I have just examined a 75-year-old female patient. This is her first examination in my practice. She is 6/9 and N8 at 35 cm in each eye. She had some drusen near the fovea in both eyes. They looked larger than the typical hard drusen I’m used to seeing and had ill-defined margins. Some of the drusen looked like they were joined adjacent drusen. What should I do?

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.

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.

It sounds like your patient has soft drusen. These are larger than hard drusen, cluster closer together and have poorly defined edges. They are associated with age-related macular degeneration. The chance of a person with a few hard drusen losing some central vision from age-related macular degeneration in a 5-year period is very low whereas the chance may be as high as 50 percent over the same time period for those with many intermediate and large-size soft drusen.

The risk of developing advanced age-related macular degeneration is elevated in people with intermediate and large soft drusen, and your patient could benefit from taking AREDS2 formula vitamins, which decrease the risk of progression to wet age-related macular degeneration by about 25 %.

Also, you should advise her to monitor progression at home, by checking her vision on an Amsler grid. One eye at a time, with the other eye closed. Early, detection of the wet form with prompt referral increases the chance that vision can be stabilized or even improved by injection of anti-VEGF drugs.