Macular degeneration

Age-related macular degeneration (AMD) is a painless eye condition that leads to the gradual loss of central vision.

Information written and reviewed by Certified Doctors.

Contents

Introduction

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Age-related macular degeneration (AMD) is a painless eye condition that leads to the gradual loss of central vision.

Central vision is used to see what is directly in front of you, during activities such as reading or watching television for example.

The central vision becomes increasingly blurred leading to symptoms including:

  • difficulty reading printed or written text (because it appears blurry)
  • colours appear less vibrant
  • difficulty recognising people's faces

AMD usually affects both eyes, but the speed at which it progresses can vary from eye to eye.

Read more about the symptoms of age-related macular degeneration.

What causes AMD?

Macular degeneration develops when the macula (the part of the eye responsible for central vision) is unable to function as effectively as it used to.

It is still unclear what causes the macula to become damaged, but getting older, smoking and a family history of AMD are known to increase the risk of developing the condition.

Macular degeneration does not affect the peripheral vision (outer vision), which means it will not cause complete blindness.

Read more about the causes of age-related macular degeneration.

Types of age-related macular degeneration

There are two main types of AMD:

Dry AMD

Dry AMD develops when the cells of the macula become damaged due to lack of nutrients and a build-up of waste products called drusens. It is the most common and least serious type of AMD accounting for around 9 out of 10 cases.

The loss of vision is gradual, occurring over many years. However, an estimated 1 in 10 people with dry AMD will then go on to develop wet AMD.

Wet AMD

Wet AMD develops when abnormal blood vessels form underneath the macula and damage its cells (doctors sometimes refer to wet AMD as neovascular AMD).

Wet AMD is more serious and without treatment, vision can deteriorate within days.

Treatment

There is currently no cure for dry AMD so treatment is mostly based on helping a person make the most of their remaining vision, such as using magnifying lenses to help make reading easier.

There is also limited evidence that eating a diet high in leafy green vegetables and fresh fruit can slow the progression of dry AMD.

Wet MD can be treated with a medication called ranibizumab, which helps prevent further blood vessels developing.

In some cases laser surgery can also be used to destroy abnormal blood vessels.

Treatment for wet AMD does not always lead to improved vision, but can prevent vision from worsening.

The sooner treatment is started the greater the chance of success.

Read more about treating age-related macular degeneration.

When to seek medical advice

If you notice problems with your vision, such as blurring, see your doctor or optometrist.

If your vision suddenly gets worse or you notice blind spots in your field of vision, seek advice immediately. Either book an emergency appointment with an optometrist or visit your local hospital's accident and emergency (A&E) department.

Who is affected

AMD is the leading cause of visual impairment in the UK, with 462,000 people experiencing some degree of AMD.

For reasons that are unclear AMD tends to be more common in women than men.

White people and people of Chinese ethnicity are more likely to get AMD than other ethnic groups

As would be expected by its name, age is one of the most important risk factors for AMD. It is estimated that around 1 in 500 people aged 55-64 have AMD. This rises to 1 in 8 people aged 85 or over.

Reducing your risk

The best ways you can reduce your risk of getting AMD, or your AMD becoming worse, are:

  • quit smoking if you are a smoker
  • moderate your consumption of alcohol – read more about recommended limits
  • eat a healthy diet high with at least five portions of fruit and vegetables a day
  • try to achieve or maintain a healthy weight

The macula is a small spot at the centre of the retina. It is the part of your eye where incoming rays of light are focused.

The retina is the nerve tissue lining the back of the eye. It senses light and colour and sends it to the brain as electrical impulses.

The term visual impairment refers to anyone who is blind or partially sighted, rather than those who are short-sighted (myopia), or long-sighted (hyperopia).

Symptoms

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Age-related macular degeneration (AMD) is not a painful condition. In fact, some people do not even realise there is a problem until their symptoms become more severe.

The main symptom of macular degeneration is blurring of your central vision. Your peripheral vision (outer vision) is not affected.

Loss of central vision

Central vision loss affects your ability to see fine detail and colours. In particular, it results in:

  • loss of visual acuity: the ability to detect fine details, or small distances, for example when you read or drive
  • loss of contrast sensitivity: the ability to see less well-defined objects, such as faces, clearly

If you wear glasses your central vision will still be blurred if you have macular degeneration.

