Modifiable risk factors for AMD the same for women, men
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Women appear to have a higher risk for developing age-related macular degeneration, but the reason for this remains unclear, according to Rishi P. Singh, MD.
Research shows, however, that certain modifiable risk factors, such as diet and smoking, and the importance of continued treatment play important roles in preventing progress of AMD, regardless of sex, Singh, staff surgeon at the Cleveland Clinic Martin Health System, Cleveland Clinic Florida, and professor of ophthalmology at the Lerner College of Medicine in Cleveland, told Healio.
In an interview, Singh further discussed these risk factors, how physicians should counsel their patients who are concerned about developing AMD and more.
Healio: What evidence suggests that women are at higher risk for developing AMD?
Singh: There are a variety of risk factors that have been associated with neovascular AMD: development, older age, Caucasian race, sunlight exposure and smoking. We know that smoking in general contributes heavily to the progression rates of neovascular AMD — about a fourfold increase over baseline — so if a patient is a current smoker, it can result in a higher than normal rate of progression to this disease. These are all significant factors in the progression of neovascular AMD. Obviously, there are modifiable and nonmodifiable factors — race not being one of them — but it is true that more Caucasian women are at risk for developing neovascular AMD. For any patient, counsel them on the risk associated with smoking and make sure that they undergo smoking cessation as a way of reducing their risk. In addition, having a balanced diet full of green, leafy vegetables, a dose of fish and a high dose of antioxidants can reduce the progression of neovascular AMD.
Healio: Why might women be at higher risk for AMD?
Singh: That is a great question. To be honest, we do not know the answer. Obviously, women and men differ in their genetic components, and genetics play a large role in neovascular AMD development. Various genes have been associated with neovascular AMD progression, mostly unrelated to sex, but certainly complement factor dysregulation or other genes that are available within the system have shown progression to that sort of disease state. However, again, the most important thing that we can take away from this is that there are ways of monitoring and maintaining vision along with good follow-up care that can prevent the progression of AMD over time.
Healio: Is there a relationship between cholesterol and AMD in women?
Singh: The cholesterol argument has been looked at in a variety of different ways. Researchers have looked at it in non-neovascular AMD and found little to no relationship between high and low cholesterol and neovascular AMD development. One of the components of drusen is lipid, so there is a thought process that once a patient has dry AMD or non-neovascular AMD, maybe a lipid-lowering medication may improve the overall drusen size or consistency and prevent progression over time. Thus far, those studies have been inconsequential and have not shown significant benefit at stopping the progression of the disease. It is mainly based on other factors.
Healio: How should physicians counsel women who are worried about developing or worsening AMD?
Singh: It is important for any patient to undergo a good history, a good dilated eye examination and likely an OCT to make sure that they do not have any signs or symptoms of non-neovascular AMD or neovascular AMD. Beyond that, there is nothing else that separates out men and women in this category. We try to make sure that we evaluate each and every patient to determine if they have any of these components because neovascular AMD is treatable and even non-neovascular AMD is treatable to some extent before atrophy or other disease states set in.
Healio: What are the unmet needs of patients at risk for AMD or with existing AMD?
Singh: First and foremost, the unmet needs center around maintenance and monitoring of the disease. These require an OCT and a dilated eye exam, both of which require an office-based appointment.
Second, there is the question of how to prevent the progression to neovascular AMD. There have been a variety of studies that have looked at this. More recently, the PRO-CON study looked at giving patients an anti-VEGF as prophylaxis to prevent progression and found no benefit.
Finally, in the realm of progression to disease and active disease, making sure that patients follow up and that they receive their regular treatments is the best recipe for success with regard to neovascular AMD outcomes. The patient who comes back often and continually will maintain or improve their vision over time. Those who do not come back or discontinue visits will see a significant detrimental decline in their vision.
Healio: What would you like to see studied further?
Singh: I would like to learn more about how remote monitoring is going to be beneficial to patients, so it would be nice to have studies comparing it with the ability to see a practitioner in person on a regular basis in order to get that evaluation done.
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