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PRESENTS
AMD From A to Z
1
AMD from A to Z
Educational Objectives
• Review current and anticipated benefits of nutraceutical intervention.
• Review how risk factors can be assessed for AMD.
• Review current and anticipated medical and surgical interventions for AMD.
• Understand the most commonly prescribed vision rehabilitation treatment options for AMD.
Ocular Nutrition & Healthy Vision Ocular Nutrition & Healthy Vision
© Kemin Industries, Inc. and its group of companies 2012 all rights reserved.Kemin & FloroGLO logos are registered trademarks of Kemin Industries, Inc., USA. American Optometric Association logo is a registered trademark of American Optometric Association
OutlineOutline
• Introduction to Ocular Nutrition• Nutrition & Age-Related Macular
Degeneration (AMD)Degeneration (AMD)• Nutrition & Visual Performance• Suggested Daily Intake• Patient Education Resources
Recommended Nutrients for EyesRecommended Nutrients for Eyes
• Antioxidants– Vitamins C
– Vitamin E
– Beta-Carotene
– Carotenoids: Lutein & Zeaxanthin
• Essential Fatty Acids– DHA
– EPA
• Zinc/Copper
Lien E and Hammond B. Prog Retin Eye Res. 2011; 30:188‐203.
Carotenoids & DietCarotenoids & Diet
600 In nature
50 In human diet50 In human diet
In blood serum14
2
Ong A and Tee E. Methods in Enzymol. 1992; 213:142‐167. Krinsky N, et al. J Nutr. 1990; 120:1654‐1662.
Khachik F, et al. Anal Chem. 1992; 64: 2111‐22.
Lutein & Zeaxanthin in the eye
2
In the MaculaIn the Macula
CH 3OH
CH 3
CH 3 O H
CH 3 CH3
OH
CH 3
CH 3
CH 3
CH3CH 3
C H3
Lutein
Bone et al. Invest Ophthalmol Vis Sci. 34:2033‐40, 1993.
CH3
CH 3CH 3 CH 3
CH3 CH 3
OH
OH
CH 3
CH 3
CH 3
CH 3
CH3
3CH 3 CH 3
CH3 CH 3
OH
CH 3
CH 3
CH 3
CH 3
Meso-zeaxanthin
Zeaxanthin
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
Lutein (L)Lutein (L)
• Especially high in green leafy vegetables
• Extracted from marigolds in an esterified formin an esterified form
• Kemin converts ester form to “free” lutein prominent in the diet & absorbed– Body doesn’t have a ready ability
to convert esters to free
MesoMeso‐‐zeaxanthinzeaxanthin (MZ)(MZ)
• Not found in the US diet
• Not present in the serum
• Converted from lutein in the macula
• Supplementation studies all simultaneously supplement with lutein & zeaxanthin– Suggest that MZ may hinder L and Z absorption
• Not a substitute for zeaxanthin
Maoka, et al. (1986) Comp Biochem Physiol B 83(1): 121‐4.Johnson, et al. (2005) Invest Ophthalmol Vis Sci 46(2):692‐702.
Thurnham, et al. (2008) Br J Nutr 100(6):1307‐14.Bone, et al. (2007) Nutrition & Metabolism 4(12)
ZeaxanthinZeaxanthin (Z)(Z)
• Found in the diet along with lutein– Corn, yellow/orange , y g
peppers
• 5:1 ratio of lutein to zeaxanthin in the diet
Nebeling, et al. J Am Diet Assoc 97, no. 9 (1997): 991‐6. Mohamedshah, et al. FASEB Journal 13, no. 4 (1999): A554.
Photos Courtesy www.shutterstock.com
L & Z in the EyeL & Z in the Eye
200
4000
5000
6000
7000
tiss
ue
Hata T, et al. J Invest Dermatol. 2000; 15:441‐448.Bernstein P, et al. Exp Eye Res. 2001; 72:215‐223.
Mac
ula
Perip
heral
retin
aIri
s
RPE/choro
id
Ciliar
y body
Lens
0
50
100
150
ng
/g
The highest concentration of carotenoids in the human body
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
Internal Internal SunglassesSunglasses
Filter damaging blue wavelengths of visible
light that pass through cornea & lensWavelength (nm)
700 400500600 300
BlueLight
Hazard Filtered by Cornea & Lens
Low Energy Less Damaging
Zeaxanthin Lutein
UV/VIS Spectrum of Lutein & Zeaxanthin
3
Powerful Powerful AntioxidantsAntioxidants
Reduces free radical damage in the eye
Lutein/zeaxanthin’smolecular structure enables it to orientenables it to orient
nearly perpendicular to the cell membrane at or near the surface helping to protect the outer lipid layer from free radicals caused
by ultraviolet or visible light.