Dry age-related macular degeneration

If you have dry AMD, it may take five to 10 years before your symptoms significantly affect your daily life.

Sometimes, if only one of your eyes is affected, your healthy eye will compensate for any blurring or loss of vision. This means it will take longer before your symptoms become noticeable.

You may have dry AMD if you find that:

  • You need brighter light than normal when reading.
  • It is difficult to read printed or written text (because it appears blurry).
  • Colours appear less vibrant.
  • You have difficulty recognising people's faces.
  • Your vision seems hazy, or less well defined.

If you are experiencing any of these symptoms, you should make an appointment with your doctor or optometrist (a healthcare professional who specialises in diagnosing vision problems and eye conditions).

Wet age-related macular degeneration

In most cases wet AMD develops in people who have had a previous history of dry AMD.

If you have wet AMD any blurring in your central vision suddenly worsens.

You may also experience other symptoms such as:

  • Visual distortions – for example, straight lines may appear wavy or crooked.
  • Blind spots – which usually appear in the middle of your visual field. The longer a blind spot is left untreated, the larger it will become. This is known as a central scotoma.
  • Seeing shapes, people and/or animals that are not really there (hallucinations).

Seek immediate medical assistance if you experience any sudden changes in your vision such as those described above.

It may be a sign you have wet AMD, which needs to be treated as soon as possible to reduce the risk of permanent damage to your vision.

If you require immediate medical attention, you will either need to book an emergency appointment with an optometrist or visit your local hospital's accident and emergency (A&E) epartment.

About 70% of people with wet AMD have the condition in both eyes. If you only have wet AMD in one eye, you have a 10% chance every year of it developing in the other eye as well. After five years, there is a 40% chance that wet AMD will also develop in your other eye.

Causes

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Age-related macular degeneration (AMD) is caused by a problem with the macula in your eye. The macula is the spot at the centre of your retina (the nerve tissue lining the back of your eye).

The macula

The macula is a small spot at the centre of the retina. It is the part of your eye where incoming rays of light are focused. The macula plays an essential role in helping you see things directly in front of you, and is used for close, detailed activities, such as reading and writing.

Dry age-related macular degeneration

As you get older, the layer of tissue that covers your retina can start to break down and become thinner. This means your retina can no longer exchange nutrients and waste products as efficiently as it used to.

Waste products start to build up in your retina and form small deposits, known as drusens. A build-up of drusens, combined with a lack of nutrients, causes the light cells in your macula to become damaged and stop working.

If the light cells in your macula are damaged, your central vision will become blurry and less well-defined.

Wet age-related macular degeneration

In cases of wet AMD, tiny new blood vessels begin to grow underneath the macula.

It is thought these blood vessels form due to a misguided attempt by the body to clear away the waste products from the retina.

Unfortunately the blood vessels form in the wrong place and actually cause more harm than good. They can leak blood and fluid into the eye, which can cause scarring and damage to your macula.

This then causes the more serious symptoms of wet AMD to develop, such as visual distortion and blind spots.

Increased risk

Exactly what triggers the processes that lead to AMD is unclear, but a number things are known to increase the risk factors of developing it. These are described below.

Age

The older a person gets, the more likely they are to develop at least some degree of AMD.

Most cases start developing in people age 55 or over and then rise sharply with age. It is estimated that in people aged 85 or over around 1 in 8 people has AMD.

Family history

Cases of AMD have been known to run in families. If your brother or sister develops AMD, it is estimated your risk of getting it is increased five-fold.

This would suggest certain genes you inherit from your parents may increase your risk of AMD. But exactly what genes are involved and how they are passed through families is unclear.

Smokers

Smoking is a significant risk factor for AMD. In general smokers are 2-3 times more likely to develop AMD than non-smokers.

The longer you have been smoking the greater the risk. Smokers who also have a family history of AMD have an even greater risk.

Gender

Women are more likely to develop AMD than men. This could simply be because women tend to live longer than men.

Ethnicity

Studies have found rates of AMD are highest in white and Chinese people, while lower in black people. This again could be the results of genetics.

Possible risk factors

Alcohol

It is possible that drinking more than four units of alcohol a day over the course of many years may increase your risk of having early AMD. One unit of alcohol is approximately half a pint of standard beer or lager, or one 25ml serving of spirits.

