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Controlling the Modifiable AMD Risk Factors

Prevent or slow your patients’ AMD progression by educating on the importance of preventative care.

MARY BONAME, O.D., M.S., F.A.A.O., SKILLMAN, N.J.

With an aging patient population, AMD has become one of the greatest threats to public health in the U.S., and we, as optometrists, are in position to rise to the occasion. We must educate the general public that routine comprehensive eye care and preventative care can help us to identify patients’ AMD risk factors and, thus, minimize the number of patients who progress to wet AMD and lose their ability to live independently. (See “AMD Overview,” page 35.)

Here, I describe the modifiable AMD risk factors and how you can educate your patients to improve their long-term visual outlook and have a significant impact on their visual health.

Smoking

AMD appears to be related to the efficiency of the circulatory system, which can be negatively affected by smoking. Also, tobacco seems to interfere with the absorption of lutein. In addition, the risk for AMD is greater with increasing number of cigarettes smoked per day, according to multiple studies on AMD. This risk increases even more based on cumulative smoking through a patient’s lifetime (mean number of packs smoked per day multiplied by duration of smoking in years).

When I talk to my patients about smoking, I preface the conversation by saying, “I have some social history questions to ask, and I do so to help protect the health of your eyes as well as your general health. I am not asking from a place of judgment.”

In addition to stressing the importance of quitting, I tell patients who are smokers that I am a strong proponent of nutritional supplements that contain the carotenoids found in the macula: meso-zeaxanthin, lutein and zeaxanthin. These carotenoids are crucial in protecting the macula from the damaging effects of reactive oxygen species. While I recommend these supplements to all patients, I stress their importance even more to smokers, in addition to those who have other modifiable risk factors in this article.

Drinking alcohol

Excessive drinking compromises the body’s immune system. Free radicals, or natural by-products of metabolic processes that can also be formed when direct sunlight passes through the lens, damage the macula and cannot be removed from the eyes without a healthy immune system.

As with smoking, I emphasize to patients that I am not judging when I ask them about their drinking habits. I explain alcohol’s impact on their systemic health (risk for diabetes and liver damage) in addition to AMD.

My patients are very candid, and some tell me immediately that they are recovering alcoholics and attend AA meetings. They often understand they have to be vigilant and maintain a support system to help control their urge to drink. Also, as some patients express the need to relax with a cocktail, I recommend they take walks or exercise to alleviate their stress.

Poor nutrition/obesity

Processed foods, such as commercial baked goods, contain saturated fat, which has been shown to contribute to an increased risk for AMD. Also, those who are obese or have elevated cholesterol have a higher incidence of AMD.

Educate patients to exercise at least three days a week and eat five to nine servings a day of fruits and vegetables, as they provide antioxidants that are protective for AMD. In particular, dark green and leafy vegetables, such as spinach, kale, mustard greens and collard greens, contain high levels of lutein. Also, these antioxidants are present in fruits and vegetables with bright color, such as red grapes, peppers, oranges, cantaloupes and mangos. In addition, I recommend eating fish, such as wild salmon, that contain omega-3, a critical nutrient for the eyes as well as the heart.

I tell patients who have poor nutrition or are obese, “The best way to preserve sight is to exercise preventative medicine: Get plenty of rest so your immune system can recharge itself, eat nourishing meals so your body has the nutrients it requires to effectively deal with free radicals, and consider a vitamin supplement that contains three critical nutrients: meso-zeaxanthin, zeaxanthin and lutein.”

Medication

Patients may be able to reduce their dosage of medications that can damage vision and cause retinal toxicity, which results in AMD-like symptoms. For example, while some medications, such as the arthritis medication hydroxychloroquine sulfate (Plaquenil, Sanofi-Aventis), may not be modifiable, those who take blood pressure medication may be able to improve their diets and exercise habits to minimize their dosage — a higher dose taken for a long time leads to a greater chance of retinal toxicity.

We can’t predict which patients will develop retinal toxicity, but ask about their medications, and take note of the following high-risk characteristics:

▸ Daily doses > 400mg or a total cumulative dose of all medications > 1000mg.

▸ Medication used longer than five years.

▸ Concomitant renal or liver disease.

▸ Underlying retinal disease or maculopathy.

▸ Older than 60 years of age.

Many medications are metabolized in the liver, so I warn against drinking alcohol with them and explain the risk for toxicity due to the drugs not being properly metabolized.

Exposure to UV/blue light

Ultraviolet (UV) and blue light can damage the retina and may increase the risk of developing AMD, so patients must take steps to avoid harmful UV light. I tell patients that high energy-efficient light bulbs and back-lit electronic devices, such as smart phones, tablets and televisions, emit blue-light radiation. I prescribe blue light-protection lenses for patients who experience above-average blue light exposure, such as those who work at computers, and also recommend they turn down the brightness on their devices.

A growing concern

Just as the 20th century was defined by youth, the 21st will be defined by aging.

You can help prevent vision loss and impairment in your aging patient base by educating them about modifiable AMD risk factors. OM

Dr. Boname is in private practice at Montgomery Eye Care. She received her Doctorate in Optometry at The New England College of Optometry. She is a member of the Alcon Speaker’s Alliance, a peer educator for Inspire Pharmaceuticals and has held roundtable discussions on behalf of Abbott Medical Optics. E-mail her at mboname@mecnj.com, or send comments to optometricmanagement@gmail.com.