Recommend diet changes, regular vision testing for patients at high risk for AMD

Issue: August 2000

Evaluate lifestyle, diet, sun exposure

Robert Abel Jr., MD: Three major stressors for people’s eyes and overall health include lifestyle (stress, in general), sunlight and inadequate nutrition. Wearing sunglasses with good UV-A and UV-B protection is imperative for all patients in general.

A diet rich in fruits and vegetables has long been known to be ocular-protective. Since the 75th Congress in 1937 declared the Midwest soil to be deficient of some minerals and vitamins, it is important for those older than 50 and those with risk factors to supplement with either a complete program, or at least with an item such as Ocuvite Lutein (Bausch & Lomb Pharmaceuticals, Tampa, Fla.). There is much evidence that lutein has an important role in protecting the macula and increasing contrast sensitivity in senior citizens.

Likewise, the use of DHA, a long-chain polyunsaturated omega 3 fatty acid, is important. DHA comprises 30% of the fat in the brain and up to 60% of the outer portion of the retinal photoreceptors.

Limiting the use of “the five white thieves” — white flour, refined sugar, white rice, salt and lard — as well as the use of artificial sweeteners, is important. In this regard, poor digestion is often a factor and patients should discontinue their dependency on antacids. A 1-month trial on digestive enzymes may resolve their problems with reflux symptoms while supporting their ocular health. Patients should also be encouraged to stop smoking and to drink at least six glasses of water daily.

Review the patient’s systemic diseases and systemic medications. Hypertension should be controlled, but blood pressure should not be too low at night, because nocturnal hypotension may be a factor in decreased perfusion to the brain and eyes. Gingko biloba is a selective cerebrovascular dilator which I encourage in patients with low-tension glaucoma or macular degeneration. An alternative is magnesium, 500 mg, at bedtime, which relieves stress and provides vasodilation.

Lastly, one’s lifestyle must be addressed. People need a positive attitude and should learn relaxation techniques such as deep breathing or meditation. I encourage patients to get enough exercise regularly and evaluate the quality of their sleep. Alcohol should be ingested in moderation and smoking should be discontinued.

Therefore, an overall approach in lifestyle, diet and sun protection is extremely important for those at risk for macular degeneration and for overall health. What is healthy for the eyes is supportive of our bodies.

Robert Abel Jr., MD can be reached at Delaware Ophthalmology Consultants, 3501 Silverside Road – Naamans Building, Wilmington, DE 19810-4910; (302) 479-3937; fax: (302) 477-2650.

Stop smoking, change diet

Leonard V. Messner, OD, FAAO: Age-related macular degeneration (AMD) is the leading cause of vision loss among the elderly in the United States. The most compelling ocular risk factors for exudative AMD are multiple large soft drusen and focal pigmentary changes. Notable non-ocular risk factors include smoking and hypertension. AMD has long been associated with familial pedigrees, and recent work suggests a link between AMD and specific genetic markers.

Historically, treatment for macular degeneration has focused on the ablation of extrafocal choroidal neovascularization (CNV) with direct photocoagulation techniques. The recent development of photodynamic therapy appears encouraging for treating patients with predominantly classic forms of subfoveal CNV. Retinal pigment epithelial transplantation, the development of antiangiogenic agents, retinal translocation and plasma exchange are all under investigation and hold future promise.

While the science of treatment options provides encouragement for patients with manifest disease, very little is known about the pathogenesis of exudative and nonexudative AMD and how to prevent disease development. Laser photocoagulation of soft macular drusen has been shown to promote resolution of individual lesions. However, there is no current proof that photocoagulation of drusen prevents vision loss. Although environmental and nutritional factors have been suggested in the development of AMD, there is little scientific evidence to support specific treatment of preventive protocols.

So where do we go from here? Perhaps it is best to begin with the following accepted assumptions:

Soft drusen, pigment epithelial detachments and focal retinal pigment epithelium (RPE) hyperplasia are significant ocular risk factors in the development of CNV.
Smoking is an established risk factor in the development of AMD.
Familial pedigrees exist for AMD, and several genetic markers have been identified.
Moderate to severe hypertension has been linked to the development of exudative AMD.
Nutritional factors may play a role in the development of AMD in some patients.

Based on these assumptions, the following recommendations are reasonable:

All patients should refrain from smoking.
For patients with a family history of AMD in the absence of ocular risk factors, a diet rich in green leafy vegetables (e.g., spinach, collard greens and kale) is recommended. These patients should also undergo funduscopic evaluation on an annual basis.
For patients with identifiable ocular risk factors (drusen and focal RPE hyperplasia), a diet rich in green leafy vegetables is recommended and additional antioxidant lutein/zeaxanthin-based vitamins may be offered. Home vision testing with an Amsler grid and careful follow-up retinal examination on a 3- to 6-month basis is advised, as over 50% of these individuals will develop CNV within 5 years.
Control of vasculopathic illness, notably hypertension, may be helpful for patients predisposed to exudative maculopathy.
Although there is no compelling evidence supporting the adjunctive use of vitamins, they, nevertheless, appear safe when used judiciously. Currently, I offer vitamin supplements to patients with ocular risk factors on an optional basis.

The Age-Related Eye Disease Study (AREDS) is a long-term, retrospective, multicenter study of the clinical course, natural history and effect of vitamin and mineral supplements on AMD and age-related cataracts. It is hoped that AREDS and other clinical trials will provide additional information on the risk factors and value of vitamin supplements in the management of AMD. Until definitive protocols spawned from clinical trials are established and the pathogenesis of AMD is established, a conservative approach to patients with risk factors is prudent.

Leonard V. Messner, OD, FAAO, can be reached at The Illinois Eye Institute, Illinois College of Optometry, 3241 South Michigan Avenue, Chicago, IL 60616; (312) 949-7108; fax: (312) 949-7389.

Urge patients to test themselves

Bert M. Glaser, MD: The first step to reducing the risk of macular degeneration is to organize and then implement a plan to detect macular degeneration as early as possible. The earlier macular degeneration is detected, the greater the number of treatment options and the greater the chances for successful treatment. I recommend the following early detection plan to my patients. It does not require expensive equipment or complicated procedures, so there is no reason why patients cannot start this immediately.

Check each eye individually. Since the stronger eye will tend to mask the symptoms of the weaker eye, be sure to test each eye individually by actually closing and covering each eye while testing the open eye.
Test daily. Make testing for macular degeneration a part of your daily ritual.
Test both near and far vision. Near vision is best tested using the Amsler grid, because it is a standard tool used by eye care practitioners for macular degeneration. However, if you do not have access to an Amsler grid, you can use a block of print in your newspaper or in a book. Far vision can be tested for distortions by reading cues in your environment. As you drive or walk, or even while waiting for a bus, look at the straight edges of buildings, the edges of road signs or highway light poles for signs of waviness or distortion.
Document your baseline pattern. The first time you use the Amsler grid, note directly on the grid any waviness or distortions you may see. If there is no distortion, be sure to note that, along with the date. This becomes your baseline pattern, which you will use to document any changes from this point forward.
For distant objects, use a plain sheet of paper and a simple sketch to note any distortions along their edges.
Report any changes to your eye doctor immediately.

Bert M. Glaser, MD, a member of the Editorial Board of Primary Care Optometry News, can be reached at Glaser & Murphy, PA, 5530 Wisconsin Ave., Suite 835, Chevy Chase, MD 20815-4401; (301) 986-8747; fax: (301) 986-8944.