Don't let age-related macular degeneration get you wrinkled. In this article, we unveil the pucker in macular degeneration. Eye health, in general, is quite important. With it being an immunologically privileged site - implying that the body’s regular immune response does not act the same here as it does in all the other sites of the body. This could be in order to reduce excessive increase of temperatures near the eye in response to pathogen attack, to avoid vision loss.¹ 

Although managing to escape vision loss in this manner, there tends to be a trend in the decline of vision with the incline of age. Usually due to the deterioration of protein in the lenses of the eye which cause them to harden.² Resulting in the reduction in 20/20 vision due to the rigidity of the lenses making them unable to readjust to focus on objects at varying distances.

Age-related macular degeneration (AMD) is a disease in the eye that causes a blurry central vision. It affects individuals who are around the ages of 50 or older. Whilst presenting with certain similar symptoms, but a separate condition, macular pucker is when scar tissue forms over the macula in the eye leading to loss of central vision as well.

They are not commonly comorbid conditions, but on the chance that they occur can cause strong vision loss, but very rarely do they lead to blindness. 

What is the Macula?

Macula is the region in the back of the eye that is rudimentarily responsible for clear central vision. It is around 5mm in size, consisting of a high volume of photoreceptor cells that aid in the detection of light generating perception of finer details and colour.³ It contains the fovea centralis, which is where vision is generated when light hits it ‘just right’. The macula is quite light-sensitive tissue. Damage to the macula can lead to straight lines looking wavy or crooked as well as blurred central vision.

You need a well-functioning macula in order to see details of objects that are in front of you like carvings, written text, and even faces! Without the macula functioning properly, it could lead to a number of macula-eye-related issues, such as:⁴

• Diabetic retinopathy
• Retinitis pigmentosa
• Stargardt disease
• Macular hole
• Macular pucker
• Age-related macular degeneration

The Macula in age-related macular degeneration

Age-related macular degeneration (AMD), a progressive retinal disease that leads to loss of the central vision in the eye. Affecting about 30% of people aged 80 and older. It is a leading cause of vision loss in developed countries. It is one of the most common eye disorders that affects central vision, classically linked to heavy smoking, but alcohol is not related to the diagnosis of AMD.⁵ It is due to damages within the macula in the eye due to Drusen formation in dry and abnormal blood vessels being formed in wet. These damages in the macula can cause the portrayal of straight lines as wavy and blurry. The blurriness spreads over a larger surface area as disease progresses, with blank spots. With this reduction in vision, colours may also appear to be less vibrant and perception of light can also be lowered. 

Traditionally, there are two sorts of AMD, dry and wet, where the former progresses slower and is characterised by geographical atrophy - the formation of yellow round spots of drusen in the Bruch’s membrane causing shrinking of the macula. Wet MD progresses quicker, accounting for 10% of the AMD cases. They are exudative and characterised by choroidal neovascularization - leakage of serous fluids and bloods with the addition of increased blood vessels and haemorrhaging subsequently causes loss in vision and carries a comparatively worse prognosis. They can occur together as metamorphopsia and scotoma.

Charles Bonnet Syndrome is a disorder that occurs when people are completely blind and tend to begin having hallucinations. It is not followed by dementia or any other mental disorder and the apparitions cannot be smelt or touched but only seen by the patient. It is one of the more uncommon signs of AMD. But, AMD can develop as a comorbidity of Alzheimer’s disease.⁶

The Macula in macular pucker

Affecting up to 20% of people aged 70 and older. It is less common than AMD but still a significant cause of visual impairment in the elderly. Similar to AMD, macular pucker leads to a decline in mainly central vision. This is due to the formation of a pucker due to a semi-transparent fibrocellular membrane that forms upon the retinal surface of the afflicted patient’s eye. The formation of the membrane leads to pucker or wrinkling in the retina, causing an impairment in vision and distortion. This could occur due to a couple of reasons - all which eventually result in the formation of scar tissue, such as:

• Trauma to the eye 
• Eye inflammation
• Previous surgery to the eye
• Detachment of the vitreous humour or tears in the retina

Macular pucker can cause issues in accurate depth perception as well, causing inaccurate judgement of distances. This is not a very common symptom but can occur with distortions in central vision, specifically by puckering.

