Technology for monitoring those at risk for the progression to Wet AMD
Those with age-related AMD are familiar with the Amsler Grid. The grid is a cheap and easy,
method of self monitoring for changes in vision related to the central vision. The grid is usually given to those patients with macular changes by their examining eye doctor. Traditionally, it is a piece of paper or card with the grid printed on it. The grid is held at 10 inches from the eye (the other eye is closed) and observe: are there any broken lines, missing squares, doubling of the lines, wavy lines? The appearance of the grid should be consistent from day to day.
Dry AMD can be a slow, progressive decline in vision. The
intent is to keep the patient alert to the status of their vision. It is very common for people to be unaware of changes to vision, especially for those with dry AMD.
There is another category of AMD referred to as ‘wet’ AMD. This is a much faster, progressing sight-threatening stage of AMD. About 10% to 15% of those with dry AMD will progress to wet AMD. If you have been identified by your eye care doctor as someone who is at risk for wet AMD, there is a technology designed to monitor and identify the onset of wet AMD sooner. The sooner, the better. The sooner treatment has begun, the more sight can be saved.
The devise is called ForeseeHome by Notal Vision. It is a table top monitoring device to be
used daily . The test takes about 3 minutes per eye. The test results are sent to Notal Vision. If changes are detected, Notal Vision notifies you eye care doctor. The plan is for your doctor’s office to call to make an appointment for you to see the doctor. In this way you can receive prompt treatment to preserve your vision.
How to get hooked up with this system:
First, you must be identified by your doctor as being at risk for developing wet AMD. It is also the first step to getting help through insurance to get coverage for the system.
Follow this link for doctors in your area who participate in this Notal Vision program: Find a Doctor
The set up is quite easy. You do not need a computer or even wifi. The Notal company has a phone number to help you get set up.
To see a video on how it works, follow this link: ForeseeHome video
Personalized Medicine, One Size Does Not Fit All
Personalized medicine identifies an individual’s risk for a disease, like macular degeneration, to help health care providers tailor management and treatment to reduce the risk of development and/or progression of the disease. What is good medicine for one person may not be so good for another. Genetic testing is the first step to personalized medicine.
Studies for the treatment of macular degeneration have yeilded a lot of data on AMD and its progression. Chief among the studies was the Age-Related Eye Disease Study (AREDS) which looked at the affect of vitamin supplementation for those at risk for age related macular degeneration (AMD) and those who had varying degrees of AMD. What they found is that some individuals responded well to vitamin supplementation and others did not respond as well. Many groups of researchers have analyzed the data generated by the AREDS and its follow-up study AREDS 2. The predictor of who goes on AMD progression or wet AMD depends on 3 factors:
- Current level of AMD,
- Genetic Factors, and
- Non-genetic factors (environmental, like general health, smokers, age, and education.)
There are presently two genetic tests available for macular degeneration : Macula Test PGX and Vita Test (Artic) . These tests look at genetic markers on known AMD associated genes. The most significant finding, for why some did not do well with the AREDS supplement formula (13%), was a particular genetic profile that resulted in AMD progression, notably because of the zinc in the formula. Genetic testing is a guide for those supplements that best helps reduce the risk for progression of the disease. Armed with this information, an eye doctor would recommend the patient not take the AREDS formula with zinc. This is personalized medicine. Giving everyone the AREDS vitamin supplement does not benefit everyone the same. Other genetic profiles do very well with the supplement.
While routine genetic testing is not the standard of care at this time, it is an option. Without genetic testing, doctors and patients do well by managing treatment and controlling health factors to decrease the progression of AMD. A t this time, both of these genetic tests may not be covered by insurance plans. and must be ordered through your eye care provider.
Trendy diets, which eliminate certain foods, are they healthy for the eyes?
Eating can be enjoyable, least we forget that eating provides us with the necessary vitamins, nutrients and minerals needed to maintain a healthy f body. Deprived of an adequate amount of these basic building blocks results in defects of function, premature aging, disease, and decreased energy reserves. What ever effects the body, has an impact on the eyes.
The three main food groups are proteins, carbohydrates, and fats. Proteins are the building blocks of body tissue, things like muscle, collagen, and epithelium. These tissues are constantly turning over and renewing themselves in a healthy body. Carbohydrates fuel the body, not just for exercise, but also for maintaining cellular function. Excess carbohydrates are stored as fat. Dietary fats are the oils and solid fats found in animal and vegetable sources. They are necessary for nerve development, as a source of stored energy, and help with vitamin absorption. The trendy, healthy diets tend to manipulate the proportions or types of these 3 food groups. The concern is not only the reduction or elimination of one or more of these groups, but the vitamins and minerals that come along with the foods that we eat.