Subczynski WK, et al. 2010 Archives of Biochemistry and Biophysics 504: 61–66
Figure accessed at: http://healthywealth.wordpress.com/2007/07/16/roles‐of‐antioxidants‐at‐cellular level/Accessed July 28,2011Figure shows skin membrane.
Macular Pigment Macular Pigment Optical DensitOptical DensitOptical Density Optical Density
(MPOD)(MPOD)
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
Macular Science HistoryMacular Science History
• 1945 – George Wald recognizes carotenoids in macula
• 1985 – Bone & Landrum specifically identify lutein and zeaxanthin and meso-zeaxanthin as macular pigments
• 1994 – Seddon et al. show relationship between dietary lutein & zeaxanthin intake and Age-Related Macular Degeneration (AMD) risk
• 2001 – Age-Related Eye Disease Study (AREDS) results validate the benefit of nutritional intervention
Wald, G. (1945). Science, 101(2635), 653–658.Bone RA, et al. (1985)Vision Res 25: 1531‐1535.
Seddon et al. (1994). JAMA, 272(18), 1413–1420.Li B et al. (2010) Photochem Photobiol Sci 9 (11): 1428‐25.
Macular Science HistoryMacular Science History
• 2004 – Lutein Antioxidant Supplementation Trial (LAST) demonstrates improved visual function and MPOD following supplementation with lutein 90 AMD patients
• 2008 – AREDS2 intervention trial begins
• 2004 – 2009 - Bernstein et al. isolate separate specific lutein & zeaxanthin binding proteins that are found in the macular region
AREDS report no. 8. 2001 Arch Ophthalmol 119: 1417‐1436. Richer et al. 2004. Optometry, 75(4), 216–230.
Chew, E. 2010. IND # 74,781, Version 8.0, 8 March 2010.
Macular PigmentMacular Pigment
Photo under license from Dr. Max Snodderly
Yellow macular pigmentcomposed of L&Z
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
MPODMPOD
• A measure of the amount of macular pigment present
• Potential biomarker for AMD risk early
Bernstein et al. (2010) Vision Research, 50: 716‐728Wooten & Hammond (2002). Progress in Retinal and Eye Research, 21(2), 225–240.
Beatty et al.(2000) Ophthalmic and Physiological Optics, 20(2), 105–111.
• Potential biomarker for AMD risk, early stage AMD and visual function
• Nearly half of Americans have low MPOD – Related to L & Z “under” consumption
4
Significance of MPOD MeasurementSignificance of MPOD Measurement
• Diagnostic tool offered by many eye care professionals
• Demonstrates supplementation benefits
within six monthswithin six months
• Encourages patient compliance
• Scale measured in density units (D.U.)• Below 0.2 low
• 0.2 – 0.5 mid-range
• Greater than 0.5 high
Bernstein P, et al. Vis Res. 2010.50:716‐728.Wooten B and Hammond B. Prog Ret Eye Res. 2002. 21:225–240.
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
Lutein & Lutein & ZeaxanthinZeaxanthinEssential Nutrients for EyeEssential Nutrients for EyeEssential Nutrients for Eye Essential Nutrients for Eye
HealthHealth
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
AgeAge‐‐Related Eye Disease Study (AREDS)Related Eye Disease Study (AREDS)
• Daily supplement dosage• Beta-carotene – 15 mg• Vitamin C – 500 mg• Vitamin E – 400 IUVitamin E 400 IU• Zinc – 80 mg• Copper – 2 mg
• Conclusions• AMD is a nutrition responsive disorder• 29% decreased risk of progression of advanced AMD• 21% reduction of visual acuity loss
AREDS Research Group (2001). Arch Ophthalmol 119(10): 1417‐36.
Lutein/Lutein/ZeaxanthinZeaxanthin and Ocular Healthand Ocular Health
57% AMD risk reduction with 6 mg
l t i / thi
0.9
1.2
dd
s ra
tio
)
lutein/zeaxanthinintake as compared
to 1 mg
Trend significant (p<0.001)
Seddon et al. JAMA 272: 1413‐1420, 1994.
