amd from a to z · • 1985 – bone & landrum specifically identify lutein and zeaxanthin and...

PRESENTS

AMD From A to Z

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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

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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


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

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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)


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


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

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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.


Lutein & Lutein & ZeaxanthinZeaxanthinEssential Nutrients for EyeEssential Nutrients for EyeEssential Nutrients for Eye Essential Nutrients for Eye

HealthHealth


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.


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.

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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




Lutein & Lutein & ZeaxanthinZeaxanthin

Improves Visual Improves Visual PerformancePerformance


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.

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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)


Increased MPOD Increases Tolerance to Increased MPOD Increases Tolerance to Intense LightIntense Light

At 6 months,subjectscould tolerate 58% more glaring lightmore glaring light


brand Lutein/day

– 2 mg OPTISHARP®

brand Zeaxanthin/day

At 6 months, r = 0.59, p < 0.0001



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


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NEI AREDS2 Dosage OptionsNEI AREDS2 Dosage Options

Lutein(FloraGLO®) 10 mg/day


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


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

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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


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

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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.

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• 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.


• 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

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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

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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

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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.

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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.


• 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.


• 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.

15


• 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.


• 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


• Material held at focal point of the lens

• Image appears to come from infinity

• Use with distance Rx

Hand Magnifiers


• 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


• 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

17

• 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

– Email

– 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.

40 - 20 - 1

• 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

http://www.aoa.org/�

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