Each of the 3 diets listed here are in effect healthy diets. In no way am I suggesting to avoid a diet that can improve your health. Just be aware that eliminating certain foods from your diet can leave a gap in nutrition. The suggestion is to find alternative sources and/or supplement. Consult your doctor as to the best alternatives.
The Paleo Diet
You can call this the Caveman diet. It eliminates processed foods, that means no wheat, sugar, beans, dairy, or alcohol. It is a diet high in proteins and fats, and lower in carbohydrates. The only source of carbs should be fruits and vegetables. The healthy aspect is high fiber, lots of anti-oxidants, and lower blood sugar levels. A good choice for those who are diabetic or pre-diabetic.
How a Paleo Diet might effect the Eyes
Since there is no dairy consumption there may be a decrease in vitamin D levels. Vitamin D helps to maintain blood vessel integrity. The central vision area , called the macula, receives oxygen and nutrients from a blood vessels that are small and delicate. Impaired vascular health and blood vessel inflammation can increases the risk for macular degeneration. Those on the Paleo diet should consider supplementing with Vitamin D.
Vegetarian and Vegan Diets
The vegetarian/vegan diet s are actually a broad catagory of specialized diets. Vegetarians usually will not eat any animal flesh, but there are some who eat fish. Within this category there are those who will not eat dairy and/or eggs. Vegans are the strictest category that eliminates any animal products. The benefit of vegetarian diets is lower body mass and cholesterol levels, meaning lower rates of cardiovascular disease and diabetes. Both of these benefits are good for the eyes.
How a Vegetarian Diet may Effect the Eyes
Most vegetarians I have met are usually aware of the nutrition deficiencies of their dietary choice. There are many nutrients and vitamins found in animal products: protein, iron, zinc, calcium, vitamin D, riboflavin, vitamin B12, vitamin A, omega-3 and iodine. Each one of these plays an important role in our general health, and therefore our eye health. Deficiencies can result in night blindness, vascular insufficiency, dry eyes, inflammation, and nerve damage. Since this is the most restrictive of diets, a vegetarian must be informed and aware of their diet deficiencies. They must be careful to maintain a balance of alternative food sources and add supplements to their diet.
Taking on a gluten-free diet is not usually a choice. Commonly individuals find that by eliminating gluten or wheat products from their diet, they enjoy feeling better. There are actually 3 categories of individuals who have a negative response to gluten or wheat proteins: non-celiac gluten sensitivity, wheat allergies, and Celiac disease. The symptoms associated with all three of these forms of gluten sensitivity are similar: bloating, diarrhea, headache, fatigue, generalized joint and muscle pain, and ‘brain fog.’ Celiac disease differs because it is an autoimmune disease (meaning it is genetic, not acquired) that can result in damage to the gastrointestinal tract. A damaged GI tract results in poor absorption of nutrients and vitamins. These deficiencies can result in weight loss and other diseases, like osteoporosis, skin disorders, and neurological disorders.
How a Gluten-free Diet can Affect the Eyes
Different from the other healthy diets, eliminating gluten is the only treatment for the signs and symptoms of gluten sensitivity. Those who have Celiac Disease and do not eliminate gluten are in for more health and eye related problems than those with non-Celiac gluten sensitivity and wheat sensitivity. The mal-absorption of nutrients and the deficiency of anti-oxidants can result in cataracts, dry eyes, retinopathy, and night blindness for those with Celiac disease.
As a side note to those with gluten sensitivity and wheat allergies, some lotions and makeup products have wheat in them, which can result in eye irritation and eczema when appplies to the skin and eye area. .
December 2016 The on-line British Journal of Ophthalmology published a report indicating that “Drinking a cup of hot tea at least once a day may be linked to a significantly lower risk of developing the serious eye condition, glaucoma.” The investigators looked an an American study which yearly, surveys the lifestyle and health status of 10,000 Americans, by means of both physical exams and interviewing.
The researchers looked at the subjects consumption of coffee, tea, and soft drinks, both with caffeine and without caffeine. After sorting through and teasing out the data (I won’t bore you with the numbers here), the investigators determined that the drinking of a cup of hot tea with caffeine daily reduced the risk of developing glaucoma by 74%. In health research 74% is a BIG number. An almost Too-Good-to-be-True number.
