AS THE AREDS1 and AREDS2 show that the addition of an oral, nutritional supplementation formula yields reductions in the risk of developing late-stage AMD, optometrists find it beneficial to prescribe vitamins and supplements to ward off worsening disease.¹ Here, eye care professionals discuss the role of supplementation in their treatment of AMD.

PART OF THE TREATMENT PROTOCOL

“AMD patients with early or intermediate disease should be taking supplementation,” says Sherrol Reynolds O.D., F.A.A.O., an associate professor at Nova Southeastern University and columnist of Optometric Management’s “Retina.” “I also recommend supplements [for] patients with advanced disease.”

“Patients with early disease benefit from supplementation as studies, including AREDS1 and 2, showed a lower risk of progressing to late stage macular degeneration,” says Dr. Reynolds.

A back-to-basics approach that features healthy diet and exercise in an attempt to prevent a condition, like AMD, is what is first needed, with supplementation playing an adjunctive function, stresses Joseph J. Pizzimenti, O.D., F.A.A.O., faculty member at the Rosenberg School of Optometry at the University of the Incarnate Word, in San Antonio.

“The conversation [with the patient] starts in the optometrist’s office and focuses on food,” says Dr. Pizzimenti. “The discussion should center on diet, lifestyle and filling in any gaps with supplements. Optometrists should be recommending specific products to patients rather than sending them to a pharmacy to pick out [supplements] on their own.”

Whether it be for AMD, dry eye disease or wellness, there are so many ocular supplements out there, with varying ingredients and dosages, so rather than leave it up to the patient to decide which one to take, Dr. Pizzimenti says he prescribes a specific supplement for each patient.

“All ocular nutraceuticals are not created equal, in terms of ingredients and purity,” says Dr. Pizzimenti. “Therefore, the doctor should specify the appropriate supplement for each patient on an individual basis. We prescribe specific treatments for glaucoma and dry eye disease, and we should be doing the same for AMD.”

To increase the likelihood of patients taking the supplements that optometrists prescribe, Dr. Pizzimenti suggests optometrists may make the supplements available within or through their practices. (For more on offering supplements, see http://bit.ly/2uOPBQq .)

Like Dr. Reynolds and Dr. Pizzimenti, Brad Sutton O.D., F.A.A.O., clinical professor at the Indiana University School of Optometry and service chief of the Indianapolis Eye Care Center is on board with his intermediate AMD patients taking supplements.

But, Dr. Sutton says the role of supplementation could be broadened to a prophylactic one in which patients who are at an earlier stage of disease or “at risk” for AMD may obtain value from supplementation.

“No study or science says that taking these [supplements] prophylactically is something that we can prove will be beneficial,” says Dr. Sutton. “But it almost certainly will not hurt [to take supplements], and there is reason to believe [the action] will be positive. [Specifically,] common sense says that it would be helpful to build up levels of carotenoids in the macula.”

COST-EFFECTIVE

There is no doubt that the addition of supplementation to triple therapy (reduced-fluence photodynamic therapy with verteporfin [Visudyne, Bausch + Lomb,] intravitreal bevacizumab [Avastin, Genentech] and intravitreal dexamethasone [Ozurdex, Allergan]) has proven cost-effective in the treatment of AMD, according to Melissa Brown M.D., M.N., M.B.A., C.E.O., of the Center for Value Based Medicine in Hilton Head, S.C., a healthcare economic research organization.

A 24-month triple-blind, randomized clinical trial with 144 participants shows daily supplementation with 20 mg of the carotenoid zeaxanthin added to triple therapy led to 27% of eyes gaining three or more lines of vision vs. 9% of eyes undergoing triple therapy without supplementation (p=0.003).²

“Using zeaxanthin decreases the cost [overall] because you [the patient] end up receiving fewer [anti-VEGF] injections,” says Dr. Brown, an author of the study. “The wet AMD was treated; however, the therapy was also found to delay the conversion of the other eye from dry to wet AMD, which was exciting to see.”

“The results of the study did not indicate that triple therapy should replace VEGF-inhibitor monotherapy as first-line therapy,” explains Dr. Brown. “Nonetheless, the cost of triple therapy with zeaxanthin is similar to that of bevacizumab [Avastin, Genentech] therapy. For the patient, the management of multiple visits and injections cost less with triple therapy and zeaxanthin, because this therapy is given a mean 2.4 times per year, vs. at least five to six injections annually, with theoretically as many as 12 annually, with VEGF-inhibitor monotherapy. Thus, the clinician and patient have another very reasonable choice referent to monotherapy.”

In terms of cost, adding zeaxanthin daily in the trial was extremely cost-effective, estimated at $30 per quality-adjusted life year.

TAKEAWAY

Eye care professionals, agree on the clear value in prescribing eye vitamins for specific types of AMD, and research supports the effectiveness of nutritional supplements. OM

Dr. Pizzimenti has received honoraria and consulting fees from EyePromise, Zeiss, Genentech, and ThromboGenics. Dr. Reynolds and Dr. Sutton had no financial disclosures.

REFERENCES

1. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report No. 8. Archives of Ophthalomology. 2001; 119: 1417-36.
2. Olk RJ, Peralta E, Gierhart DL, Brown MM, Brown GC. Combination Therapy with Dietary Zeaxanthin for Neovascular Age-Related Macular Degeneration. A Randomized Clinical Trial. Journal of Clinical & Experimental Ophthalmology. 2017; 8. DOI: 1000692.