This is a very long page..see separate pages

• dry macular degeneration
• wet macular degeneration

This page.................................................................

The causes

• genes
• healthy lifestyle & exercise
• smoking
• blood pressure & exercise & weight
• diet
• Vitamin supplements
• Oily fish
• cholesterol
• statins
• cataract surgery
• vitreous changes

pathology

• invisible changes
• What does a person notice with these early changes
• drusen
• soft drusen
• atrophic ARMD
• Drusen formation 2003

types of dry ARMD  

• progression
• drusen
• soft drusen
• diagram..drusen
• geographic
• foveomacular dystrophy
• Choroidal Sclerosis
• mixed/retinal pigment epithelial hypertrophy

Distortion of vision and other symptoms:
dry ARMD changing into wet ARMD

• distortion of Vision
• Amsler grid test
• the other eye                               (separate page)

'Wet' or neovascular types of ARMD

• Fibrovascular Pigment Epithelial Detachment:
  occult type 1..this page               (separate page)
• Type 2 Occult CNV..this page     (separate page)
• Classic CNV..this page                (separate page)
• Polypoidal choroidal vasculopathy
• myopic CNV
• extensive subfoveal haemorrhage (due to cnv)
  (separate page)
• RAP (separate page)
  
  
  
• laser
• PDT (photodynamic therapy)
• scarring
• Feeder vessel laser
• Rip..photos     rip / tear text
  

Further details

• abbreviations
• links
• Macular Disease Society
• BMJ article   a slide show
  

• Coping / Low vision
  • Hints & Coping
  • Coping with one eye
  • Magnification
  • Low Vision Assessment
  • Low vision Gateway (US)
• Support
  • Rehabilitation & local services
  • Birmingham Focus (link)
  • Walsall Eyes Newsletter
  • Macular Disease Society
  • Rehabilitation Centre
  • RNIB.talk and support
• Macula degeneration
  • Explanation (link)
  • Understanding
  • Pathology ARMD
• dry ARMD
• wet ARMD & Lucentis
  • wet ARMD
  • Lucentis treatment program
  • myopic macula degeneration
  • Macula degeneration: understanding
  • Risk simulation
  • Diabetic maculopathy (link)
  • PDT program
  • New drugs..Lucentis, Macugen, Avastin
  • A table comparing drugs
  • Studies published and in progress
  • Audio interview (NEJM)
• Types of wet ARMD
  • Occult type 1, PED
  • Occult type 2
  • Classic
  • Rip
  • Polypoidal
  • RAP
  • extensive subfoveal haemorrhage
• Myopia
  • refraction
  • dry macula changes
  • wet macula disease (CNV)
• Abbreviations
• Animations etc
  • Large diagram 1
  • Large diagram 2
  • wet /dry ARMD full size
  • Lucentis
  • SWF file for laptops: ARMD animation: 1mb
  • Excellent animation..link
• Cases for students etc
  • Case 1 ARMD etc
  • Case 2 hard drusen
  • Case 3 Central Serous Retinopathy
  • Case 4 Wet macular degn (CCNV)
  • Case 5 Occult CNV
  • Case 6 Soft drusen
  • Case Pre-macula haem
  • Case Bests
  • Case 10 PDT
  • Case 11 rip
  • Case 12 CNV
  • Case 13 CSR & PED
  • Case 14 Dry/Occult
  • Case 15 polypoidal
  • Case 16 myopic early CNV
  • Atlas...Bests, Haem
• Juvenile macular dystrophies
• Further information
  • dry ARMD (link)
  • US Aging Times Review
  • Links
  • RNIB page (link)
  • epidemiology
  • Genes
• Lifestyle
  • Alcohol
  • Smoking
  • Diet
  • Blood pressure
  • exercise

Age-related macular degeneration (ARMD) is one of the commonest causes of poor sight in developed countries.

The main factor is age.  Whilst the causes are different in different people, other factors contribute.

cholesterol

a high fat diet is probably directly related to this condition

alcohol

We now know that alcohol excess is also related to ARMD, see 

Sunlight exposure, especially the summer sun, contributes to ARMD; and sunglasses protect, see.  Some sunlight exposure is important...gentle sun exposure increases vitamin D production, and this will reduce the risk of many conditions such as diabetes, osteoporosis, and prostate cancer. Bright sunlight does contributes to ARMD, and eye protection is advisable.

