A 68-year-old Indian patient presents with gradual central vision loss over 2 years. Fundoscopy reveals the lesion marked **A** in the diagram — soft confluent yellow drusen at the macula with preserved foveal light reflex. The patient is a former smoker with hypertension. Based on the AREDS2 classification and the morphology of the drusen shown, which of the following is the most appropriate management to reduce the risk of progression to advanced AMD?

Question

Accepted Answer

C. AREDS2 formulation (Vitamin C 500 mg, Vitamin E 400 IU, Zinc 80 mg, Copper 2 mg, Lutein 10 mg, Zeaxanthin 2 mg) and smoking cessation. ## Why AREDS2 formulation and smoking cessation is right

The soft confluent yellow drusen marked **A** are ≥63 μm with indistinct margins, indicating intermediate to advanced dry AMD. According to the AREDS2 Research Group (JAMA 2013), the AREDS2 formulation — Vitamin C 500 mg, Vitamin E 400 IU, Zinc 80 mg, Copper 2 mg, Lutein 10 mg, and Zeaxanthin 2 mg — reduces the 5-year risk of progression to advanced AMD by approximately 25% in patients with intermediate AMD or advanced AMD in one eye. Smoking cessation is the strongest modifiable risk factor and is essential in this former smoker. The preserved foveal light reflex indicates dry AMD without exudative features, making this the standard-of-care intervention.

## Why each distractor is wrong

- **Intravitreal ranibizumab monthly injections**: Anti-VEGF therapy is reserved for neovascular (wet) AMD, not dry AMD with drusen. This patient has no clinical or angiographic evidence of choroidal neovascularization.
- **Pegcetacoplan intravitreal injections**: Pegcetacoplan (complement C3 inhibitor) is approved only for slowing geographic atrophy progression in advanced dry AMD. This patient has intermediate dry AMD with drusen but no geographic atrophy yet; it is not indicated at this stage.
- **Beta-carotene supplementation**: Beta-carotene was explicitly REMOVED from AREDS2 due to increased lung cancer risk in smokers. This patient's smoking history makes beta-carotene contraindicated.

**High-Yield:** AREDS2 formulation (without beta-carotene) is first-line for intermediate/advanced dry AMD; anti-VEGF is for wet AMD; complement inhibitors are for geographic atrophy.

[cite: AREDS2 Research Group JAMA 2013; AAO PPP AMD 2023]

Answer

A. Intravitreal ranibizumab monthly injections

Answer

B. Beta-carotene supplementation with high-dose antioxidants

Answer

D. Pegcetacoplan intravitreal injections for geographic atrophy

Explanation

Why AREDS2 formulation and smoking cessation is right

Why each distractor is wrong

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