0 1 2 3 4 5 6
0.0
0.3
0.6
Lutein/zeaxanthin intake (mg/day)
AM
D r
isk
(o
Lutein/Lutein/ZeaxanthinZeaxanthin Increases MPODIncreases MPOD
LAST Study• 90 males w/ AMD
– 10 mg FloraGLO®
b d L t i
* **
*
0.6
0.5
0.4
pti
cal
den
sity
36%improvement
43%improvement
brand Lutein– 10 mg FloraGLO
brand Lutein + antioxidants
– Placebo
• Improvements in visual function
Richer et al. Optometry. 2004 Apr;75(4):216‐230.
Lutein Lutein + antioxidants
Placebo
0 Left eye Right eye Left eye Right eye Left eye Right eye
0.3
0.2
0.1
Mac
ula
r p
igm
ent
op
Baseline Final visit *P<0.05
FloraGLO is a registered trademark of Kemin Industires, Inc.
Lutein/Lutein/ZeaxanthinZeaxanthin Increases MPODIncreases MPOD
49%
20%• 40 healthy subjects:
43%
49%
Stringham and Hammond. Optom Vis Sci 85: 82‐88, 2008.
– 10 mg FloraGLO®
brand Lutein
– 2 mg OPTISHARP®
brand Zeaxanthin
FloraGLO is a registered trademark of Kemin Industires, Inc. OPTISHARP is a registered trademark of DSM IP Assets B.V.
5
MPOD MPOD & Ocular & Ocular HealthHealth
AMD is in part a disease of oxidative stress
• Risk factors for AMD & low MPOD- Age- Gender
Nolan JM, et al. 2007 Experimental eye research 84: 61‐74.
Gender- Light eyes- Caucasian race- Eating a diet low in L & Z- Smoking- Obesity- Family history
Eye Protective NutrientsEye Protective Nutrients
Significantly lower MPOD in• Eyes at high risk for AMD
Beatty et al. Invest Ophthalmol Vis Sci 42: 439‐446, 2001. Bernstein et al. Ophthalmol 109: 1780‐1787, 2002.
Obana et al. Ophthalmol. 115: 147‐157, 2008.
• Eyes diagnosed with AMD– High-dose L/Z supplementation increased MPOD to
comparable levels of healthy subjects
• Eyes with late AMD than with early AMD
AgeAge‐‐Related Eye Disease Study (AREDS2)Related Eye Disease Study (AREDS2)
Feature Description
Objective Assess effect of a alternative combination of vitamins and minerals on the progression of AMD and vision loss
Age‐Related Eye Disease study 2 Protocol. Available at: www.emmes.com/study/areds2 . Accessed July 14, 2011.AREDS2 Study Overview. Available at: http://clinicaltrials.gov/ct2/show/NCT00345176?term=AREDS2&rank=1. Accessed July 21, 2011.
a d s o oss
Design NEI 5 year, multi-center, randomized, double-masked, placebo-controlled trial
Population 4000 patients at higher risk of developing AMD (men and women; 50 – 85 years)
AREDS2AREDS2
Ingredients being studied in AREDS2:– FloraGLO® brand Lutein (10 mg)
– OPTISHARP® brand Zeaxanthin (2 mg)
Omega 3 fatty acids (350 mg DHA 650 mg EPA)– Omega-3 fatty acids (350 mg DHA, 650 mg EPA)
– β-carotene
– Decreased zinc
Patients are assigned to different combinations of ingredients
FloraGLO is a registered trademark of Kemin Industires, Inc. OPTISHARP is a registered trademark of DSM IP Assets B.V.
Age‐Related Eye Disease study 2 Protocol. Available at: www.emmes.com/study/areds2 . Accessed July 14, 2011.AREDS2 Study Overview. Available at: http://clinicaltrials.gov/ct2/show/NCT00345176?term=AREDS2&rank=1. Accessed July 21, 2011.
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
Lutein & Lutein & ZeaxanthinZeaxanthin
Improves Visual Improves Visual PerformancePerformance
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
Visual PerformanceVisual Performance
High MPOD levels enhance– Visual acuity
– Glare tolerance
– Glare recovery
– Contrast sensitivity
– Chromatic aberration
– Photophobia
Bahrami et al. 2006. BMC Ophthalmol 6(1):23. Cangemi et al. 2007. BMC Ophthalmol. 7:3. Kvansakul et al. 2006. Ophthalmic Physiol Opt 26(4):362‐71. Massacesi et al. 2001. IOVS. 42(4):S234. Olmedilla et al. 2003. Nutrition.