Some communities in Japan did not develop macular degeneration as people aged, but as soon as they started eating Western food the condition started to occur. Similarly, when Japanese people move to Western countries, they develop the condition more frequently.

These observations suggest that the high fat (and type of fats, such as saturated and trans-fats) in our diet, the lack of protective fats (omega 3s, from fish), and salt (by increasing blood pressure) increases the number of people with ARMD.

click here for full size image

We inherit these from our parents. Genes are the genetic information that tells our body what chemicals to make. Overall, our genes may contribute to more than 50% of ARMD. This paper suggests that we will soon be able to work out who is at risk...the main genes have been found.

See Gene page   The genes that may cause macular degeneration probably control the way used-up chemicals are removed from the eye.

Being long-sighted (hyperopic) is also a risk factor

• Smoking, accounts for 32% of ARMD
  
• regular exercise,
  
• alcohol,
  
• a healthy diet
  

• Overall smoking accounts for 32% of ARMD. Even stopping at the age of 80 will reduce the risk of developing the disease.
  So if you have a relation with macular degeneration, try and stop as smoking may make it develop earlier.
  
  
• Smoking increases the risk of macular degeneration about 3 times. Macular degeneration occurs 10 years earlier in smokers.
  
  
• If you have macular degeneration, do try and stop. Even if you are 90 years old stopping smoking will help your eyes considerably.
  
  
• Passive smoking is also harmful: for instance, if your partner smokes cigarettes a day, you body receives 25% of the smoke, so that is equivalent to you smoking 5 cigarettes a day. 28000 cases a year in the UK.
  See 2002 report and 2003 study . Lithuania     Japanese  
  
  
• A new report here describes the risk of passive smoking (doubles the risk) and personal smoking (triples the risk) of both types of ARMD, that is geographic atrophy and neovascular.
  
  
  
• Each cigarette probably increases the progression rate or ARMD ~15%

larger

• 30 minutes a day at least, walking, or more active exercise for younger people,  reduces risk by 70%  : a 2006 study. Exercise may help by preventing hardening of the arteries.
  30 minutes walking a day for example...regular walking, for example, three times a week will result in less than a third of the amount of neovascular ARMD compared to people who don't walk or exercise and who drive everywhere.
  
  
• A low blood pressure helps. A level of 140/85 or below is likely to be best. Blood pressure is written as '140/85', with the systolic/diastolic. Above 115 (systolic) the risk of heart disease increases. See the evidence and more. Macular haemorrhages are more likely with high blood pressure.
  
  
• Obesity is also a risk factor see. 
  
  
• A low salt diet is important Salt and more than 2 units of alcohol a day may cause blood pressure to rise.
  

Blood pressure rises after drinking (opposite...drinking 4 pints/bottle of wine).

Each gram of alcohol puts systolic blood pressure up 0.24mmmHg, diastolic 0.16 mmHg. This means 1 pint of beer (2 units, each unit 8g alcohol) with 16gm of alcohol, if drunk every day, will put the systolic blood pressure up (16 x 0.25=) 4mmHg.

enlarge

• This should include a variety of vegetables and fruit
  (at least 5-9 x 100gm portions/day) ( 2008)
• low fat only dairy food
• the minimum of trans and saturated fat
• the minimum of red meat, as part of a balanced diet
• oily fish ...2 small portions a week, Blue Mountain 2009, Australia 09 reduces aging
• 1-2 hours exercise a day
• A low salt diet is important
• Vitamin D reduces risk, (Vitamin D increases with sunilght)
• a Mediterranean or Japanese diet (as was 20years ago) will almost certainly protect. 
• Losing weight (if overweight) reduces risk

Fruit/vegetables prevent 36-50% of ARMD see, see and see (fruit & vegetables lower homocysteine levels, and this improves blood flow).

Pulses like beans are fine. Bread, pasta, rice and potatoes provide ‘energy’.

Vegetarians have lower blood pressures and healthier lipid levels,  see . A healthy diet reduces homocysteine levels, which are associated with ARMD .

Certainly saturated fats increase the risk of ARMD; and fish and polyunsaturated fats halve the risk. Avoiding certain fats helps, with strong evidence here (explained more clearly here for heart disease). Nuts may help prevent ARMD (small amounts...they are fattening).