So what is it? Why would the caffeinated tea reduce the risk, but not the caffeine in coffee or soda? For that matter, de-caffeinated tea was not a factor in reducing the risk, at least not in this study. The American survey did not delve into types of tea (green tea, black tea,, Oolong tea, Lipton tea), brewing times, size of the cup, etc. The information was general: one cup (or more) daily.
Glaucoma is a progressive, sight threatening eye disease. The common understanding is that it is a disease of high eye pressure, that damages the light sensing neurons of the retina of the eye. The progressive damage to these nerves results in nerve cell death, and subsequent loss in vision. Most therapies are centered on controlling the pressure inside of the eye. But doctors are finding that these therapies are sometimes not enough. Medical research is focusing on other factors that contribute to the progression of glaucoma.
So that brings us back to the role that hot tea may play in reducing the risk of glaucoma. The questionable aspect is the caffeine. Other research has shown that the eye pressure can go up, which is undesirable, when caffeine, in the form of coffee, in ingested. (JGlaucoma) Tea has other beneficial factors, such as antioxidants, anti-inflammatory, and neuro-protective substances. These factors are also essential for good general health. They have been studied as an important nutritional component for heart and vascular health, diabetic control, and cancer prevention. That which is good for the body is good for the eyes.
The researchers conclude that more research needs to be done to sort out the effects of tea on the risk for the development of glaucoma.
See a review of the article by the British medical Journal
What is it, and do I need it?
The Age-Related Eye Disease Study 2 (AREDS2) was a 5 year study published in 2013. Notably, in this second study, was the addition of two carotenoids as part of the supplement group. The carotenoids are lutein and zeaxanthin. The conclusion of the study was that these two carotenoids helped limit the progression of AMD. Lutein and zeaxanthin are concentrated in the macula of the retina where they provide protection, by the absorption of light and anti-oxidant activity, and thereby aid in the function of the macula.
Studies have shown that it is not just lutein and zeaxanthin that provide support to the retina, but there is a third carotenoid, meso-zeaxanthin that needs to be present for optimum anti-oxidant effect.
Scientists indicate that meso-zeaxanthin is made from lutein. The question arises; have you ingested enough lutein and is it converted to the meso-zeaxanthin form in sufficient amounts to make enough macular pigment to provide protection to the macula?
Although it is thought that some of the meso-zeaxanthin is derived from lutein, the rest needs to be derived from foods. Food sources are fruits, vegetables (green and yellow), whole grains, egg yolks, and fatty fish (Rainbow trout and salmon, especially the skin). We can never be really sure how much of the vital carotenoids we are getting, even from what we think is a nutritious diet. In an age where our foods are produced by farm “factories” and may be genetically modified, the nutritional value may not be what we expect. That is where supplementation becomes important for those with critical needs to maintain ocular and general health. Supplementing the diet directly with MZ (safely) can prevent the macula from becoming deficient.
Biochemistry is complicated. The AREDS2 found that the beta-carotene had the capability of competing with, and therefore decreasing the absorption of lutein, zeaxanthin, and meso-zeaxanthin. So do not take them together. (Note; AREDS supplement formula has beta-carotene, whereas AREDS2 does not have beta-carotene, but does have lutein and zeaxanthin).
Studies have shown that there is a drop in macular pigment decades before the onset of macular degeneration. There is a bonus to supplementing with the carotenoids; multiple studies have found that test subjects who supplemented with carotenoids not only increased macular pigment, but also experienced improved cognitive function. Even young college students in one study benefited from carotenoid supplements. The trend is that eye doctors are now recommending to their patients who have macular degeneration and those at risk for developing MD, supplements which include lutein, zeaxanthin, and meso-zeaxanthin.
Be aware, when shopping for eye vitamins, the most popular AREDS and AREDS2 formulass do not include meso-zeaxanthin.
We are living longer than our ancestors did less than one hundred years ago. Diseases associated with old age in the past were rare, like cognitive impairments, cardiovascular disease, and some types of cancer, but are now more common in an aging population. It can also be said that macular degeneration is on the rise because of the increase number of those living to be older.
It is not known yet how the eyes of the younger generation will fair after decades of chronic blue light exposure emitted from technology. Medical professionals question their risk for retinal damage and macular degeneration.
So as the population ages, what can be done to decrease the risk for age-related eye diseases? What can the individual do to help themselves to maintain good ocular health?