19(1):21‐4. Richer et al. 1999. J Am Opt Assoc 70(1):24‐36. Richer et al. 2004. Optometry. 75(4):216‐230. Stringham and Hammond. 2008 Opt Vis Sci. 85(2):82‐8. Wenzel et al. Vis Res. 46(28):4615‐22.
6
ZeaxanthinZeaxanthin & Visual Function (ZVF) Study& Visual Function (ZVF) Study
• 60 patients (57 men) with mild-to-moderate AMD
• 3 arms of 1 year daily supplementation regimens– 8 mg zeaxanthin (n = 25)
8 mg zeaxanthin + 9 mg lutein (n = 25)– 8 mg zeaxanthin + 9 mg lutein (n = 25)
– 9 mg lutein (“faux placebo”) (n = 10)
• Tested at 4, 9 and 12 months:– MPOD (by HFP)
– Low- and high-contrast visual acuity
– Glare recovery
– Contrast sensitivity function (CSF)
Richer et al. 2011. Optometry. 82(11):667‐680
ZVF StudyZVF Study
• No adverse events
• MPOD increased in all three groups– 0.33 (± 0.17) → 0.51 (± 0.18)
N b t diff
Richer et al. 2011. Optometry. 82(11):667‐680
– No between-group differences
• Lutein + Zeaxanthin group had the lowest MPOD increase. Competition?
• Authors note that AREDS2 5:1 dosage ratio “appears judicious”
Macular Pigment & Glare RelationshipMacular Pigment & Glare Relationship
Individuals with higher MPOD levels 3.0
3.2
3.4
3.6
W /
cm2 )
can tolerate a higher intensity of the
glaring light
Statistically significant (p < 0.0001).
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.12.0
2.2
2.4
2.6
2.8
Log
ener
gy (W
MPOD (30' eccentricity)
Stringham and Hammond. Optom Vis Sci 84: 859‐864, 2007.
Increased MPOD Increases Tolerance to Increased MPOD Increases Tolerance to Intense LightIntense Light
At 6 months,subjectscould tolerate 58% more glaring lightmore glaring light
– 10 mg FloraGLO®
brand Lutein/day
– 2 mg OPTISHARP®
brand Zeaxanthin/day
At 6 months, r = 0.59, p < 0.0001
Stringham and Hammond. Optom Vis Sci 85: 82‐88, 2008.
FloraGLO is a registered trademark of Kemin Industires, Inc. OPTISHARP is a registered trademark of DSM IP Assets B.V.
L/Z Supplementation Improves L/Z Supplementation Improves Recovery Time After Glaring LightRecovery Time After Glaring Light
Improved glareImproved glare recovery by up to
5 seconds
r = -0.988, p = 0.012
Stringham and Hammond. Optom Vis Sci 85: 82-88, 2008.
SuggestedSuggestedSuggested Suggested Daily IntakeDaily Intake
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
7
NEI AREDS2 Dosage OptionsNEI AREDS2 Dosage Options
Lutein(FloraGLO®) 10 mg/day
Age‐Related Eye Disease study 2 Protocol. Available at: www.emmes.com/study/areds2 . Accessed July 14, 2011.AREDS2 Study Overview. Available at: http://clinicaltrials.gov/ct2/show/NCT00345176?term=AREDS2&rank=1. Accessed July 21, 2011.
Zeaxanthin(OPTISHARP®))
2 mg/day
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association FloraGLO is a registered trademark of Kemin Industires, Inc. OPTISHARP is a registered trademark of DSM IP Assets B.V.
Broccoli1.7 mg
Romaine lettuce
2.3 mg
Dietary Sources of L/ZDietary Sources of L/Z
Kale40 mg
Spinach12 mg
L/Z values based on a 100 g serving
U.S. Department of Agriculture, Agricultural Research Service. 2010. USDA National Nutrient Database for Standard Reference, Release 23. Nutrient Data
Laboratory Home Page, http://www.ars.usda.gov/ba/bhnrc/ndl © Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
6789
10
xa
nth
in
g/d
ay
)
U.S. Consumption of L/ZU.S. Consumption of L/Z
19-3031-50
51-7071+
Men
Women
Suggested intake
0123456
Lu
tein
+ z
ea
xin
tak
e (
mg
Age
CDC. National Health and Nutrition Examination Survey Data 2001‐2002. http://www.cdc.gov/nchs/about/major/nhanes/nhanes01‐02.htm
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
How Can We Bridge the Gap?