5-9 portions of fruit/vegetables a day, with portions of different colours
5 is a minimum..best 9 for men, 7 women, 5 children, see.

The Guardian (2005) reviewed healthy diets etc, here, here , here , here and so on.

See some epidemiology

If you are unable to eat this many vegetables, low dose multivitamin tablets may help, but too many vitamins may be harmful.   Lack of vitamins has been linked to macular degeneration

Some research suggests that the pigments in vegetables, lutein, and two types of zeoxanthin might be helpful, as these are the pigments found in the healthy macula.

Against. See AREDS. BMJ

Lutein is in most fruits and vegetables, one type of zeoxanthine is in corn, nectarines and oranges (and other yellow/orange fruits/vegetable), but one type is not normally present in the diet. However, some supplements include doses that are too high, so once again, these are probably best as part of a healthy diet.

'Ocuvite-Lutein' is one preparation that may help. One paper suggested zinc may be helpful, but only in low dose, and is probably best as part of a healthy diet.
ICap (Alcon), is available in pharmacies and optometrists. This has lutein and other vitamins in, and had been recommended by some ophthalmologists. Beta-carotene supplements are not recommended for smokers, as they may contribute to lung cancer. I Cap is similar to the AREDS vitamins that reduced ARMD risk by 28%.

These supplements may not help (see), as some experts advise that people with a healthy diet may be harmed by taking vitamin supplements. A review (2006, Drug and Therapeutics Bulletin, not free online) recommmeded a healthy diet including green vegetables diet was preferable to supplements.
If you have a healthy diet, ophthalmologists disagree.

The AREDS vitamins reduce ARMD by 25% if diet is not discussed. It is not known whether or not they help patients who have a healthy diet.

Ocuvite-Lutein has the most logical formulation...but a healthy diet may be better still.

ARMD is commoner in people with higher cholesterol levels. Atherosclerosis, caused by a high cholesterol, does contribute to ARMD, see  

Statin treatment reduces macular degeneration. See    see,   Although statin tablets are not yet formally recommended by all agencies, this author would recommend them for people with ARMD.  
This paper & another found no benefit, so it is difficult to be certain.

Naturally all relatives of ARMD patients should address this issue of fat levels in the blood, sticking to a low fat diet with plenty of exercise, avoiding obesity, just as described on this page for ARMD patients.

Age-related macular degeneration is explained in more detail on other web-sites, such as the RNIB and NIH. This is an excellent animation: www.eyesight.org. Below is a brief description.

Age-related macular degeneration (ARMD) is usually a progressive condition.

Dry ARMD progresses over many years. See dry ARMD page. Sight does deteriorate, but most people manage to cope well, although reading is difficult and life may be different. In some types of dry ARMD progression may be very slow, but it may be quicker in other types.

Dry ARMD may progress to the 'wet type', but this is not always the case.

Wet ARMD  begins as new vessels growth in the macular area, causing retinal leakage and swelling. See wet ARMD page. It progresses to cause a scar in the macular area. If the scar is small, sight is reasonable; if large, the sight can be very poor.

Imagine your retina has five layers. Normally this retinal appearance stays constant even in old age, but changes may develop as you get older.

As we get older, changes develop in the retina. The bruchs membrane thickens and the choroidal blood vessels change.

The thickened bruchs membrane prevents waste products leaving the retina (see animation and the link), and also prevents nutrients entering. This is thought to be a direct cause of the condition. Lipofuscin (type of fat) accumulates in the retinal pigment epithelium; this damages the pigment cells which eventually die.

The choroidal circulation changes...the blood vessels become larger but fewer. This is probably mainly due to a 'hardening of the arteries' that happens elsewhere in the body, particularly with a Western diet.

The invisible changes progress to cause dry ARMD,

• patches of extra thin retina develop, just as though the retina is 'worn out .  Often the patches of thin retina gradually get larger, reducing sight.
• Deposits of waste products may develop, called drusen
• pigment changes develop
• the dry changes may convert to 'wet ARMD'

These changes are described with photos below.

• difficult seeing in dim light
• difficult seeing in bright light
• slow recovery in bright light
• poor central vision when you wake up

If you notice these problems then you are probably at risk and need a check from an optometrist or ophthalmologist. If there are no visible changes, the author would strongly recommend a healthy lifestyle as prevention...it helps your general health in any respect. (This section: after Prof. Bird).

