Age Related Macular Degeneration - Risk Factors & Visual Performance Assessment Form
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1Age Related Macular Degeneration
Risk Factors & Visual Performance Assessment
Name ___________________________________________________________________________________
DOB _______________________________ Age ____________ Exam Date _______________________
AMD Risk Factors
Age-Related Macular Degeneration (AMD) is
the leading cause of vision loss in adults, currently
(Please check all that apply)
affecting more than 15 million Americans. Its
Age (over 50)
effects may be permanent and irreversible however
you can reduce your risk. Consuming adequate
Family history of macular degeneration
quantities of dietary nutrients that support eye health
Low macular pigment
on a regular basis has been demonstrated to
Smoker (current or prior)
reduce risk. Patients not routinely consuming
these nutrients may supplement their diet with
Cardiovascular disease
vitamins formulated specifically for eye health.
Light colored eyes
Our doctors strongly recommend the QuantifEye®
Caucasian
macular pigment optical density (MPOD) measure-
ment to determine the density of the pigment
Female
in your macula. These pigments protect your
Overweight
visual cells and their density can be increased in
most people. The measurement is not covered by
Visual Performance Challenges
insurance however it is available for a nominal fee
and our doctor feels it is very important.
(Please check all that apply)
Night driving difficulty
Visual Performance Challenges may be related
to low MPOD. Routinely consuming adequate
Discomfort due to glare, night or day
quantities of zeaxanthin and lutein has been
Sensitivity to bright light
scientifically demonstrated to increase MPOD,
Difficulty seeing objects against their background
thereby improving visual performance factors
(contrast sensitivity)
such as glare recovery time, decreased bright
light sensitivity, improved contrast sensitivity, and
improved visual acuity (ability to read more letters
FOR OFFICE USE
and lines on an eye chart). Many also report an
improved ability and confidence to drive at night
PATIENT RISK DETERMINATION
after increasing their MPOD. Scientific evidence
suggests macular pigment density may also
# of AMD Risk Factors ________
be important for optimal visual performance in
# of Visual Performance Factors ________
athletes, shooters, military personnel, commercial
pilots, truck drivers, etc.
MPOD Score ________ L / R
QuantifEye MPOD Test: Accept ____ Decline ____
<.50
>.50
Lower Range
Higher Range
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