Sunlight

If you are exposed to lots of sunlight during your lifetime, your risk of developing macular degeneration may be increased. To protect yourself, you should wear sunglasses in bright sunlight.

Obesity

Some studies have reported that being obese (very overweight with a body mass index (BMI) of 30 or greater) may double your chance of developing AMD.

High blood pressure and heart disease

There is some limited evidence that having a history of high blood pressure and/or coronary heart disease may increase your risk of developing AMD.

The macula is a small spot at the centre of the retina. It is the part of your eye where incoming rays of light are focused.

The retina is the nerve tissue lining the back of the eye. It senses light and colour and sends it to the brain as electrical impulses.

Diagnosis

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In some cases early age-related macular degeneration (AMD) may be detected before it begins to cause any symptoms, during a routine eye test.

If you are experiencing symptoms of macular degeneration, visit your doctor or make an appointment with an optometrist (a specialist in the diagnosis and treatment of poor eyesight).

If there is a sudden change in your vision, visit your nearest accident and emergency (A&E) department.

Referral

If your doctor or optometrist suspects macular degeneration, you will be referred to an ophthalmologist (a medical doctor who specialises in eye disease and its treatment).

Your appointment will usually be at an eye department in a hospital. If travelling by car, ask someone else to drive you because you may be given eyedrops during the appointment that make your vision blurry.

Eye examination

Your ophthalmologist will first carry out a routine check of your eyes. You will be given eyedrops to enlarge your pupils. These take around half an hour to start working, and may make your vision blurry or your eyes sensitive to light. The effect will wear off after a few hours.

Your ophthalmologist will look at the back of your eyes where your retina and macula are located, using a magnifying device with a light attached to it. They will look for any abnormalities around your retina.

The ophthalmologist will then carry out a series of tests to confirm a diagnosis of macular degeneration.

Amsler grid

One of the first tests involves asking you to look at a special grid, known as an Amsler grid. The grid is made up of vertical and horizontal lines, with a dot in the middle.

If you have macular degeneration, it is likely some of the lines will appear faded, broken or distorted. Telling your ophthalmologist which lines are distorted or broken will give them a better idea of the extent of the damage to your macula.

As the macula controls your central field of vision, it is usually the lines nearest to the centre of the grid that appear distorted.

Retinal imaging

As part of your diagnosis, your ophthalmologist will need to photograph your retinas to see what damage, if any, macular degeneration has caused. This will confirm the diagnosis and prove useful in planning your treatment. There are several different ways of taking pictures of the retinas.

Fundus photography

A fundus camera is a special camera used to take photographs of the inside of your eye. The camera can capture colour stereoscopic (three-dimensional) images of your macula. Your ophthalmologist can then look at the different layers of your retina to see what damage, if any, has occurred.

Fluorescein angiography

An angiography is a type of X-ray examination that creates detailed images of your blood vessels and the blood flow inside them. A special dye is injected into your blood vessels and pictures are taken that show any abnormalities inside them.

The angiography can confirm which type of age-related macular degeneration (AMD) you have and may be done if your ophthalmologist suspects wet AMD.

During a fluorescein angiography, the ophthalmologist will inject a special dye, called fluorescein isothiocyanate, into a vein in your arm.

Over the next 10 minutes they will use a magnifying device to look into your eyes, and take a series of pictures using a special camera.

These images will allow your ophthalmologist to see if any of the dye is leaking from the blood vessels behind your macula. If it is, this may confirm you have wet AMD.

Indocyanine green (ICG) angiography

The technique that is used for an ICG angiography is the same as for fluorescein angiography, but the dye is different. ICG is used as an alternative dye to fluorescein isothiocyanate and may be used as it can highlight slightly different problems in your eyes.

Coherence tomography

Coherence tomography uses special rays of light to scan your retina and produce an image of it. This can provide your ophthalmologist with detailed information about your macula. For example, it will tell them whether your macula is thickened or abnormal in any way, and whether any fluid has leaked into the retina.

Staging of AMD

Once these tests have been completed the ophthalmologist should be able to tell you how advanced your AMD has progressed.

