financial disclosures · 1.ola, mohammad shamsul, et al. “role of oxidative stress in diabetic...

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OCULAR NUTRITION IN DIABETES

THE ROLE OF MACULAR CAROTENOIDS AND OMEGA-3 IN DIABETIC RETINOPATHY AND VISUAL PERFORMANCE

Mark W. Roark, OD, FAAOAllisonville Eye Care Center

Fishers, IN

FINANCIAL DISCLOSURES

The Speaker is a consultant for and/or has received honoraria from:• MacuHealth, LLC• M&S Technologies• Marco

As Primary Eye Care Providers We Must Do More Than

Detect And Manage RetinopathyFor Our Diabetic Patients.

*Though experimental animal models can be of value, the findings referenced in this presentation are based on human studies.

PREDIABETES:Affects 84.1 million adults in the USWill likely lead to Type 2 diabetes within 10 years without lifestyle change

DIABETES IS ON THE RISE!

DIABETES:

• 30.3 million people in the US (9.4% of the population) in 2015

• About 7 million of these not yet diagnosed but 1.5 million diagnosed yearly

• Approximately 1.25 million are Type 1 (children and adults)

• Rates of diabetes vary with race/ethnic background

If Poorly Controlled X >15 Years, Nearly 80% Are Likely To Have Ocular Disease

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Healthand Human Services; 20172. Mansberger SL, Gleitsman K, Gardiner S., et al. Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial. Telemedicine Journal and E-Health. 2013;12:942–948.

DIAGNOSED DIABETES--OVER THE LAST TWO DECADES1

1996 20162006

1.Data available at www.cdc.gov/diabetes/data2.2015-2020 Dietary Guidelines for Americans. HHS Publication #: HHS-ODPHP-2015-2020-01-DGA-A

The Total Estimated Cost Of Diabetes In 2012: $245 Billion!2

DIABETES IS ON THE RISE!

So Over 30 Million People In The US Who Were Not Diabetic When They Were Born Are Now Diabetic!

The Prevalence Of Diabetes Is Expected To Rise To

44 Million By 2034!

WHY?

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SUCROSE(Table Sugar)

2015-2020 Dietary Guidelines for Americans. HHS Publication #: HHS-ODPHP-2015-2020-01-DGA-A

→Non-Alcoholic Fatty Liver Disease ↑TG/WT/RISK FOR DM AND CVD!

SUGAR INTAKE FOR AMERICANS IS HIGH!

Glucose Fructose


SUGAR INTAKE FOR AMERICANS IS HIGH!

Soft drinks: supply 25% of added sugars in the American diet

PHYSICAL ACTIVITY GUIDELINES

Adapted from 2015-2020 Dietary Guidelines for Americans. HHS Publication #: HHS-ODPHP-2015-2020-01-DGA-A

AGES 18-64WEEKLY AEROBIC PHYSICAL ACTIVITY

AGES 18-64WEEKLY MUSCLE- STRENGTHENING

MINIMUM: Moderate (Vigorous) Muscles: All major groups

2.5 h (1.25 h) Minimum 2 days

MORE BENEFITS: Moderate (Vigorous)

5.0 h (2.5 h)

For more than 25 years, more than half of the adult population has been overweight or obese

MODERATE VIGOROUS

Brisk walking Jogging

Dancing Singles tennis

Swimming Swimming- laps

Bicycling- level Bicycling- uphill

2015-2020 Dietary Guidelines for Americans • Required under a 1990 Legislative Act• Published every 5 years jointly by the HHS and USDA• Provides nutritional and dietary information and guidelines• Resource for healthcare professionals /general public

A HOLISTIC APPROACH

https://health.gov/dietaryguidelines/2015/guidelines

THE BASICS OF DIABETESBlood glucose from food requires insulin to enter and fuel the body’s cellsBlood glucose is also stored in the liver for use prn

TYPE 1 (5%)Little or no insulin is produced by the pancreasTYPE 2 (95%)Insulin is produced but insulin resistance occurs

Without insulin, glucose stays in the blood and is “locked” outside the cells.

ELEVATED BLOOD GLUCOSE CAN LEAD TO SERIOUS HEALTH PROBLEMS!

https://www.cdc.gov/diabetes/pdfs/library/socialmedia/diabetes-infographic.pdf

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UNDERSTANDING HbA1C AND BSL RESULTS

A1c (2-3mo average) RESULT

<5.7% Normal

5.7 -6.4% Prediabetes

≥ 6.5% (repeated) Diabetes

FASTING BSL RESULT

70-99 mg/dl Normal

100-125 mg/dl Prediabetes

≥126 mg/dl (repeated) Diabetes

QUESTION #1From 2000 to 2010, the number of cases of Diabetic Retinopathy INCREASED by nearly _____ in the US.

