The increasing accumulation of lipofuscin in the RPE cells may reach such proportions that cell death can occur. Drusen increase the damage by hampering the RPE cells nutritional supply from the choroid [125]. Drusen can accelerate the decompensation of RPE cells and their cell death. This process results clinically in geographic atrophy (Fig. 5.19) [62, 125]. Areas with destroyed RPE cells become depigmented [62]. The borders of these atrophic areas are often hyperpigmented because of cell proliferation and phagocytosis of released melanin and lipofuscin granules. A small locally limited pigment change can develop into an extensive atrophic area. After atrophy of the RPE cells, also the underlying deposits regress. As no further debris is produced and simultaneously existing depositions are disposed of, drusen in the atrophic area regress and finally disappear completely [62]. Parallel to this process, the photoreceptors above the athrophic RPE also show degenerative changes. Single retinal cells undergo apoptosis, and slowly a reduction of the central vision develops [104]. For a detailed review of geographic atrophy, see Chap. 8.

Summary for the Clinician

›Comprehending the histopathological changes of early and especially late AMD is pre-condi- tion for the correct interpretation of established as well as novel high-resolution macular imaging technologies. It is also a mandatory prerequisite in the search of new therapeutic approaches.

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