• Clinical trials are using 10 mg/day
• Diet
• Eye Vitamins
– Most multi-vitamins contain only 250 mcg of L/Z
U.S. Department of Agriculture, Agricultural Research Service. 2010. USDA National Nutrient Database for Standard Reference, Release 23. Nutrient Data Laboratory
Home Page, http://www.ars.usda.gov/ba/bhnrc/ndl
L/Z AbsorptionL/Z Absorption
• Incorporated into mixed micelles– Requires fat
• Absorbed and transported to liver
• Available for deposition via blood stream– Eyes, skin, breast tissue, brain
van Vliet. Eur J Clin Nutr. 1996;50:S32‐37. Landrum and Bone. Arch Biochem Biophys. 2001;385:28‐40.;
Peng et al. Cancer Epidemiology Biomarkers Prev. 1993;2:139‐144.; Yeum et al. J Nutr. 1998;128:1920‐1926.; Craft et al. J Nutr Health Aging 2004;8:1561‐62.
All Lutein is Not the SameAll Lutein is Not the Same
• Lutein brand in eye vitamins matter
• Proven absorption– Studies that show increases in serum
lutein & MPOD
• Proven eye benefits– Studies that show improvements in
visual function
8
L/Z SafetyL/Z Safety
• Acceptable Daily Intake (ADI) Level– 2 mg/kg body weight
– Equals 140 mg/day for 70 kgEquals 140 mg/day for 70 kg (154 lb) person
• GRAS Status – Food
– Beverages
– Medical food
– Infant formula
Synthetic zeaxanthin, JECFA monograph (http://www.fao.org/ag/agn/jecfa‐additives/specs/Monograph1/Additive‐492.pdf)
Lutein from Tagetes erecta, JECFA monograph (http://www.fao.org/ag/agn/jecfa‐additives/specs/monograph3/additive‐255.pdf)
Ocular Nutrition Ocular Nutrition Patient Education Patient Education
ToolsTools
© Kemin Industries, Inc. and its group of companies 2011 all rights reserved.American Optometric Association logo is a registered trademark of American Optometric Association
AOA ResourcesAOA Resources
• Feast Your Eyes Brochure
• Recommended Nutrients Tear Pad– English & Spanish versions available
• Ocular Supplement Sheet• Ocular Supplement Sheet– Also customizable for your practice
• Nutrition & Eye Health Presentation
• AOA.org– Ocular Nutrition Research Library
KeminKemin ResourcesResources
• FloraGLO® Lutein brochures – English & Spanish versions available
• Lutein research packet &Lutein research packet & lecture materials
• Monthly F.Y.Eye newsletter• Sign up to receive free patient
tools - [email protected]
FloraGLO is a registered trademark of Kemin Industires, Inc.
SummarySummary
• L/Z are essential nutrients your eyes need daily –internal sunglasses
• L/Z intake may reduce the risk of AMD & can improve visual performance
• MPOD is a potential biomarker for retinal health• Nearly 1 in 2 Americans have low MPOD• Maintain healthy L/Z levels through diet & eye
vitamins: 10+2 mg• Not all lutein in eye vitamins is equal
Current Understanding of Macular Degenerationg
9
Age-Related Macular Degeneration
• AMD is the leading cause of vision loss for Americans older than 65 years of age.
• 33% of eyes of individuals with late AMD have Central Geographic Atrophy (CGA)• 20% of cases of severe vision loss are caused by CGA.
• 67% of eyes of individuals with late AMD have Choroidal Neovascular (CNV) membranes
• Inflammation appears to play a significant role in this disease process.
Early AMD
Advanced AMD AMD with CNVM
AMD with CGA
www.redatlas.org
Central Geographic Atrophy
• CGA is the advanced form of dry AMD. – Currently, there is no effective treatment for GA
• CGA is characterized by one or more large, well defined areas of RPE atrophy that enlarge and coalesce over time.
10
Central Geographic Atrophy
• Distance visual acuity findings tends to over estimate visual function in individuals with CGA because the fovea may be intact until l t i th di (f l i )late in the disease (foveal sparing).
• However, the perifoveal area may be severely impaired by atrophy with corresponding scotomas.
