I have just examined a 76-year-old female patient. She had some drusen near the fovea in her right eye. Very subtle and I could only just see them during ophthalmoscopy and in the retinal photograph. What should I do?

I can just about see the drusen in the retinal photograph of the right eye. Drusen is a sign of an older eye. Similar to having grey hair and/or some wrinkles in older age. Drusen themselves are not a sign of disease but simply a sign of age. The drusen in the photograph look to me to be hard drusen.

Drusen are small yellow deposits of extracellular waste (fatty proteins) that accumulate under the retina, between a specialized layer of cells called the retinal pigment epithelium (RPE) and Bruch’s membrane. The RPE maintains the photoreceptors (the light-sensing cells that make up the bulk of the retina), transporting nutrients and wastes between the photoreceptors and the blood vessels that supply them.

By age 60, changes take place that can cause drusen to build up on Bruch’s membrane, which displaces the RPE and forces the two layers apart. Such disruption to the RPE can damage the photoreceptors. An increase in the number or size of the drusen increases the risk of age-related macular degeneration.

There are two types of drusen: soft and hard. Hard drusen are smaller and more spread out. Having a few hard drusen is normal as people age and on its own is not a sign of disease. Many older adults have at least one hard drusen. This type of drusen typically does not cause any problems and doesn’t require treatment.

Drusen are detected by examination of the macula during ophthalmoscopy. People with drusen are more at risk of developing age-related macular degeneration and should be examined on a yearly basis. It is common for changes to occur in one eye more than the other and the patient might not notice the visual effects of these changes in their everyday life.

Yearly monitoring will assist in the detection of wet age-related macular degeneration which can be followed by prompt referral for consideration of treatment. Yearly monitoring will also assist in the detection of dry age-related macular degeneration which can be followed by referral to rehabilitation services.

I suggest that you explain to the patient what you have seen, advise a yearly examination, advise to come back if there are any changes to vision, and, of course, make a note of your results and advice given to the patient in the clinical records.