WELLNESS

  amd prevention

Preventive Care for AMD

Minimizing modifiable risk factors is key to prevention

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

Genetics and lifestyle play a major role in the development of ocular disease. Therefore, the cornerstone of providing the best possible care to patients is collecting a thorough ocular, medical, social and lifestyle history. As optometric physicians, we have a responsibility to educate our patients on their risks of developing potentially blinding eye diseases, such as AMD. And, as the old adage says, “an ounce of prevention is worth a pound of cure.”

Though we have no control over a patient’s genetic makeup, we can help to prevent or minimize disease progression by focusing on the modifiable risk factors, such as obesity.

Here, I discuss the major modifiable risks factors of AMD and your role in minimizing the occurrence and progression of the disease through patient education and preventive care.

Genetic risk factors

Genetics has an extremely high influence on the risk of developing and progressing to advanced AMD. In fact, studies have shown that genetics plays a major role in AMD development. Therefore, it’s imperative to identify genetic risk factors, such as positive family history, light skin pigmentation, light-colored eyes and gender, as soon as possible.

Genetic testing can help identify genetic risk factors and determine a patient’s lifetime risk of developing AMD or risk of conversion of Dry AMD to Wet AMD.

The testing helps to optimize patient surveillance. It also creates the potential for improved home compliance.

Though genetic risk factors can’t be changed, the results of these tests prompt a discussion of the modifiable risk factors, such as cessation of smoking, change in diet and nutrition, exercise, etc., and help tailor the evaluation and management plan to the patient’s needs.

Modifiable risk factors

In addition to genetic factors, there are a number of non-genetic risk factors that contribute to the likelihood of developing AMD. These include smoking, obesity, high cholesterol, fatty diet, hypertension, sun exposure, and cardiovascular disease, as well as certain medications, whose use may be discontinued as a result of improved health.

Another major risk factor is having a low macular protective pigment (MPP) in the macula. This yellow layer made up of lutein, mesozeaxanthin, and zeaxanthin acts as a shield over the delicate retinal cells that give us sight, filtering out and absorbing cell damaging, high-energy, blue wavelengths of light as well as protecting the central retina from free radicals.

There is a growing and compelling body of evidence from the Macular Pigment Research Group that concludes that an insufficient level of MPP substantially increases the risk for developing AMD by as much as 40%.

Though a low MPP level can be multi-factorial, the most common causes are dietary insufficiency, absorption problems, a lack of ability to convert lutein to mesozeaxanthin, as well as a slow decline in MPP levels that can occur with aging.

Our bodies do not manufacture the three carotenoids found in MPP, so they must be consumed. Lutein and zeaxanthin can be found in foods, including peppers, corn, green leafy vegetables and egg yolks, and can be measured in blood serum. However, research has proven that mesozeaxanthin is created in the center of the macula and is converted from lutein, most likely by an enzyme-mediated process. Studies have shown that by oral supplementation of mesozeaxanthin, it is taken up and accumulated in the central macula.

Patient education

Preventive care is ongoing, and requires a life-long commitment from patients. Therefore, education is critical to improving compliance.

▶ Proper diet and exercise. A healthy, balanced diet coupled with a fitness regimen can help to minimize a number of risk factors, including obesity, poor diet, high cholesterol and hypertension. However, it can be difficult to convey these recommendations to patients.

When it comes to educating my patients about diet and exercise make it a group effort. For example, I tell patients, “I would like you to join me in devising an evaluation, management and treatment plan that is unique to your needs in order to keep you feeling and seeing your best.”

I begin with a thorough social and medical history. For example, I ask what they do to alleviate the stresses of daily life (e.g., a walk after dinner, spin class, etc.). Based on their answer, I provide fitness recommendations that best fit into their lifestyle.

For reluctant patients, I use myself as an example as to how changing or establishing a fitness routine can improve overall health. I explain, “My brother died in a car accident in February 2013, and afterward, I felt so weak emotionally. I decided that if I felt stronger physically, it might help. It has transformed me, and I think it could help you, too.”

▶ Sun exposure. Though the harmful effects UV exposure on the skin is largely understood by the public, its effects on vision is not. O.D.s can help minimize sun exposure risks by prescribing quality sunwear and educating patients on the dangers of overexposure.

A number of lens and frame companies now offer free educational resources to help O.D.s convey this important message, including posters and signs, as well as take-home brochures for patients.

▶ Supplementation. Nutritional supplements are another tool to help achieve and sustain visual, ocular and systemic health. While obtaining patients’ social and medical history, I check to see whether they are taking any nutritional supplements. If they are, I ask what they are taking and from where they purchase their supplements. Our practice now offers a line of nutritional products, and this is an ideal way to introduce them to patients.

For patients who have a low MPP level, supplementation can help aid in increasing MPP levels if a change in diet itself is insufficient.

▶ Smoking. It’s no secret that smoking can have devastating effects on our health, including vision. Though kicking the habit can be extremely difficult, cessation can help to minimize the risk of AMD development.

Physician responsibility

This past March, my mother had an ischemic stroke, and it has been emotionally, physically and financially devastating to my family. Stroke and AMD both have modifiable risk factors, and the key is patient education and a thorough history.

As a result of how my family has been affected, I consider it my responsibility to my patients, as their primary eyecare physician, to help them devise a strategy for optimizing their ocular, visual and systemic health. It benefits my patients, their families and society as a whole. OM

Dr. Boname is in private practice at Montgomery Eye Care. She is a member of the Alcon Speaker’s Alliance, a peer educator for Inspire Pharmaceuticals and has given presentations on Macuhealth. Send comments to optometricmanagement@gmail.com.