• progression
• drusen
• soft drusen
• diagram..drusen
• geographic
• foveomacular dystrophy
• Choroidal Sclerosis
• mixed/retinal pigment epithelial hypertrophy

Once the invisible changes above develop, the dry changes develop.

1. drusen develop. These are deposits of various types of fatty (lipids) substances.
2. the drusen may may small and hard...in which case progression is slow
3. alternatively the drusen may soft, in which case the condition usually progresses
4. the soft drusen cause thinning of the retina and loss of sight
5. the degree of sight loss is very variable...depending on the amount of retina that becomes thin. If the very centre of the macula is affected (the fovea) the reading becomes a problem. Sometimes the fovea appears healthy, but the fovea is surrounded by thin 'atrophic' retina....reading may still be a problem as the images of letters that are being read fall  on the damaged non-seeing retina...so you can only see part of words at any one time.
6. the thinning of the retina is called 'geographic atrophy'. Atrophic changes are present in most of the of the 'dry' types of ARMD as below.
7. A number of patients with the dry geographic atrophy or soft drusen also develop wet  macular degeneration. Wet ARMD occurs when blood vessels grow under the macula, and leak and bleed.
   But in some ways it is best to consider wet and dry as different conditions, with different genetic and environmental 'causes'.

The retina becomes very thin, just as though it is worn out. The patches of such thin retina do not 'see', so the central vision becomes patchy. Essentially it is a type of wear and tear.

Dry types of macular degeneration can get very slowly worse, but only affect the macular area. The rest of the retina, which helps you see at the sides so you can walk round the house, always stays good. The progression is a usually a very slow process taking years.

This movie  is excellent.

If this wear and tear is mild you may be able to read and even drive, although it takes a little longer to adjust to different lighting.

Often it is a little more severe, and reading is difficult, and driving is impossible. TV is not too bad if you sit close: this is discussed in Hints & coping.

Some types are non progressive, and not discussed here in detail (such as old macular holes).
Every person is different, and often it is very difficult for your doctor to predict what will happen to your sight.

Sometimes changes can occur more rapidly, and this would suggest that you are also developing the 'wet' type of ARMD as below. See www.macula.org .

The appearance of the retina may be same in different patients (phenotype.) But in fact each person's condition (even though it looks the same to the doctor on the photographs or scans may have different factors such as different genes (genotype).

This is one of the reasons it is so difficult how each person's condition will progress.

see photo

Patchy vision in atrophic macular degeneration

Drusen may develop. These are accumulations of material, probably some waste products of the retinal cells. These are common, and do not usually affect the sight.

The accumulation occurs as bruch's membrane becomes thicker and prevents the free flow of materials to and from the light or photoreceptors layer.

Also, the retinal pigment cells accumulate lipofuscin. This pigment will also slow down the passage of chemicals to and from the retina.

Some people with a lot of drusen do have slightly reduced sight.
Drusen look like little white spots in the retina. See tiny drusen.

Hard drusen: If they are well defined with a sharp edge, the sight is likely to stay good.

Soft drusen: If they are a little like cotton wool, they are more serious as they may lead to more serious disease with 'exudative changes' as below: prevention is most important (see above). Reference.  

If there are a few drusen you may be said to have very early 'dry' macular degeneration.

See types of drusen,  risks and epidemiology. Soft drusen are inherited: see CFH Y402H.

see a retinal photo
and confluent soft drusen
and another large one. another

See hard drusen (right) & case.

Areas of thin retina develop. These areas form like the patterns of countries of the world. The areas get bigger (over years), slowly causing more damage to the sight.
Geographic atrophy is the main type of dry ARMD. See a photo. another . 

We now know here that the risk of passive smoking (doubles the risk) and personal smoking (triples the risk) of both geographic atrophy. See genes and here.

Geographic atrophy (GA) accounts for a third of ARMD, with new 12,000 cases a year. It is believed to be caused by retinal pigment epithelial atrophy leading to cell death. It is best examined with the autofluorescence technique but this is seldom available. There is not treatment available yet, although trials are in place.

Atrophic myopic macular degeneration is usually similar.

If the damage is in a very small central area, this may be the type described by Gass, and here foveomacular dystrophy , and will not progress.

