Transcript Macular Pigment Optical Density

Macular Degeneration
(AMD)
Abbey Hoffman, OD
South Grove Eye Care
Macular
Degeneration
Macular degeneration is the leading cause
of severe vision loss in people over age 60.
It occurs when the small central portion of
the retina, known as the macula,
deteriorates. The retina is the light-sensing
nerve tissue at the back of the eye.
Normal eye
View through pupil to normal retina
Dry Macular Degeneration
Dry Macular Degeneration
Dry AMD is most common type of
macular degeneration and affects 90%
of the people who have the condition.
In the dry form, there is a breakdown or
thinning of the layer of retinal pigment
epithelial cells (RPE) in the macula.
These RPE cells support the light
sensitive photoreceptor cells that are
so critical to vision.
Dry Macular Degeneration
Drusen are tiny yellow or white deposits
in a layer of the retina called Bruchs
membrane. They are the most common
early sign of dry age-related macular
degeneration. Drusen are made up of
lipids, a type of fatty protein. They may
be the result of a failure of the eye to
dispose of waste products that are
produced when the photoreceptors of
the eye drop off older parts of the cell.
Wet Macular Degeneration
Wet Macular Degeneration
•Wet macular degeneration is the more
advanced type of AMD. Although it affects
only 10-15 percent of those who have the
condition, it accounts for 90 percent of
the severe vision loss caused by macular
degeneration.
Wet Macular Degeneration
• With this type, the membrane underlying the
retina thickens, then breaks. The oxygen
supply to the macula is disrupted and the
body responds by growing new, abnormal
blood vessels. These begin to grow through
the breaks of the membrane behind the retina
towards the macula, often raising the retina.
Wet Macular Degeneration
• To visualize this, imagine the roots of a tree growing and
spreading until they crack and grow through a sidewalk.
Then imagine rainwater seeping up throughout the cracks.
These abnormal blood vessels (the “roots”) tend to be
very fragile. They often grow and leak or bleed, causing
scarring of the macula. This fluid is called exudate and wet
AMD is sometimes called exudative macular
degeneration.
Wet Macular Degeneration
•This damage to the macula results in rapid
central vision loss. Once this vision is
destroyed, it cannot be restored.
However, there are several treatment
options for wet AMD which can be very
effective if applied early.
Stages of AMD
• Early AMD- presence of medium sized drusen
(about the size of a human hair). Typically
does not have any vision loss
• Intermediate AMD-large drusen, pigment
changes in retina or both. Will cause some
vision loss but typically patients will have no
symptoms.
Late AMD
• Late Dry AMD(geographic atrophy)- longterm
gradual breakdown of special light sensitive
cell in macula and their supporting cells
• Wet AMD (neovascular AMD)- results from
abnormal blood vessel growth underneath the
retina.
• Both types of Late AMD will result in vision
loss
Example of Vision with AMD
How Common is AMD?
AMD occurs in about 10% of people over age 50.
The rate rises to about 33% over age 75.
Annually 1.2 million people lose some of their central
vision to AMD and about 200,000 lose their central
vision entirely in one or both eyes.
Risk of Dry Going to Wet AMD
• Not everyone with early AMD will develop late
AMD.
• If early AMD is in one eye and none in the
other, 5 % will develop late AMD after 10 yrs.
• If early AMD is in both eyes, about 14% will
develop late AMD in at least one eye after 10
years.
How is AMD detected?
•Regular eye exams that test visual acuity
(how well you see in the distance and
near) and dilation of the pupil that check
the inside health of your eyes.
•Amsler grid- changes to your central
vision may cause the lines to appear
missing or wavy.
How is AMD detected?
Optical Coherence Tomography (OCT)- A machine
that uses light waves to create a very detailed 3-D
image of the eye. It can map the severity of the
AMD.
Fluorescein Angiogram- Fluorescein dye is injected
into a vein in the arm. Pictures are taken as the dye
passes through the eye vessels. Leaking blood vessels
are easily visualized. Not done as commonly now due
to OCT.
Other AMD tests you may hear about
• Macular Pigment Optical Density- this is an
instrument that measures the level of lutein and
zeaxanthin (harmful light protecting pigment in the
macula).
• The common machines you will hear about are
QuantifEye MPSII and Macuscope.
• There is not agreement on use of MPOD machines.
It is not covered by insurance.
Other tests you may hear about
• Preferential Hyperacuity Perimeter (PHP)This is a new approach to find early wet AMD
in patients who already have dry AMD.
• It uses the ability to detect small misalignment
in lines called hyperacuity
• It is known as ForeSee PHP commerically.
• It is not covered by insurance.
Other tests you may hear about
• Genetic testing– commercially available as Macular
Risk and is done using a simple cheek swab. It is
currently not typically done and does not affect
treatment of particular AMD cases.
