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AMD: Dry Versus Wet Board Review

Master age-related macular degeneration staging, imaging, AREDS2 indications, and neovascular AMD treatment for eye-care board exams.

Reviewed for accuracyAugust 1, 20263 min read
Warm-up

Which pair correctly names the two broad forms of age-related macular degeneration?

Lesson

Age-related macular degeneration (AMD) is a macular disease with non-neovascular and neovascular forms. Board questions test staging, risk lesions, optical coherence tomography findings, and when to use AREDS2 supplements versus intravitreal treatment.

Dry Versus Wet AMD

Dry AMD, also called non-neovascular AMD, progresses through early, intermediate, and late stages based on drusen size, pigment changes, and geographic atrophy. Geographic atrophy and neovascular AMD are both late AMD because each causes advanced macular tissue loss or exudation. Neovascular AMD most commonly develops from intermediate AMD, although it is not inevitable and requires vigilant monitoring.

Key Clinical and Imaging Findings

  • Hard drusen are small, discrete deposits. Soft drusen are larger with indistinct borders. Large soft foveal drusen carry greater progression risk.
  • Hyperpigmentation and hypopigmentation of the retinal pigment epithelium are intermediate AMD risk markers, especially with large drusen.
  • Geographic atrophy is late dry AMD with loss of retinal pigment epithelium and overlying photoreceptors. Central involvement reduces central vision.
  • Subretinal fluid, intraretinal fluid, and pigment epithelial detachment (PED) on optical coherence tomography suggest active neovascular disease.
  • The Amsler grid is the classic self-monitoring tool. New distortion, missing areas, or wavy lines suggest metamorphopsia and possible conversion.

4 Facts Exams Always Ask

  • AREDS2 contains vitamin C 500 mg, vitamin E 400 IU, zinc 80 mg, copper 2 mg, lutein 10 mg, and zeaxanthin 2 mg. It benefits intermediate AMD or late AMD in one eye.
  • Intravitreal anti-VEGF (anti-vascular endothelial growth factor) injections are standard care for neovascular AMD. They suppress VEGF-driven leakage and neovascular growth.
  • Major non-modifiable risks include older age and genetic susceptibility. Smoking is the strongest modifiable risk factor.
  • Metamorphopsia means visual distortion. On an Amsler grid, straight lines appear wavy or bent. Drusen alone do not cause vision loss. Vision declines when there is geographic atrophy, retinal pigment epithelium dysfunction, or neovascular complications.

The Classic Trap

Do not label geographic atrophy as harmless because it lacks fluid. Geographic atrophy is late AMD, although anti-VEGF is not indicated unless neovascularization is also present. Complement inhibitor therapies are now available to slow geographic atrophy enlargement in selected patients, though they do not restore lost vision. Monitor progression, continue AREDS2 when indicated, and assess the fellow eye carefully.

Clinical Pearl

Fluid is the board-level clue to activity. Drusen and atrophy indicate structural AMD risk or damage. New intraretinal or subretinal fluid on OCT indicates exudation until proven otherwise.

Check yourself

Checkpoint 1

The main current treatment class for neovascular AMD is:

Checkpoint 2

In AMD, which drusen characteristic most strongly suggests greater risk of progression compared with normal aging changes?

Clinical case

A 74-year-old former smoker has large soft drusen and pigmentary changes in both eyes. She reports new waviness of doorframes in her left eye. Optical coherence tomography shows new subretinal fluid beneath the fovea.

A patient with known intermediate AMD develops an acute drop in central vision and metamorphopsia. Which progression should be most strongly suspected?

Sources & Reviewer Info
Reviewed by Vasilis Inglezis: Optometrist and Ocular Oncology Imaging Specialist, Ocular Oncology Center, Athens, Greece. Last updated August 1, 2026.

References

  • Vitale S, Clemons TE, Agrón E, Ferris FL, Domalpally A, Danis RP, Chew EY. "Evaluating the Validity of the Age-Related Eye Disease Study Grading Scale for Age-Related Macular Degeneration: AREDS2 Report 10." JAMA Ophthalmology. 2016;134(9):1041-1047. doi: 10.1001/jamaophthalmol.2016.2383.
  • Schmitz-Valckenberg S, et al. "Non-Neovascular Age-Related Macular Degeneration Assessment: Focus on Optical Coherence Tomography Biomarkers." Diagnostics. 2024.
  • Evans JR, et al. "Antioxidant Vitamin and Mineral Supplements for Slowing the Progression of Age-Related Macular Degeneration." Cochrane Database of Systematic Reviews.
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