Symptoms of AMD and macular pucker

With similar diagnosis, the two conditions also present with similar symptoms that affect the eye. Some of them being:

• Blurriness in vision
• Inability to notice finer details
• Reduction in perception of colour and brightness
• Distortion of vision 
• Difficulty reading, sewing, typing
• Inability to recognise faces
• Sensitivity to flickering light
• Changes in peripheral vision as well, with slight distortion

A medical professional or healthcare provider must be sought at the instance of these symptoms being presented. They may direct you toward the Amsler grid test or other similar procedures after testing your eyesight. However, a professional must be consulted immediately upon the presentations of these symptoms to reduce eyesight from worsening.

Though similar in the symptoms, they are due to different mechanisms changing in the eye. For example,

• The blurring in AMD is because of overall central vision impairment whilst macular pucker is as a result of blurring on the surface of the macular membrane 
• The distortion in vision in AMD is due to the wavy or bending of lines occurring due to metamorphopsia whilst in macular pucker is because of the puckering of the retina eluding the effect
• Scotoma damage in macular pucker is not as severe as in the case of AMD

The impact of the two conditions can extend beyond just physical symptoms, with psychological symptoms presenting as anxiety or depression due to their symptoms and loss of central vision that impairs them from functioning efficiently in their day-to-day life. Rendering them to be dependent on others. 

FAQs

Is macular pucker related to macular degeneration?

Although age-related macular degeneration (AMD) and macular pucker are both conditions that affect the macula of the eye - which is the part that contains the fovea centralis, responsible for accurate central vision. 

Macular pucker occurs due to the detachment of the retinal pigment as a result of the formation of the scar tissue on the surface of the eye. The retina puckers up or wrinkles leading to distorted or blurry vision. 

Age-related macular degeneration develops in people over the ages of 50. It is characterised by the loss of central vision. AMD can be characterised as wet and dry, where abnormal blood vessels and drusen are formed respectively. 

The both are not exactly related, apart from the loss of central vision. AMD is more due to ageing, whilst macular pucker occurs as a result of mechanical changes. 

What happens if you don't fix a macular pucker?

If left untreated, macular pucker can lead to wrinkling of the retina causing progressive loss of central vision. Overtime, distortion of vision can also occur that makes it difficult to perform tasks that require fine detail or reading or identification of face of any sort. It also tends to reduce quality of life, potentially leading to issues in maintaining independence in one's own life. 

What age do you get a macular pucker?

More commonly seen in people around the ages of 50, the probability of macular pucker increases with age. As the vitreous humour dries up within the eye and shrinks it causes the retina to shrink and pucker leading to the formation of scar tissue. 

There are other factors that can lead to macular pucker, such as: trauma to the eye or inflammation, previous history of eye surgery like in the procedure for cataract removal, or retinal disorders that tend to predispose one to developing macular pucker.

Summary

Age-related macular degeneration and macular pucker, although both leading to issues and impairment in central vision due to changes in the macula. Have differing reasons for their onset. Whilst the former occurs due to mere changes in the macula of the eye - responsible for clear central vision and perception of colour, as a result of old age. Macular pucker is due to retinal damage causing shrivelling up of it that leads to mechanical changes in the macula making it harder to recognise finer details and loss of central vision. They both can be diagnosed using the Amsler grid test and have prospects to be treated and at times reversed. Due to affecting only central vision, unless in extreme cases, one’s peripheral vision remains unaffected. The two disorders, though presenting with the same end result, are different issues that are not synonymous to one another. Macular pucker can form with AMD but only in rare cases.