• The cost of the macula risk genetic test can be from
several hundred dollars to a few thousand dollars
and insurance may not cover the cost of the testing.
Risk Factors for AMD
• Age
• Family History—If a close relative has AMD your risk
rises about 3-4X
• Smoking- Smokers have about 2-3x higher risk than
those who have never smoked
• Uncontrolled Hypertension and Cholesterol-have
about 1.5X increased risk
• Race– Whites have AMD more than races of color
Risk Factors for AMD
• Poor diet
• Sunlight exposure
• Obesity– Obese people have about 2X increase risk
of developing advanced AMD
• http://caseyamdcalc.ohsu.edu/
What Should I Do?
• Have regular eye exams—Early AMD has no
symptoms. Don’t wait until you can’t see to get
your eyes checked.
• Don’t smoke or quit smoking
• Eat a healthy diet
• Wear sunglasses (maybe even consider special Antiglare coatings for indoor use)
• Take a good Multivitamin or special Eye Vitamin
What Should I Do?
• Stay active– A British Journal of
Ophthalmology found active people(walked at
least 2 miles a day 3X per week) were 70% less
likely to have AMD during a 15 year follow up.
• Control Blood Pressure and Cholesterol
What Should I Eat?
• A ½ cup of spinach or kale (raw) 3x per week has
been shown to decrease risk of AMD
• Eat green leafy vegetables such as kale, spinach,
turnip greens,
romaine lettuce, broccoli, peas, Brussel sprouts
• People who eat fish 3x per week in one study were
found to have about a 50% lower risk of AMD than
those who never ate or ate very little fish
What Should I Eat?
• Eat a handful of raw unsalted nuts per week, such as
almonds, walnuts, Brazil nuts, pecans, pine nuts,
pistachios.
• Carrots are a good source of Vitamin A but they are not as
beneficial to eye health as green leafy vegetables.
• Avoid eating processed or high glycemic index foods like
white bread, pretzels, white potatoes. Foods that have
refined carbohydrates have increased risks of AMD.
Nutrient Content of Foods
Lutein and Zeaxanthin- 10mg/2mg per day in AREDS2
1/2cup Kale contains 11.9mg, 1 cup spinach raw 3.7mg, 1/2 cup Brussel sprouts
1.2 mg
Omega 3 Fatty Acids- not in AREDS2 but found in fish and thought to be healthy in
about 1000mg per day dosing
3.5 oz of salmon contains about 1.8 g
3.5 oz of tuna contains about 0.2g
Vitamin C- 500mg per day in AREDS2 is suggested
1 medium orange has 69mg
Vitamin E-400 IU per day in AREDS2 formula(360mg)
20 almonds is about 30g contains about 7.8mg
Zinc – 80mg in AREDS2
½ cup rice bran contains 3.5mg
What is AREDS?
• Age Related Eye Disease Study- the initial study was
completed in 2001 and found up to a 25% reduced
risk of AMD progressing to an advanced stage after
taking an antioxidant vitamin formula of Vit C
500mg, Vit E 400 IU, beta carotene 15 mg, zinc
80mg, copper 2 mg.
• It had no effect on those with no AMD or early
AMD.
AREDS 2 Supplement
• Based on success of AREDS1, AREDS2 began in 2006 and
results released in May 2013. It is now the supplement
most people should consider.
• It eliminated beta-carotene and replaced with
lutein/zeaxanthin and lowered the zinc dosage to increase
safety.
• It showed a 10-25% reduction in risk of AMD progression.
Those with the lowest intake of foods containing healthy
carotenoids had the greatest benefits.
A bit more on Supplements
• No supplement is better than eating a healthy diet
• Supplements are not regulated by the FDA. This
means quality and purity vary.
• $27 Billion is spent annually on supplements so
there is a lot of interest in this area.
• Before beginning any supplements or vitamins you
should consult your physician. Especially if you take
blood thinners, or are pregnant or nursing.
What about Sunglasses?
• To provide adequate protection for your eyes, sunglasses
should:
• block out 99 to 100 percent of both UV-A and UV-B
radiation;
• screen out 75 to 90 percent of visible light;
• be perfectly matched in color and free of distortion and
imperfection; and
• have lenses that are gray for proper color recognition.
Blue Light
• Blue light is in the visible light spectrum and
contains the most energy.
• Blue light is blocked best by amber tinted lenses.
• Blue light reaches the retina and may cause damage
that leads to AMD.
• Not all blue light is bad. Some blue light helps us
regulate our sleep patterns.
Blue Light
• About 25% of sunlight is in the blue light wavelength.
• We get exposed to blue light indoors!