“Food be thy medicine and medicine be thy food.” Hippocrates
Ideally, our doctors would like to know that their patients are eating healthy and nutritious foods for both ocular and general medical health. What the famous AREDS (age-related eye disease study) studies showed us is that nutrition makes a difference. In the case of this study, the improvements were modest but improvements nonetheless.
Eating healthful foods with adequate
nutritional proportions is not always easy It is the rare individual who spends time evaluating the quality and nutritional benefits of the foods they eat each day. What we eat is limited by time of year, geography, preferences, and availability. That is where supplements come in. Not everyone eats fish (for omega 3s) or likes leafy green vegetables. What you need to do is to look at what may be missing in your diet. Talk to a dietitian or a naturopath.
Adequate nutrition with supplementation serves us 3 ways:
- optimize your vision and physical health,
- disease prevention, and
- reduce progression of macular disease.
The concept of movement as exercise is nothing new. Many athletic types have made lots of money showing us how to exercise. TV doctors and talk show hosts all expound on the benefits of exercise. It does make a difference both for eye health and general health. Many health problems such as high blood pressure, diabetes, and high cholesterol are linked to eye disease. What is good for the body is good for the eyes.
Here is how it helps the eyes.
Exercise increases blood flow, resulting in more blood perfusion to the eye. This can help reduce the risk for glaucoma and increase oxygen and nutrients to a macula which may be degenerating. Those suffering from diabetes are encouraged to exercise to control blood sugar, which in turn helps to reduce the risk for diabetic retinopathy.
Here we go…another reason to stop smoking. Quitting smoking reduces your risk for some eye diseases. Those who smoke are more likely to develop cataracts at an earlier age. It is known that smoking effects blood vessel function, and anything that effects blood flow will impact the very tiny blood vessels that feed the very sensitive macula. Smoking increases the risk of macular degeneration.
We apply onscreen lotions with SPF (sun protection factors) to prevent sunburns to the skin. Think of sunglasses as SPF for the eyes. Good quality sunglass lenses will protect against 100% of the tissue damaging ultra violet rays. Bigger lenses are better, not only to protect the lens and retina of the eye, but also protects the delicate tissues around the eyes.
Studies have shown that chronic, long-term UV light exposure can cause early
onset of cataracts and macular degeneration later in life. Exposure of the conjunctiva (whites of the eyes)and eyelids can result in growths and worst yet…cancers.
The Blue Light Hazard
Both young and old who use technology chronically for long periods of time, as many of us do, need to be aware of the potential for eye damage due to exposure to blue light. This is not the ultra violet invisible ‘light’, it is the high energy visible blue light. Eye doctors are concerned that excessive exposure over an extensive period of time to high energy blue light will cause retinal degeneration.
Consider reducing time spent on digital devices. For those who need to , there are computer screen filters which can be purchased to reduce blue light. Eye glass lenses are made, which filter out specific wavelengths of blue light, thought to be the most damaging. You would need to ask your eye doctor or optician for these specialty lenses.
Finally, there is an app for that! Type in to your browser or app store:. blue light filter for…Apple, Windows, Android, Mac, Chrome, etc. As a bonus, blue light filters can also help with computer eyestrain and difficulty getting to sleep after an extensive period of computer viewing in the evening.
Just a few notes about watching a solar eclipse. A patient called me a few days ago looking for solar eclipse glasses. In my mind it is never a good idea to look in the direction of the sun. I do realize, however, that there are a lot of people who want the experience of seeing a solar eclipse since it is so rare.
There is eye pathology associated with sun gazing called solar retinopathy. This damage is caused by high intensity light exposure. Retinopathy is damage to the very sensitive light detecting neurons in the back of the eye, which are responsible for vision. While solar retinopathy will not result in total vision loss, it is damage to the macula, which is the area of our most critical and detained vision.
Looking at the sun, if inadequately protected, can result in solar retinal damage in 30 seconds or less. Sunlight is not only a source of high intensity UVA and UVB wavelengths, but also radiates other potentially damaging wavelengths of light, such as Infrared and near infrared. For this reason, regular UV 400 protective sunglasses, no matter how dark, are not enough.
Symptoms of solar retinopathy are felt a few minutes to a few hours after exposure, depending on the intensity of the burn. Visually there may be blurring, a scotoma (an area of no vision, a ‘blind spot’), and/or distortion accompanied by a headache.
The solar eclipse glasses which are recommended have additional specialty filters to guard against the other high intensity wavelengths of light. The international safety standard is labeled ISO 12312-2. This should be indicated on the glasses, along with the name of the manufacturer. A list of reputable manufacturers of solar eclipse glasses can be found at American Astronomical Society(AAS), Vendors of Solar Filters and Viewers. They are not expensive, but don’t take a chance on poorer quality, or even worse; fake solar filters.