A. 30%B. 50%C. 70%D. 90%

VISION LOSS IN DIABETES

Can We Make a Difference?

QUESTION #1From 2000 to 2010, the number of cases of Diabetic Retinopathy INCREASED by nearly _____ in the US.

A. 30%B. 50%C. 70%

D. 90%



https://nei.nih.gov/eyedata/diabetic

QUESTION #2With proper management, more than _____ of cases of visual loss can be prevented.

A. 30%B. 50%C. 70%D. 90%



QUESTION #2With proper management, more than _____ of cases of visual loss can be prevented.

A. 30%B. 50%C. 70%

D. 90%!



Wu, Lihteh et al. “Classification of diabetic retinopathy and diabetic macular edema.” World journal of diabetes vol. 4,6 (2013): 290-4.

QUESTION #3Currently the number of those with diabetes who have yearly examinations to look for DR is about _____.

A. 40%B. 60%C. 75%D. 90%



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QUESTION #3Currently the number of those with diabetes who have yearly examinations to look for DR is about _____.

A. 40%

B.60%C. 75%D. 90%



American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern® Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2017. Available at: www.aao.org/ppp. 1.National Eye Institute Statement. Sharp rise in diabetic eye disease makes American Diabetes Month ever more important. November 2012.

http://www.nei.nih.gov/ news/statements/diabetesmonth2012.asp

Can We Make A Difference?

DR WITHIN 5 YEARS OF DIAGNOSIS (TYPE 2)

38%

DR WITHIN 20 YEARSOF DIAGNOSIS (TYPE 2)

60%

Diabetic Retinopathy (DR) Is The Leading Cause Of Blindness In Adults Ages 20-741

> 200,000 cases of significant vision loss yearly- inability to read or drive

FINDING EFFECTIVE STRATEGIES TO PREVENT/DELAY DIABETIC RETINOPATHY

A MAJOR PUBLIC HEALTH ISSUE

2.Brownlee M. The pathobiology of diabetic complications: a unifying mechanism. Diabetes 2005;54:1615–25.

Oxidative Stress Occurs in the Retina- Even Without Diabetes!

Metabolic rate highest at the macula!• 3x higher than in the brain• 6x higher than in the heart

Free radicals disrupt cellular physiology

Metabolic disorder with diabetes:• Elevated intracellular glucose and fats ↑ retinal oxidative stress

• Important enzyme inactivated - normal metabolism interrupted• Results in damage to neuronal cells• Also endothelial damage---vascular occlusion---ischemia•

Central factor in diabetic retinopathy1,2

1.Ola, Mohammad Shamsul, et al. “Role of Oxidative Stress in Diabetic Retinopathy and the Beneficial Effects of Flavonoids.”Current Pharmaceutical Design, vol. 24, no. 19, 2018, pp. 2180–2187.

Diabetes affects all layers of the retina and is more than a “microvascular disease”3

3.Cohen, Steven R., and Thomas W. Gardner. “Diabetic Retinopathy and Diabetic Macular Edema.” Developments in Ophthalmology, vol 55 (2015); pp. 137–146.

ANATOMY: CLOSE-UP VIEW OF RETINAL CAPILLARIES

Intramural pericyte

Retinal capillary

Tight junction

Endothelium

Basement membrane

Endothelium Nucleus

Lumen

Pericytes Capillaries

Image L: Available at: http://www.udel.edu/Biology/Wags/b617/stereo/stereo9.gif.

1.Stewart JM, Coassin M, Schwartz DM. Diabetic Retinopathy. [Updated 2017 Apr 14]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-.2. The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus.

New England Journal of Medicine, vol. 329, no. 14, 1993, pp. 977–986.