• About 30% of light from LED or CFL bulbs is harmful blue
light
• Looking at LED screens exposes us to blue light
• By 2020 90% of indoor light will be from sources that emit
harmful blue light
Blue Light
• There is certainty that blue light reaches the retina.
However, no large population studies have shown
with certainty that blue light exposure increases the
rate of AMD
• The bottom line is that if you spend a lot of time
looking at screens and you have high risk for AMD,
you should consider with your doctor a blue light
anti-reflective coating on your glasses.
Blue Light
• There are now lens coatings available that can block UV
and the harmful range of blue light
• Some patients feel these coatings make looking at
computer screens more comfortable
• Keep in mind, these coatings can sometimes make things
to appear to have a bit of a yellow tint so you may or may
not like how these coatings look
Brand Names to look for SeeCoat Blue, Crizal Prevencia,
iBluCoat, Recharge, Unity BluTech
I have early Dry AMD, now what?
• You could consider taking vitamin supplements following
the guidelines set by the AREDS 2 study. However, these
studies have only proven to slow progression in Moderate
and Advanced AMD. Taking an AREDS 2 supplement has
not been shown to benefit patients with early AMD.
Studies take a long time complete and vitamins are likely
beneficial but I cannot tell you with certainty that you
should take eye vitamins in this case.
I have early Dry AMD, now what?
• You need to control your personal risk factors
• Eat a better diet/ consider a good multivitamin like
Centrum Silver
• Get exercise
• Don’t smoke!
• Keep your blood pressure and cholesterol under
control
• Wear sunglasses/Use blue blocking coatings
I have Moderate AMD, now what?
• You need to consider taking an AREDS2 formulation.
Please discuss with your PCP before starting any
supplements but in most cases is very safe.
• AREDS 2 contains 500mg Vit C, 400 IU Vit E, 80 mg Zinc,
2mg Copper, 10 mg Lutein, 2 mg Zeaxanthin.
• The AREDS studies have shown those with moderate to
advance AMD have up to a 25% reduction in progression
to advanced AMD.
I have Moderate AMD, now what?
• You need to control your personal risk factors
• Eat a good diet
• Get exercise
• Control your blood pressure and cholesterol
• Wear sunglasses/use blue blocking coatings
I have advanced dry AMD, what should I do?
• Take an AREDS 2 supplement
• Control your personal risk factors
• Wear sunglasses/use blue blocking coatings
• Check your Amsler Grid at home daily
• Consider a low vision evaluation
• Low vision experts can show you how to better cope with
your vision and how to use aids such as magnifiers or
computer to perform everyday tasks.
Treatments for Wet AMD
• This is the type that causes the most vision loss. It needs
to be caught early and can sometimes be noticed at home
with AG changes
• Most common treatment today is injection of anti-VEGF
medications. VEGF is a protein that promotes the growth
of abnormal blood vessels. These medications block this
growth. The most common are Avastin and Lucentis.
• Often several monthly injections are needed
Anti-VEGF Medications
• Lucentis (ranibizumab)-gold standard, 95% patients during
phaseIII trials maintained vision. 40% actually improved
up to 3 lines on eye chart. 40% were 20/40 or better at
one year. Very costly medication
• Avastin (bevacizumab) was invented to treat colon cancer.
It is longer version of same molecule as Lucentis. It is was
used off-label to treat AMD. Proven to be almost exactly
as effective and safe as Lucentis and much cheaper.
Less Common Treatments for Wet AMD
• Eyelea(aflibercept)-another Anti-VEGF injectable
medication released with the idea it would need to be
injected less often. However, Lucentis and Avastin are
now used on similar treatment schedules. Usu. 1/month
for 3 months and then every 8 weeks.
• Photo Dynamic Therapy (PDT)- A drug (verteporfin) is
injected into your veins and then activated with a special
cold laser inside the eye to close off abnormal vessels.
Usually if used done in combo with anti-VEGF injections.
Treatments of the Future
• New medications that block PDGF (platelet derived
growth factor) will be combined with existing medications
such as Lucentis or Avastin for better visual outcomes.
• Fovista (anti-PDGF) is undergoing study and appears to
have good results so far.
• There are eye drops (MacuCLEAR) undergoing study for
dry AMD as well to try to improve blood flow to macula.
Very early in FDA trials.
Eye Health Checklist Summary
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Get regular eye exams
Don’t smoke
Keep a healthy lifestyle
Control your weight, blood pressure, and cholesterol
Eat fish 2-3 times per week, green leafy vegetables, fresh fruit, and a handful
of nuts per week
Avoid high glycemic foods
In consultation with your doctor, consider taking an AREDS2 supplement
Use an Amsler Grid daily to check your vision
Wear sunglasses, consider blue blocking coating
Questions?
Thank you!
• You can reach me at South Grove Eye Care 317-5353935
• SouthGroveEyeCare.com
• [email protected]