Central Geographic Atrophy
• This may result in a decrease in contrast sensitivity, reading speed, foveal dark-adaptation sensitivity, and low luminance i l it th t k di d i ivisual acuity that can make reading, driving
and recognizing faces significantly difficult.
• Also, response to optical and electronic magnification can be limited by the parafovealscotomas.
Geographic Atrophy
• Treatment options being studied include,– Neuroprotective agents
– Antioxidants
– Anti-inflammatory agents
– Complement inhibitors
Epidemiology of CGA
• 3.5% of people over 75 years of age (Rotterdam & Beaver Dam Studies).
• Increases with age to 22% over age 90years (Hirvela, et al, 1996, Quillen et al, 1996).
• Responsible for 50% of CNVM.– It is important to tell your patients that all wet AMD
begins as dry AMD
Natural History of CGA(Sunness, 1995, 1999)
• Of eyes with VA > 20/50 – 50% lost 3 or more lines at 2 years.
2 % l 6 li 2– 25% lost 6 or more lines at 2 years.• 3 lines of vision equals a doubling of the minimum angle
of resolution
– Example: 20/50 to 20/100
• Fundus appearance is often symmetrical, however acuity may vary depending on amount of foveal sparing.
Risk Factors for CGA in the AREDS
• Bilateral drusen– 10% developed CNVM while 6% developed CGA
• Advanced unilateral AMD– 10% developed CGA
• Additional risk factors: increased BMI, smoking > 10 pack/year, antacid use & high school education or less
• Protective: anti-inflammatory meds
11
Failed Therapies for CGA
• Anecortave Acetate Risk-Reduction Trial (AART)
• Rheopheresis– Blood filtering
TENS• TENS– Microstimulation
• Complications of Age-Related Macular Degeneration Prevention Trial (CAPT )– Low intensity laser applied in annulus centered at fovea
• Retinal translocation – discussed later
Vision Rehabilitation for CGA
• 19 patients
• Age 56-91(mean 79 +/-8 years)
• 37% female
• 63% male
Source: CGA Study Results - Dawn DeCarlo, OD
CGA Study Results
• Range of VA in the better eye - 20/25 to 20/100 (mean 20/52)– 58% complete ring scotoma
42% partial ring scotoma– 42% partial ring scotoma
• Range of VA in the worse eye - 20/25 to 20/919 (mean 20/276)– 36% complete ring scotoma – 11% partial ring scotoma– 53% central scotoma
CGA Study Results
• 26% prescribed new glasses.• Binocular near VA ranged from 0.5M to 4M
(mean 1.1M).M i l f i i h bilit ti f 84%• Main goal of vision rehabilitation for 84% was reading.
CGA Study Results
Adaptive Equipment Prescribed • Hand held magnifiers (8-10D) 16%
• Stand magnifiers 32%
• High add 26%
• Electronic magnification 11%
• Natural daylight lamp/penlight 21%
• Only 1 patient had 2 devices prescribed• No distance devices were prescribed
CGA Study Results
• OT recommended for 17/19 (89%)– 9 declined referral
– 4 completed
– 2 still receiving OT
– 2 terminated before meeting all goals
12
Assessing Risk Factors for AMD
Risk Factors for AMD
• Advancing age
• Smoking
• UV exposurep
• Obesity
• Diet
• Family history
Visual Field Testing
• Preferential Hyperacuity Perimetry – Foresee PHP, Reichert Technologies
• Proposed use is for patients with high risk intermediate AMD
• PHP has been shown to detect choroidal neovascularization with a sensitivity twice as high as the Amsler grid.
Preferential Hyperacuity Perimetry
• The PHP study group found the PHP sensitivity to detect CNV of 82% and specificity to differentiate CNV from intermediate AMD of 88%.
• PHP testing may assist in the earlier detection of CNV lesions, when they are smaller and the baseline acuity is better.– Earlier detection has been shown to result in a better
absolute level of visual acuity after long-term treatment.
Preferential Hyperacuity Perimetry
• CMS concerns about in office testing– Is quarterly testing appropriate, cost effective and
needed to monitor for the development of CNV membranesmembranes
– May be of greater value as a testing device for regular screening use in the home.
Genetic Testing
• Complement factor H gene on chromosome 1q31 shows a strong genetic link with AMD.
