retinylidene ethanolamine (A2E), a by- categorized (Ferris et al., 2013): The early stages (early and inter- product of the visual cycle (Suter et al., 2000)(Palczewska et al., mediate AMD) are characterized by pigmentary alterations
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