Dry AMD has three main stages:

  • early AMD – in this stage there may be multiple small collections of waste products (drusen) inside the eye, or fewer medium-sized drusen or some minor damage to your retinal pigment epithelium; early AMD does not usually cause any noticeable symptoms
  • intermediate AMD – there may now be some larger drusen inside the eye or some tissue damage to the outer section of the macula; people with intermediate AMD will have a blurred spot in the centre of their vision
  • advanced AMD – the centre of the macula is now damaged; people with advanced AMD will have a much larger blurred spot and have difficulties reading and recognising faces

Wet AMD is always regarded as an advanced form of AMD.

The macula is a small spot at the centre of the retina. It is the part of your eye where incoming rays of light are focused.

The retina is the nerve tissue lining the back of the eye. It senses light and colour and sends it to the brain as electrical impulses.

An X-ray is an imaging technique that uses high-energy radiation to show up abnormalities in bones and certain body tissue, such as breast tissue.

Treatment

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There is currently no cure for dry age-related macular degeneration (AMD).

With dry AMD, the deterioration of vision is very slow. You will not go completely blind as a result of dry AMD, and your peripheral (outer) vision should not be affected.

Help is available to make tasks such as reading and writing easier. Getting practical help may improve your quality of life and make it easier for you to carry out daily activities.

You may be referred to a low vision clinic. These clinics can provide useful advice and practical support to help minimise the affect dry AMD has on your life. For example, things that may make it easier for you to carry out close, detailed work include:

  • magnifying lenses
  • large print books
  • intensive (very bright) reading lights

There are also a number of devices that can help you adjust to low vision, such as screen-reading software on your computer so you can ‘read’ emails, documents and browse the internet.

Read more about living with visual impairment.

Dry AMD and diet

There is some limited evidence that a diet high in vitamins A, C, and E – as well as a substance called lutein – may slow the progression of dry AMD and reduce your risk of getting wet AMD.

These contain molecules called antioxidants that may be able to help maintain healthy tissue and prevent further damage.

Foods high in vitamins A, C, and E include:

  • oranges
  • kiwi
  • green leafy vegetables
  • tomatoes
  • carrots

Green leafy vegetables are also a good source of lutein, as are:

  • peas
  • mangos
  • sweetcorn

For more information see the Macular Society’s factsheet on Nutrition and your eyes (PDF, 71kb).

So far, there is no definitive proof that this type of diet is effective in everyone with dry AMD, but eating a diet as healthy as this will bring other important health benefits.

Dietary supplements are also available, but you should check with your doctor before taking them as they are not suitable for everyone.

Wet AMD

There are two main treatment options for wet AMD:

  • using a type of medication called anti-VEGF medication to prevent the growth of new blood vessels
  • using laser surgery to destroy abnormal blood vessels

Anti-VEGF medication

Anti-VEGF medication is a newer type of treatment that can also help stop the progression of wet AMD.

VEGF stands for 'vascular endothelial growth factor'. It is one of the chemicals responsible for the new blood vessels that form in the eye as a result of wet AMD. Anti-VEGF medicines work by blocking this chemical and stopping it from producing the blood vessels.

The anti-VEGF medication has to be injected into your eye using a very fine needle. You will be given a local anaesthetic so the procedure does not hurt.

Anti-VEGF medication is primarily used to stop wet AMD from getting worse. However, in some cases it has also been shown to restore some of the sight lost as a result of macular degeneration. It is important to be aware that your sight will not be restored completely, and not everyone will see an improvement.

The anti-VEGF medications currently available on the NHS are ranibizumab and aflibercept, but these will only be prescribed if there is clear evidence that using the medication would help improve or maintain your eyesight.

Current recommendations are that ranibizumab and aflibercept should only be used if:

  • your visual acuity (your ability to detect fine details or small distances) is between 6/12 and 6/96 – this means your central vision is at least good enough to see something at six metres that a person with normal eyesight could see at 96 metres
  • there is no permanent damage to the fovea, which is the part of the eye that helps people see things in sharp detail
  • the area affected by AMD is no larger than 12 times the size of the area inside the eye where the optic nerve connects to the retina
  • there are signs the condition has been getting worse

Your ophthalmologist should be able to tell you if you are suitable for treatment with ranibizumab or aflibercept.

Other anti-VEGF medicines - such as pegaptanib - are available, but you will usually have to pay for treatment and these medicines can be very expensive. For example, a two year course of pegaptanib can cost over £9,000.

Ranibizumab

Studies show that [ranibizumab] can help slow loss of visual acuity in over 90% of people, and may even increase visual acuity in around a third of people.

