Macular Degeneration

What if I Have Drusen?

 Drusen and the diagnosis of macular degeneration.  Randall Wong, M.D., Retina Specialist, Fairfax, Virginia 22031


Drusen are not diagnostic of macular degeneration.  These whitish/yellow spots of the retina can be a normal finding and their presence does not mean you will develop macular degeneration (ARMD).  There are other criteria necessary to make the diagnosis of ARMD.

“Druse” may occur in 3 locations within the eye;

  • The Macula
  • The Peripheral Retina (non-macular)
  • and the Optic Nerve

In the Optic Nerve Head (ONHD)

These are not even found in the retina.  These are calcified and found within the optic nerve, but can be diagnosed when looking into the eye during a retinal examination.

These drusen have nothing to do with macular degeneration.  Loss of the peripheral vision is possible.  Patients with ONHD are probably best evaluated by a glaucoma specialist as the mechanism of vision loss is similar to that of glaucoma.

Diagnosis is usually pretty straight forward.  Often these tiny round globules can be seen during a dilated eye exam and can also be detected with ultrasound and CT scan due to the calcification.  They can run in families.

Outside of the Macula

These whitish spots are found in the retina, but not in the macular area.  These are usually whitish/yellow looking flecks found within the layers of the retina and are visible during examination.

When outside of the macula, they are commonly feared to be related to ARMD, but there is no association.  Non-macular lesions are sometimes called “familial drusen” and are a normal finding with no predisposition to the development of ARMD.

Macular Druse: Can Be Associated with ARMD

These are the most confusing and also the most worrisome.  Drusen in the macula can be NORMAL and do NOT necessarily mean you have or will develop macular degeneration.

Those lesions located within the macula are worrisome due to the association with macular degeneration, or ARMD.  There are two types:  hard and soft.  Both may be found in patients with macular degeneration

Hard and soft types differ in appearance and probably have a different association with macular degeneration.  In general, the “hard” variety are more common, especially as we age.  The “soft” lesions are probably found more often in wet ARMD.

Both types of druse may be found in patients with macular degeneration, but the mere presence of  either drusen does not make the diagnosis of macular degeneration nor are they prognostic indicators for the development of the disease.

What If You Have Drusen?

If your doctor diagnosis you with drusen, do the following;

  1. Relax.
  2. Are the within the macula?  If not, probably nothing to worry about.
  3. If they are located in the macula, do you have any symptoms such as decreased vision, distortion or blind spots?  By decreased vision, I mean, with correction, do  you have any of these symptoms?  If not, probably okay to monitor, but make sure you visit your eye specialist if any symptoms develop.

Retina specialists, like me, are the most appropriate to make the diagnosis.  If there is any question, make an appointment to see a specialist.

What Does This Mean?

There are several criteria needed to make the diagnosis of macular degeneration.  You have to look like you have the disease, have the right genetic makeup, be the right age and have evidence of decreased vision.

A retina specialist might consider additional testing, such as a fluorescein angiogram, to determine if there is any evidence of deterioration or degeneration of the retina.

Drusen only are commonly normal.


Diabetic retinopathy Testing

A1C Now Used to Diagnose Diabetes

The American Diabetes Association now recommends basing the diagnosis of diabetes upon the hemoglobin A1C levels and not on fasting glucose tests.  In addition, an A1C of less than 7.0% should be the target for glucose control.  How with this impact the treatment of diabetic retinopathy?

The change in recommendations stems from the fact that the A1C blood test is an easier, and faster, test to run than measuring a fasting plasma glucose and an oral glucose tolerance test.  Both tests require overnight fasting for accuracy; that is, it relies on patient compliance.  The A1C does NOT require overnight fasting.

A1C measures the average blood glucose levels for the period of up to 3 months and was previously used just to measure sugar control over time, but now, it is recommended to be used for diagnosis;

  • A1C  of 5%  – no disease
  • A1C of 5.7 to 6.4% – likely prediabetes
  • A1C > 6.5% – likely diabetes

The ability to diagnose the test using A1C guidelines now means that the diagnosis of diabetes can be made earlier.  Earlier detection (diagnosis) may mean a greater chance of  “curing” type II diabetes by making lifestyle changes earlier.