See a photo.   another

If there is a large thinned area this may be the ‘choroidal sclerosis’ type of ARMD. This often affects both eyes, but is not treatable, often causing poor central vision.

The thin area actually looks white, and the thick choroidal blood vessels can be seen underneath. May be this is a type of geographic atrophy?

Changes may include thinning of the retina, drusen, pigmentation, or thickening of the retina. There is a variable outcome. ‘Prevention’ may help.

photo     photo    photo

Patients should probably be given the Amsler Grid test to use every day, or at least once a week, at home. These authors recommend this test, although personally I have found that patients may still present late.

Patients are given a grid, told to look at the central spot with their reading glassses on, using one eye at a time. If any of the adjacent lines become bent or wiggly or distorted, then CNV (blood vessels growing under the macula) may be present, and patients should see their ophthalmologist (in Birmingham attend the Eye Centre Casualty, City Hospital).  

The test is explained well here .

Distortion of straight lines which may start to appear crooked over a few weeks usually means the ARMD is progressing. Sometimes this is due to the 'neovascular' ARMD developing, and you are advised to be checked in case laser may help.

• The atrophic or dry type usually does occur in both eyes, but remember this generally gets very slowly.
  
• There may be a gap of years before the process begins in the second eye.

There are different types of wet ARMD

• Fibrovascular pigment Epithelial Detachment: occult type 1
• Type 2 Occult CNV
• Classic CNV
• Polypoidal
• RAP (separate page)
• Myopic

In wet ARMD the damaged retina releases a chemical VEGF (Vascular endothelial growth factor). The VEGF stimulates blood vessel growth, to produce the different types of wet ARMD. In addition, the new blood vessels leak, causing fluid under the retina in these condtions.

In this type of ARMD, there are new blood vessels, but they are not clearly seen with the angiogram. ‘Occult’ CNV is the term given to a specific ‘blotchy’ appearance of the angiogram. Occult ARMD is probably an early phase of classic, see .
Regular laser is not effective, but even with PDT  laser 50% of eyes lose some sight. New anti-VEGF drugs such as Lucentis and Avastin are likely to be the best option, perhaps in addtion to PDT. Results appear excellent for this type of ARMD.
Occult and classic patterns can occur together. If the percentage of ‘classic’ is high, PDT helps (early results).

The symptoms of this type of CNV are the same as 'classic CNV' . This type 2 occult CNV usually turns into classic CNV over the next months or years, to cause poor central vision.

Large occult membranes can develop haemorrhages with  anti-VEGF treatment (BJO 2008)

• See a photo
• another
• another
• another
• another..occult/mixed
• another   
• flash (can enlarge)
• another

Some dry types of macular degeneration progress to form this type of wet ARMD.

It is very difficult to predict whose dry ARMD will progress, but the risk factors include those mentioned above (soft drusen, high blood pressure, smoking, poor diet, lack of exercise).

When blood vessels grow under the macula, this is termed choroidal neovascularisation (CNV or CCNV).

When the new vessels are seen easily on a fluorescein angiogram, they are called 'classic CNV': They look like a net of blood vessels.

See a photo,   another , another , another (case 12) and a healthy fluorescein for comparison.

When a doctor looks in the retina looks elevated, there may be tiny haemorrhages, a grey area, or exudates. This photo is a severe case. In milder cases vision may still be good.

The condition may develop over days or weeks, with increasing distortion or blurred central vision. If this process is mild you can still read, but if it becomes severe reading with any magnifier is impossible.

Treatment, if possible, will be include new ant-VEGF drugs.

Laser  may help (see details of the Verteporfin treatment program) but is becoming less important as it is not effective as the new drugs.

If you notice the symptoms (central vision becoming distorted or blurred, sometimes like looking through water) you should have your eye checked: see distortion below.

This is usually a very serious type of macular degeneration, serious because it can cause very poor sight. It never blinds in the sense that you cannot see light and dark, but in its serious form it can damage the central vision so you can only see fingers or even the movements of hands. Once again, the side vision will normally be good, so you should always be able to walk around the house.

Surgery has not proved very helpful.

The CNV grow at 20microns/day, reaching 3000 microns in 6 months. They can be extremely difficult to see in early stages. Small membranes gain, on average, 5 lines of vision with the Lucentis.
The biggest problem is detecting them early, and much work ('Replacing the Amsler Grid")   is being carried out to detect early membranres.