You will be given one injection of ranibizumab into your affected eye once a month, for three months. After this time, you will have a break which is known as a 'maintenance phase'. During the maintenance phase, your visual acuity will be monitored.

If your vision deteriorates by a loss of one line on the Snellen chart (a chart with blocks of letters that gradually get smaller) during this maintenance phase, you will be given another injection of ranibizumab. This monitoring will continue, and you will have injections as necessary, with at least one month in between injections.

If your condition does not show signs of improvement after treatment with ranibizumab, or continues to get worse, your treatment will be stopped.

Common side effects of ranibizumab include:

  • bleeding from your eye
  • pain in your eye
  • inflammation or irritation of the eye
  • feeling like there is something in your eye

For a full list of side effects, visit the [medicines information for ranibizumab].

Aflibercept

Aflibercept is a relatively new treatment for wet AMD and studies have shown that it is at least as effective as ranibizumab in treating people with the condition.

At first, you will be given one injection of aflibercept into your affected eye once a month, for three months. Injections will then be given once every two months. After a year of treatment, the intervals between injections can be extended depending on how well the medication is working.

On average, treatment with aflibercept tends to involve fewer injections and monitoring visits then treatment with ranibizumab.

Common side effects of aflibercept include:

  • bleeding in your eye
  • pain in your eye
  • vitreous detachment - where the clear jelly-like substance in your eye called the vitreous gel shrinks and separates itself from the retina (the light-sensitive layer at the back of the eye)
  • cataracts - cloudy patches in the lens that can make vision blurred or misty
  • floaters - small shapes floating in your field of vision
  • increased pressure within your eye

Surgery

Photodynamic therapy

Photodynamic therapy (PDT) was developed in the 1990s. It involves having a light-sensitive medicine called verteporfin injected into a vein in your arm. The injection lasts around 10 minutes.

The verteporfin attaches itself to the abnormal blood vessels in your macula (the part of your eye responsible for central vision).

A low-powered laser is then shone into your damaged eye, over a circular area just larger than the lesion (wound) in your eye. This usually takes around one minute.

The laser is not powerful enough to damage your eyes, but the light from the laser is absorbed by the verteporfin and activates it. The activated verteporfin destroys the abnormal vessels in your macula without harming any of the other delicate tissues in your eye.

Destroying the blood vessels stops them leaking blood or fluid, preventing damage and therefore stopping the macular degeneration from getting worse.

You may need this treatment every few months to ensure any new blood vessels that start growing are kept under control.

Who can use PDT?

PDT is not suitable for everyone. It will depend on where the blood vessels are growing, and how severely they have affected your macula.

PDT may be suitable if your visual acuity is 6/60, or better. This means you can see from a distance of six metres what someone with normal vision can see from a distance of 60 metres. Around one in five people with wet AMD are suitable for PDT.

Laser photocoagulation

Laser photocoagulation can also be used to treat some cases of AMD.

This type of surgery is only suitable if the abnormal blood vessels are not close to the fovea, as performing surgery close to this part of the eye can cause permanent vision loss.

Around one in seven people are suitable for treatment with laser photocoagulation.

Laser photocoagulation uses a powerful laser to burn sections of the retina. These sections harden, which prevents the blood vessels from moving up into the macula.

The surgery is performed under local anaesthetic to numb the eye, so it is not painful.

You should be aware that an inevitable side effect of laser photocoagulation is that you will develop a permanent black or grey patch in your field of vision. This loss of vision is usually (but not necessarily always) less severe than untreated wet AMD.

If you're considering laser photocoagulation, you need to discuss the pros and cons of this treatment with the doctor in charge of your care.

As the results of laser photocoagulation tend to be less effective than the other treatments discussed above, it now tends to only be used in people who are unable to be treated with ranibizumab or PDT.

Newer types of surgery

In recent years two new surgical techniques have been introduced to treat wet AMD.

These are:

  • macular translocation – where the macula is repositioned over a healthier section of the eyeball not affected by abnormal blood vessels
  • lens implantation – where the lens of the eye is removed and replaced with an artificial lens designed to enhance central vision

Both approaches tend to achieve better results in restoring vision than conventional surgery, but there are also disadvantages, such as:

  • access to these treatments is limited and may only be available in the context of a clinical trial
  • as these are new techniques it is uncertain whether they are safe and effective in the long term
  • they carry a higher risk of serious complications than conventional surgery

Complications

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Your eyesight is very important, and finding out you have a condition that affects your vision can be difficult to come to terms with.