What Does This Mean? The ability to diagnose and treat this disease now has some firm, “black and white,” guidelines.  More patients will be detected and at an earlier age.  Therapy and education may be instituted earlier.  For instance, patient education regarding diabetic retinopathy may be instituted sooner.  In this respect, more patients will be “saved” over the long run.  In theory, patients will be directed for eye exams before the retinopathy begins.

It is also likely, that with tighter sugar control (i.e. good A1C levels), diabetic eye disease will progress slower.  We’ll see.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist
Fairfax Virginia

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American Diabetes Month: Diabetic Eye Disease, What Every Doctor Should Know (so, tell them!)

November, 2009, is American Diabetes Month.  In my effort to support American Diabetes Month, there are a few things that every doctor should know about diabetic eye disease.  The list is short and very direct.  Please share this with others; especially your doctors.

I have been in practice since 1993.  As a retina specialist, I take care of patients with diabetic retinopathy.  There was a “movement” to stamp out blindness from diabetes by the year 2000.  While we have dramatically reduced the rate of blindness as of 2007, in fact, with early detection most patients with diabetes are unlikely to suffer severe loss of vision (clic for recent post), there are still far too many people losing vision.

Most people are simply not getting to the eye doctor.  Most doctors are still not aware that patients with diabetes should get regular dilated eye exams (with the pupils dilated)!

What I believe every doctor should know about diabetic eye disease;

1.  Every patient with diabetes needs a dilated eye exam once a year.  Even if the patient has no symptoms. Remember that vision has no correlation with the severity of disease.  I hear from too many patients that they were not referred by their doc because they had no complaints of blurry vision.  Don’t wait for symptoms!

2.  Diabetic retinopathy is not a result of poor sugar control. While sugar control may influence the diabetic retinopathy, the duration of the disease is the clearest predictor of developing eye disease.  Okay, in English, the longer that a patient has been diagnosed with diabetes, the greater the chance of developing eye disease.

3.  Diabetic eye disease may be inevitable. This is a corollary to #2.  While no one knows if this is absolutely true, almost all patients with diabetes do develop the disease.   I have seen only a handful of patients in over 16 years that have no evidence of the disease despite having diabetes for over 25 years.

4.  Having diabetic retinopathy does not mean loss of vision. In fact, the earlier a patient is diagnosed, the less likely there will be severe loss of vision.

Spread the word!  Diabetic eye disease may be inevitable, but the visual prognosis is excellent.  Early detection is the key!


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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Diabetic retinopathy

Diabetes Unlikely to Cause Blindness

Today’s post is about one of my own observations from over 15 years in practice.  While it is a fact that significant vision loss from diabetes is declining, it is not widely known that there is also a very finite time where patients with diabetes can go blind, there is only a finite time while the risk of blindness is highest.  In short, the chance of a diabetic patient going blind these days is much less than 0.5%, especially when under the care of an eye doctor.

Let me explain. Recently, I wrote about the decline in the incidence of diabetic patients going blind.  The statistics say that severe vision loss was reduced to about 0.3% by 2005-2007 (read the article “Vision Problems in Type I Diabetes on the Decline”).  This is truly great news.

I have two observations; 1)  I have never had a patient with diabetes go blind if I had been following them before they developed any complications from proliferative diabetic retinopathy, and 2)  in most cases, when patients develop signs of proliferative diabetic retinopathy, the retinopathy usually becomes controlled within a year and becomes stable.  This means they are highly unlikely to lose vision or to go blind.  The patients that have gone blind usually wait until they have lost vision before seeking medical attention.

What does this mean? There are two major points.  My observations are consistent with published data that correlates early detection of diabetic retinopathy with an excellent long term visual prognosis.  In other words, the earlier we can detect diabetic retinopathy, the better chance that you will never lose vision.  Second,  there is a small window of a year or so (my personal observation) that patients are susceptible to vision loss once proliferative changes are noted.  Once diagnosed with proliferative diabetic retinopathy, a patient is NOT destined to loss of vision or blindness.

So, chances are that most diabetics will not lose vision.  We are stressing early examination to detect diabetic retinopathy early.  Last, diabetics are not a ticking timebomb; waiting for blindness to ensue.

It’s really good news that seems to get lost in this information gap.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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