This patient with moderate dry age-related macular degeneration (AMD) should be treated with antioxidant vitamins and zinc, using the Age-related Eye Disease Study 2 (AREDS2) formulation. AMD is a degenerative disease of the macula that results in loss of central vision. Dry AMD is typically seen as subretinal deposits of yellowish or white extracellular material (drusen) and atrophy of the retinal pigment epithelium. Wet AMD is characterized by growth of abnormal blood vessels (neovascularization) into the subretinal space. Although dry AMD is more common, wet AMD is associated with a greater risk of vision loss. The Age-related Eye Disease Study (AREDS) found that daily high doses of vitamins C and E, β-carotene, and the minerals zinc and copper (the AREDS formulation) slowed the progression of moderate dry AMD (defined as extensive intermediate size drusen or at least one large lesion, or significant retinal pigment epithelium atrophy in one or both eyes) to advanced AMD. A second randomized trial, AREDS2, focused on whether the AREDS formulation could be improved with the addition of omega-3 fatty acids and/or certain antioxidants (lutein and zeaxanthin) and the subtraction of β-carotene. Although omega-3 fatty acids did not provide any additional benefit, lutein and zeaxanthin were found to be an appropriate substitute for β-carotene. Since β-carotene has been associated with an increased risk of lung cancer, particularly in smokers and former smokers, the AREDS2 formulation is a more appropriate choice for this patient with a significant smoking history; the AREDS formulation would be an appropriate choice for nonsmokers.

Laser therapy has not been shown to be beneficial in patients with dry AMD and may be detrimental by increasing rates of neovascularization. Laser therapy may have a very limited role in treating selected patients with wet AMD, but it would not be an appropriate therapy in this patient.

Vascular endothelial growth factor inhibitors are an established therapy for wet AMD due to their inhibitory effect on neovascularization, but they do not have a role in treating dry AMD.

Clinical observation without treatment with antioxidant vitamins would not be appropriate in this patient with moderate dry AMD given the established benefit of antioxidants in reducing the risk of developing more advanced and potentially sight-threatening disease.