• Other genes associated with AMD include LOC, Y402H, C2, C3, ARMS2, TIMP3 and mitochondrial DNA mutation a4917G
13
Genetic Testing
• Macula Risk (ArcticDX, Toronto, Ontario) is a commercially available genetic test.– Purports to measure inheritability risk factors for
AMDAMD • Genetic testing results are combined with risk factors to
help to predict an individual’s prognosis for progression towards more advanced stages of macular degeneration
Genetic Testing – Macular Risk
– Testing involves a check swab that is sent directly to the genetic lab
– CMS currently provides coverage for this testing if AMD already existsAMD already exists
• The patient has to cover the cost of testing when at least early AMD is not present (~$750.00)
– Value of this testing is currently unknown.• Will knowledge of risk change lifestyle?
– Stop smoking, loss weight, etc.
Genetic Therapy
• Gene therapy, as well as gene directed therapy for AMD are still a number of years in the future.
AMD Evaluation Guidelines
• Screen patients over 65 years for drusen(early/intermediate AMD)
• Refer “high risk” to retina specialist for a baseline exam
• Low risk: monitor every 12-24 months
• Moderate risk: evaluate twice a year
• High risk: evaluate 3-4 times per year
• Refer advanced cases to a retina specialist
Current and Anticipated Medical and Surgical Interventions for AMDg
Anti-Vascular Endothelial Growth Factor (VEGF)
• VEGF is a potent angiogenic factor and an effective target for inhibiting retinal neovascularization.
• Currently, anti-VEFG therapy is the only treatment approved for CNVM AMD.
14
Anti-Vascular Endothelial Growth Factor (VEGF)
• The use of anti-VEGF treatment has resulted in significant improvement of vision in patients with choroidal neovascular AMD.– Another form of late AMD
• Geographic atrophy is the other form of late AMD and does not respond to anti-VEGF treatment
• Anti-VEGF therapy prevents deterioration of vision in >90% of CNVM cases.– In only 30-40% of cases, is visual acuity improved.
Alternate Treatments
• The treatment for advanced AMD, geographic atrophy and/or non-responders to anti-VEGF treatment is still controversial.
Macular Translocation Surgery
• Used for advanced neovascular AMD characterized by the development of subfoveal choroidal neovascularization.
• Results of this surgery included improved visual functioning and vision-related quality of life, increased macular sensitivity and improved retinal structure.– In one study of 40 patients, 25% maintained a 3-
line gain in vision over 3 years.
Macular Translocation Surgery
• Counter-rotation surgery (CRS) is required following macular translocation surgery with 360° retinotomy to correct for resultant tilt secondary to cyclorotation. seco da y o cyc o o a o– 100% complained of tilted vision following MTS
• ~60% experienced diplopia following MTS
• Transposition surgery involves having the superior oblique transposed to the inferior-nasal quadrant and the inferior oblique is transposed to the supero-temporal quadrant.
Macular Translocation Surgery
• Even after CRS, binocular single vision is rarely achieved, resulting in diplopia or suppression of the poorer acuity eye.
• With anti-vascular endothelial growth factor• With anti-vascular endothelial growth factor (VEGF) treatments now readily available, macular translocation surgery is now confined to a limited number of centers and a limited number of cases such as those with recent RPE rips or extensive submacularhemorrhage.
Human RPE Transplantation
• Maculoplasty may become an alternate surgical approach for patients who cannot or do not benefit from anti-VEGF therapy.– Advanced AMD
– Geographic atrophy
– Non-responders to anti-VEGF therapy
• May provide the potential of restoring the retinal anatomy with resultant long-term retinal stability.
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Human RPE Transplantation
• Both autologous RPE-choroid sheet and RPE suspension transplantation techniques have been undertaken.
• Both techniques had similar anatomical and functional outcomes.– Intrastructural irregularities of the choroidal sheet
transplants are felt to have limited visual gains in some successful sheet transplantations.
Human RPE Transplantation
• In a small study, transplantation enabled the maintenance of distance vision, and in the best cases, restoration of foveal function.
• However, reading ability was rarely restored or improved.
• Functional outcomes of current RPE transplantation do not approach the levels of improvement seen with anti-VEGF treatment.
Most Commonly Prescribed Vision Rehabilitation Treatment
Options for AMDOptions for AMD
• Relative Size Magnification – enlarge the print
• Relative Distance Magnification
Options to Read Print
– hold the materials closer to the eye
• Angular Magnification– low vision device
• Electronic Magnification – high tech
• Conventional spectacles– Refraction is the starting point for the care of all
individuals with vision loss
Types of Glasses
• Multifocal lenses
• Bifocals
• Trifocals
• Progressive addition lenses
• Franklin segments
Image provided by Lighthouse International
• Used for individuals who require a high add to read (>6D)
• These individuals still need magnification for
The +4.00D Intermediate Add
less detailed tasks…– Signing name
– Cutting finger nails
– Seeing food on plate
– Cooking
– Reading larger print – headlines, etc.
