WELLNESS

PRACTICE WELLNESS

FOLLOW THESE STEPS TO MAKE PREVENTION A FOCUS

Mary E. Boname, O.D., M.S., F.A.A.O., Skillman, N.J.

FOR CENTURIES now, health care in the U.S. has been directed at treating patients who have developed a chronic medical condition. In many cases, these patients are started on a regimen of prescription medications that they will remain on for the rest of their lives. With the advent of the Affordable Care Act — and spiraling health care costs — we look to a different approach: preventative care.

With this in mind, I morphed my practice into one focused on prevention. I prescribe medical and optical solutions alongside recommendations for preventative health measures, such as nutrition, exercise, sleep and relaxation, to provide patients with the best possible care of their ocular and systemic health. I also utilize cutting-edge research in genetics and psychology to inform my patients.

Here I discuss how to focus on preventative care in your practice.

SCRUTINIZE THE PATIENT’S HISTORY

Take a strong look at each patient’s ocular and medical history. Identify modifiable and genetic risk factors for both ocular and systemic disease. Examples of modifiable risk factors include obesity and reduced physical activity, which leads to an increased susceptibility to Type 2 diabetes. For genetic factors, DNA tests are available to determine the risk of developing ocular diseases, such as AMD and glaucoma.

When discussing DNA tests with patients, I utilize my own experiences. I discuss how I have benefited from such testing and learned that I have a gene snip called methylene tetrtahydrofolate reductase (MTHFR). It has been associated with an increased risk of myocardial infraction, stroke and several types of cancer, to name a few. Taking the test was my first step in taking control of my total health, and it could be for them as well.

LOOK FOR EARLY PATHOLOGY

After scrutinizing the patient’s history, perform an exam for any health red flags. These could include drusen in patients at risk for AMD and nerve fiber layer dropout in patients who are glaucoma suspects. Dry eye disease is also something to watch in patients with diabetes mellitus and rheumatoid arthritis, as it can have more devastating consequences.

DEVELOP THE PLAN

You will then monitor these red flags to track and, where necessary, combat disease progression. For example, in patients who are at risk for AMD, I elect to see them annually for an eye exam and to do a baseline OCT of the macula. I also discuss the role of carotenoids in protecting the macula from oxidative stress. While I recommend increasing carotenoid intake with leafy greens, most people do not take in a beneficial amount from diet alone, so I prescribe a supplement containing the carotenoids meso-zeaxanthin, lutein and zeaxanthin. These patients’ prescriptions also include blue light protection lenses, to filter out the blue radiation that is damaging to the macula, and UV-filtering sunglasses to prevent damage from ultraviolet radiation to the macula.

In those with a family history of glaucoma, I educate them on the risks of asymptomatic sight loss, and the need for annual threshold visual field tests and OCT testing. In addition, I discuss the option of having a cheek swab genetic test to determine their risk of developing the disease. I also talk about the link between sleep apnea, obesity, heart disease and glaucoma. Further, all my female patients with a history of migraines are educated about the increased risk for normal tension glaucoma and the need for more frequent follow-up visits vs. an annual eye examination.

Also have a conversation with patients about emotional health. I begin by asking what they do to stay mentally and physically fit and relax. (A good social history is just as important as a good medical and ocular history.) I then discuss other ways to alleviate stress and get better rest. I use myself as an example: I do a BarreAmped workout (isolating muscle groups and fatiguing them until you shake). I also recently started meditating and I enjoy yoga. I discuss the positive effects that these activities have on my health and encourage patients to find activities that will achieve similar results. If time permits, I may do an Internet search for books or materials to recommend. Patients will appreciate your investment in their overall wellbeing and their lives in general.

One study found that behavioral interventions to reduce emotional reactivity may be of benefit in chronic inflammatory conditions. This study was done by comparing an eight-week Mindfulness Based Stress Reduction (MBSR) intervention with a well-matched active control intervention, the Health Enhancement Program (HEP), in ability to reduce psychological stress and experimentally induced inflammation. The Trier Social Stress Test was used to induce psychological stress and inflammation was produced using a topical application of capsaicin cream to forearmed skin. Immune and endocrine measures of inflammation were collected before and after MBSR training.

EPIGENETICS & GLAUCOMA

O.D.s NEED to stay abreast of new studies, such as “The role of epigenetics in the fibrotic processes associated with glaucoma” from the “Journal of Ophthalmology,” in order to best guide and treat patients. Of the 60 million worldwide with glaucoma, some patients show disease progression despite well-controlled IOP. Another possible therapeutic target is the extracellular matrix changes in glaucoma.

Epigenetics is heritable changes in gene function that occur without a change in nucleotide sequence. DNA methylation is associated with transcriptional silencing. Low levels of DNA methylation at gene promoters have been proposed to generate active genes through increased binding of transcription factors and elevated DNA methylation at promoters may inhibit gene expression.

Epigenetic mechanisms have been shown to drive renal and pulmonary fibrosis by upregulating profibrotic factors. Hypoxia alters epigenetic mechanisms through regulating the cell’s response, and there is a hypoxic environment in the lamina cribrosa and trabecular meshwork in glaucoma. Scientific research suggests that a hypoxic environment in glaucoma may induce aberrant epigenetic mechanisms that contribute to disease fibrosis. These also may prove to be therapeutic targets in glaucoma.

Results show those randomized to MBSR and HEP training had comparable post-training stress-evoked cortisol responses, as well as equivalent reductions in self-reported psychological distress and physical symptoms. However, MBSR training resulted in a significantly smaller post-stress inflammatory response compared to HEP, despite equal levels of stress hormones, according to the study from “A comparison of mindfulness-based stress reduction and an active control in modulation of neurogenic inflammation” published in “Brain, Behavior, and Immunity.”

MAKE THE PATIENT YOUR TEAMMATE

Whether I am prescribing ophthalmic medication or a regimen of nutritional supplements, I always say: “no matter what I prescribe for you, it won’t be effective if you don’t use it.” I educate my patients on being my teammate in taking the best possible care of their ocular, visual and systemic health. The foundation of good optometric care (and health care) is for each patient to take personal responsibility for his or her own health.

BRINGING IT ALL TOGETHER

I am a strong proponent of leading by example. I am setting a course for myself that I share with my patients, and it can be customized to each patient based on his or her ocular and systemic health histories. My goal is to partner with them and help them to take the best possible care of their eyes, their health and to lead productive, fulfilling lives for as long as possible. OM

DR. MARY E. BONAME, O.D., M.S., F.A.A.O., is the owner of Montgomery Eye Care, located in Skillman, N.J. She is CEO of Ivy Eye Talk LLC, where she educates patients about isotonic nutritional supplements and genetic testing to help create a personalized plan for their ocular and systemic wellness. Dr. Boname has been a peer educator for Alcon, Abbott Medical Optics, Bausch + Lomb, Inspire Pharmaceuticals and MacuHealth. Visit tinyurl.com/OMcomment to comment.