Adjusting to the change in your sight can be frustrating. Simple everyday tasks, such as reading, may suddenly become much more difficult.

You should speak to your doctor if you are struggling with everyday activities, or finding your macular degeneration is having a significant effect on your daily life. They should be able to put you in touch with local support groups who can provide guidance and practical help.

Depression and anxiety

Having to cope with losing part of your vision, and coming to terms with the loss of some of your independence, can affect your mental health. It is estimated that around a third of people with age-related macular degeneration (AMD) may have some form of depression and/or anxiety.

If you are struggling with the changes to your life, you should speak to your doctor or ophthalmologist (your eye specialist). They will be able to discuss treatment options with you, such as counselling, or they can refer you to a mental health professional for further assessment.

Driving

You will need to inform your driving licence issuer and your insurance company if you drive and are diagnosed with macular degeneration. This is because the condition may affect your ability to drive.

If your eyesight is only minimally affected, it may still be safe for you to drive a vehicle. However, you may have to perform a series of sight tests to prove this. Central vision is very important for driving, and if you do not meet the standards set by your driving licence issuer, you will not be able to drive.

Charles Bonnet syndrome

Sometimes, people with macular degeneration can experience Charles Bonnet syndrome, a condition that causes visual hallucinations. It is estimated that approximately 12% of people with macular degeneration experience Charles Bonnet syndrome.

As macular degeneration can prevent you from receiving as much visual stimulation as you are used to, your brain can sometimes compensate by creating fantasy images, or using images stored in your memory. These are known as hallucinations.

The hallucinations you experience may include unusual patterns or shapes, animals, faces or an entire scene. They can be either black and white, or colour, and may last from a few minutes to several hours. They are usually pleasant images, although they may be unsettling and scary to experience.

Many people with Charles Bonnet syndrome do not tell their doctor about their symptoms because they worry it may be a sign of some sort of mental condition. However, the hallucinations that you experience with this syndrome are the result of a problem with your vision and not a reflection of your mental state.

Speak to your doctor if you experience any kind of visual hallucination. There are ways they can help you learn how to cope with your hallucinations. The hallucinations will usually last for around 18 months, although for some people they may last years.

Barbara's story

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Twenty years ago, Barbara Watson discovered she was suffering from age-related macular degeneration (MD). Now aged 79, she talks about how it's affected her.

"I found out I had macular degeneration when I went to the optician for some new glasses. The optician examined my eyes and bluntly told me: "You’ve got MD, but don’t worry, you won’t go completely blind."

"It was a horrible surprise. My mother had suffered from MD, but it hadn’t occurred to me that I might have it one day. The signs had probably been there, but I hadn't noticed them. I’d been doing a lot of numerical work and was having problems reading the numbers 6, 8 and 3. I had to concentrate very hard in order not to get them muddled up.

"At first it wasn’t too much of a problem. My right eye was affected, and it stayed that way for three years. But when I began to get MD in my left eye, I had to give up driving. That was hard – a part of my independence had gone. Luckily, my husband drives, so I can still get around, but it was a difficult time.

"In the last few years, the MD has progressed more rapidly. I’ve had to give up a number of things I really liked doing, such as calligraphy and tapestry. Reading has become difficult, so I now listen to talking books. I’ve also been in some embarrassing situations when I’ve passed friends in the street and not recognised them.

"I always tried to hide it from people, but lately I’ve started using a white stick when I’m somewhere that's busy or unfamiliar. At first I wasn’t keen on doing so, but once I got over the embarrassment I’ve found that it's helpful because people do get out of your way.

"However, I'm still a steward at the local museum, and I’ve also joined a walkers group, which is great fun. When I joined the MD Society it opened up lots of new doors, and I’ve done a lot of fundraising. I’ve written about my feelings in two books of poems, which have both been published. That's been lovely. And I help my husband with the gardening when I can, although last week I dug up the sage instead of the mint – so it can be a bit hazardous sometimes."

Lee's story

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Lee has age-related macular degeneration, which is a painless eye condition that leads to the gradual loss of central vision (the ability to see what is directly in front of you). He describes the symptoms, diagnosis and treatment options available to him.

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