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• Material held at focal point of the lens
• Image appears to come from infinity
Reading Spectacles
Image provided by Lighthouse International
• Material held at focal point of the lens
• Image appears to come from infinity
• Use with distance Rx
Hand Magnifiers
Image provided by Lighthouse International
• Material positioned inside focal length of lens
• Virtual image appears to come from a finite distance behind the lens
Stand Magnifiers
• Need to use with a reading (near) Rx
Image provided by Lighthouse International
• Reduces glare/photophobia
• Enhances/increases contrast
• Type of filter is determined
Absorptive Lenses
yp– by assessment and trial,
– not by the diagnosis
• Typoscopes– Reduces glare from glossy
paper
– Minimizes figure ground
Non-Optical Devices
confusion
• Enhanced contrast adaptations and devices
• Illumination is the single most important factor in enhancing visual functioning!!!
• Types of illumination
Lighting
– Incandescent
– Fluorescent
– Halogen
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• Light fixtures– Are as important as the bulb– Must be flexible to allow for
adjustment of distance to
Lighting
jpaper and angle of the light
– Adjust position of light source for maximum comfort/contrast enhancement
• Moderate to profound vision loss.
• Decreased contrast sensitivity.
Who Benefits from High Tech Devices?
• Higher magnification needs (>6x).
• Flexible or longer working distance needed.
• Augment visual input with auditory or tactual input.
High Tech Options Desk Options
Transportable Options Portable Options
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Computer Accessibility
Screen Enlarging SoftwareScreen Reading SoftwareText to Speech Software
Operating System SoftwareVoice Recognition Software
• First out of the box fully accessible device
• Zoom capabilities
• Voice capabilities
Provides access to
IPad
• Provides access to– Internet
• Newspapers
• Magazines
– Books• Enlarged and/or Speech
Who needs vision rehabilitation services?
Developed by Roy G. Cole, OD
Determining who needs low vision rehabilitation services?
Screen patients in 1 minute by asking;
• Do you have trouble doing what you want to do because of your vision? For example:because of your vision? For example:– Reading your mail?
– Watching television?
– Recognizing people?
– Paying your bills?
– Signing your name?
– Walking stairs, curbs, crossing the street or driving?
Determining who needs low vision rehabilitation services?
• During the past month, have you often been bothered by:– Feeling down, depressed or hopeless?
Having little interest or pleasure in doing things?– Having little interest or pleasure in doing things?• ~90% effective in detecting depression
• If the answer to any of the above 8 questions is “yes,” and you are not able to ameliorate the cause, the patient should be referred for additional vision care and/or vision rehabilitation services and/or mental health services.
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• Dr. Cole’s take home message: think about implementing vision rehab strategies when…– Visual acuity 20/40 or worse
– Visual field 20 degrees or less
– One or more functional complaint(s) related to decreased vision
BECOME A MEMBER TODAY!
Vision Rehabilitation Section membership benefits include:
Timely informative electronic newsletter
Quality continuing education
Representation to advocacy groups and third party programs
Professionally produced patient education materials to enhance your practice
Online Doctor Locator- www.aoa.org
A forum which affords networking and the exchange of ideas about new developments and techniques
Membership certificate suitable for framing
Make checks payable to: AOA Vision Rehabilitation Section, 243 N. Lindbergh Blvd., Floor 1, St. Louis, MO 63141-7881, OR, call 1-800-365-2219, ext. 4224 to pay by credit card. VRS MEMBERSHIP CATEGORYS: Licensed OD (3rd+ year) ($75) Retired/Partial Practice OD ($15) Licensed OD (2nd year) ($50) Active or Post-graduate Student ($5) Licensed OD (1st year) ($25) Paraoptometric ($10) Name Degree _________________ Address __________________________________________________________________ City ___________________________________ State ___________ Zip __________ Telephone ( ) Email
MEMBERSHIP IN THE AOA IS REQUIRED PRIOR TO JOINING THE AOA VISION REHABILITATION SECTION.
243 North Lindbergh Boulevard Saint Louis, MO 63141-7881
314.983.4224 800.365-2219 www.aoa.org