If you would like a comprehensive description of eclipse viewing, go to the NASA.gov website. On this page, they describe how to use the solar filters and make other safety recommendations. They also describe an indirect technique to experience the solar eclipse. Through the NASA.gov website you can access ways to watch live streams:
Here is another excerpt from my book from the chapter titled: Acceptance-Adjustment-Adaption
The low vision evaluation is different from the medical eye examination that you receive from your optometrist or ophthalmologist. The medical examination is focused primarily on evaluating the health of the visual system, concluding with a diagnosis and subsequent treatment, if needed. The refraction, which determines the eyeglass prescription, is generally a part of that medical examination. Your eye doctor wants you to leave the office with the best vision possible.
If your vision is not optimal, in other words, not “20/20’ with a new eyeglass prescription, additional testing will be done and a diagnosis determined. The doctor next considers the appropriate treatment, either medication or surgery. Sometimes there is no treatment, or the maximum treatment has been given, and there is no improvement in vision. The doctor may say ‘nothing more can be done, see you in three months.”
Nothing more can be done! This clinician may be brilliant within his/her scope of practice, but may not be aware of what the low vision specialist does, is too busy to concern himself, or may not be familiar with a referral network. They may think the patient is too old or the vision loss is too severe. I have heard of doctors, at the top of their profession, who send the patient out shopping for magnifiers.
This is where you need to be your own advocate. Low vision services can be found in private practices (optometrists or ophthalmologists who also practice low vision), low vision multidisciplinary centers, and state or federal agencies. Multidisciplinary low vision referral centers will have low vision specialists who work with occupational therapists, rehabilitation therapists, and counselors.
Low vision specialists are licensed optometrists or ophthalmologists, who understand the disease process and will have insight into the prognosis because of their medical training. They are knowledgeable about functional vision loss and understand their limitations. They have seen people with similar problems before, and will not think you are too old or too debilitated. Their goal is to help maximize your visual potential, and help you through the adjustment and adaption process.
The low vision specialist evaluates the type of vision loss, whether it is a loss of visual acuity, visual field, or contrast sensitivity, and then evaluates what visual function remains. Their goal is not to treat the disease process in a medical sense, as with medications or surgery. Medical treatment is still the domain of your regular eye doctor, with whom you should continue to see on a regular basis.
Here are the reasons to get a low vision evaluation;
- To Advocate for Yourself;
- Introduction to Visual Aids and Techniques;
- Education and Counseling, and
- Appropriate Referrals.
Thought for the Day: The beautiful thing about learning is that no one can take it away from you. B.B.King
Adjustment is the psychological and social resetting of your life. There are many factors that will affect how you adjust: things like age of onset, rate and severity of disease progression, living situation, and financial concerns.
Coping is how we deal with the changes. It is how we adjust and adapt to the nuances of our psychological, social, and personal functional needs. An individual’s coping mechanisms at the beginning of the disease are different from those at the various stages of the disease process. Someone who loses vision suddenly will need to overcome the shock of sudden disability, while someone with a slow, progressive onset of vision loss may have years to adjust and develop compensatory techniques. An individual with profound vision loss will need to work harder to compensate versus having to adapt to a milder vision impairment. One’s living situation, whether living alone or in a family unit, can impact the capability to cope, depending on the situation, either positively or even negatively. Sadly, financial resources can impact the capability to cope. While state and federal agencies provide some valuable services, those extras like electronic technology, transportation, and home assistance may be financially out of reach.
There are several emotional issues that can affect one’s capability to cope with a disability;
Loss of Independence
It has been a busy season. I have neglected to keep up with posting. Whenever I have time to write, I have been working on a second book on Low Vision. For the next couple of weeks I will be posting topics from my book Insight into Low Vision. This excerpt is from the chapter titled Interesting (Not Totally Understood) Phenomenon.
This phenomenon varies from a flash of light to moving patterns of light. These lights appear randomly with no other visual associations. It can occur in one eye or both eyes. They have been seen by those with retinitis pigmentosa , age-related macular degeneration, and Stargardt’s Disease.
Photopsia should be differentiated from light flashes associated with retinal detachment or traction on the retina. These are both active processes that can be a sign of potential vision loss. Photopic visual experiences, are thought to be residual neurological activity, as they occur in the area of retina which is already damaged. This would be analogous to the phantom pain experienced by those who have lost a limb.