The condition is occasionally unresponsive to treatment. Macugen is probably the least effective of the new anti-VEGF drugs, and even combined with laser may give a poor response.

New vessels growing under the central retina in a 'classic' pattern: PDT treatment may help

enlarge

This is slightly more common in Chinese and Afro-Caribbeans. PDT can be very helpful.

Seen as a branching choroidal network of vessels with vascular dilatation. Often occurs with a serous haemorrhagic PED. A common treatment plan:

• ICG will identify this condition
• PDT any well defined lesions, 80% resolution
• if not well defined, anti-VEGF, and then when retina drier proceed with PDT
• anti-VEGF not very effective
• Afro-Caribean..female; Asian...male; Caucasian ..bilateral peripapillary
• Yanuzzi
• Argon laser
• Cackett     haemorrhagic ped is predictive of PCV 2010
• Cackett, classification
• PDT and and anti-vegf combined are effective BJO 2010

Occasionally large haemorrhages develop in the macular area. These are more oikely in smokers, especially if there is hypertension, or in very elderly patients.

Various treatments have been tried.

Perhaps the best treatment at present is gas tampanade. (Sacu 09).

Injection of tissue plaminogen activator followed by gas often displaces the blood. By displacing the blood, vision may imporve, but also there will be less maular scarring and better sight in the long-term.

Until recently the only treatment was laser treatment.

If the classic new vessels (CNV) are not in the very centre of the retina, regular laser can help. (Laser is a very bright light that makes tiny burns at the back of the eye.)

This appearance is called classic extra-foveal CNV.

If the CNV were away from the fovea, regular laser may help. However, over the years laser burns expand and this can reduce central vision years later. This treatment is only suitable if the CNV are well away from the fovea.

If the area of neovascular ARMD (CNV), shown as the red area, is not under the very centre (the yellow spot, called the fovea), regular laser may help.

Most people with neovascular ARMD have CNV in the centre of the retina. This appearance is called classic sub-foveal CNV. Regular laser cannot be used as it itself would destroy the central vision, so photo-dynamic laser (PDT) laser may help. But even with this treatment many people lose vision.

Now Anti-VEGF drugs are being used, and success rates are much higher. They may be used in addition to PDT. This is discussed here. The drugs are given by injections in the eye itself about 8 times a year.

Traditionally after laser the CNV often return, and this may be the case with new drugs. We have to await further research results. Here is an up to date treatment plan, if the new anti-VEGF drug Lucentis is available  see.

See PDT

If the area of CNV is under the very centre PDT laser may help.

There are other treatments for neovascular ARMD (CNV), such as surgery or transthermal laser, but apart from PDT laser these are not very successful and not in general use:

Many types of macular degeneration progress to cause scarring. 'Dry' types usually progress more slowly, but occasionally can cause very poor central vision, but this is commoner in the 'wet types'.

If your conditions is severe wet (example) scarring is likely.

See a scar ,  another. another large

Sometimes the retina in the macula area can tear and shrink. This is call a 'rip' or a 'tear' of the pigment epithelium. It may occur spontaneously as part of wet ARMD, but can occur after PDT or anti-VEGF treatment. A rip causes significant loss of central vision.

See a case, with reports  a pigment epithelial rip   (thanks to Ajith Kumar/BMEC). Even the new drugs can cause the retina to 'rip', but the risks are only slightly increased.

The chances of rip depend on how elevated the PED is (the retinal pigment epithelial detachment). For instance, an 840 micron elevation has a 50% chance of ripping. A 500 micron elevation has a 10% chance of ripping. Gelsiken 2009

Here is a summary of some of the abbreviations ophthalmologists use in this condition:

http://www.nei.nih.gov/health/maculardegen/armd_facts.asp
http://www.macula.org/what_is/index.html

http://www.visudyne.com/index.jsp ....for patients (needs enrollment)
http://www.visudyne.com/hcp/index.jsp for professionals

http://www.macula.org/what_is/wet_mov.html      ( very helpful)
http://www.eyesight.org/Macular_Degeneration/Pictorials/pictorials.html

http://www.maculardisease.org       info@maculardisease.org 
The Macular Disease Society
PO Box 1870
Andover
SP10 9AD
Tel: 01264 350551

ARMD web site http://www.armd.org.uk/index.html

thanks to