DIABETIC RETINOPATHY OVERVIEW1

Non-proliferative (NPDR)• Mild

• Moderate• Severe

Proliferative (PDR)

The Diabetes Control and Complications Trial (DCCT) showed that in Type 1 diabetes, improved BSL control (per HbA1c)

correlated with reduced rates of DR onset and progression2

NPDRSTAGE

RETINALFINDINGS

RISK OF PDR W/I 1 YEAR1,2

MILD Microaneurysms (MA) (diameter 15-60 um) 5%

MOD MAs, hemorrhages, hard exudate 12-27%

SEVERE MAs and hemorrhages in 4 quadrants,venous beading in at least 2 quadrants,

or IRMA in at least 1 quadrant (4:2:1 rule)

52%

VERY SEVERE ≥ 2 of these features of 4:2:1 rule

60x risk compared to mild NPDR

2. Stewart JM, Coassin M, Schwartz DM. Diabetic Retinopathy. [Updated 2017 Apr 14]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext

[Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK278967/

1.American Optometric Association: Evidence-based Clinical Practice Guideline: Eye Care of the Patient with Diabetes Mellitus, Feb 7 2014, page 20

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Macular Edema1,2(can occur at any stage of DR )• Leading cause of visual impairment among diabetics• 75,000 new cases are diagnosed each year

Clinically Significant Macular Edema (CSME)- from ETDRS• No longer the preferred terminology

Macular Ischemia• Vascular compromise leads to dropout of capillaries/nonperfusion• Earliest sign of diabetic retinopathy for some patients• Increased risk of progressive retinopathy and proliferative disease• May only be detected at the earliest point with OCT A

1. Cohen, Steven R and Thomas W Gardner. “Diabetic Retinopathy and Diabetic Macular Edema” Developments in ophthalmology, vol. 55 (2015): 137-46.2. Kumar, J Innovations in Diabetic Retinopathy, Optometric Management, Feb 2019

DIABETIC MACULOPATHY

Anti-VEGF therapy is now considered first-line therapy

for DME and may be followed by focal laser treatment2

2.Stewart JM, Coassin M, Schwartz DM. Diabetic Retinopathy. [Updated 2017 Apr 14]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext[Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK278967/

DIABETIC MACULAR EDEMA (DME)

Current Preferred Terminology:Center-involved vs Non-center Involved DME1

1.Evolve Medical Education Then Now and Tomorrow Evolving the Management of Diabetic Retinopathy DR and the Role of the Optometrist Course Group, https://evolvemeded.com/online-courses/1908-print-1/, Accessed July 3, 2019

WHAT IS THE ROLE OF MACULAR PIGMENT IN DIABETIC RETINOPATHY?

CAROTENOIDS ARE PRESENT THROUGHOUT THE VISUAL SYSTEM

~50 in

diet

~20 in serum Only lutein, zeaxanthin,

and meso-zeaxanthin

found in the eye

(concentration over

1000X serum)1

Auditory cortex Occipital Cortex

HippocampusFrontal cortex

1Landrum JT, et al. Arch Biochem Biophys. 2001; 385:28-40.

*Courtesy Jim Stringham Ph D

MACULAR CAROTENOIDS ARE STRONG ANTIOXIDANTS

Binxing Li, Fasial Ahmed, Paul S. Bernstein. Studies on the singlet oxygen scavenging mechanism of human macular pigment. Arch. Biochem. Biophys. (2010), doi:10.1016/j.abb.2010.07.024

BENEFITS OF MACULAR PIGMENT (MP)Strong antioxidants!

MZ > Z > LHighest protection with L + Z + MZ

MACULAR CAROTENOIDS – LACKING IN THE DIET

MOST AMERICANS LACK ADEQUATE MACULAR PIGMENT DUE TO POOR DIET.

HOW DO DIABETIC PATIENTS COMPARE?


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Type 2 Diabetic Patients Are LIKELY To HaveLow Macular Pigment

0

0.1

0.2

0.3

0.4

0.5

0.6

2010 Study 2015 Study

MP

OD

STUDY COMPARISON

Type 2- no DR Type 2- mild DR Type 2- All Controls

1.Lima, Verônica Castro, et al. “Macular Pigment Optical Density Measured by Dual-Wavelength Autofluorescence Imaging in Diabetic and NondiabeticPatients: A Comparative Study.” Investigative Opthalmology & Visual Science, vol. 51, no. 11, 2010, p. 5840.

2. Scanlon, Grainne, et al. “Macular Pigment Optical Density Is Lower In Type 2 Diabetes, Compared With Type 1 Diabetes And Normal Controls.”Retina, vol. 35, no. 9, 2015, pp. 1808–1816.

DOES DIABETES AFFECTVISUAL PERFORMANCE?

CONTRAST SENSITIVITY IN DIABETES

Stavrou, Efty P., and Joanne M. Wood. “Letter Contrast Sensitivity Changes in Early Diabetic Retinopathy.” Clinical and Experimental Optometry, vol. 86, no. 3, 2003, pp. 152–156.

STUDY : LETTER CS IN DIABETICS VS CONTROLS

• Pelli-Robson test was used for CS testingLetter CS for controls (m=24): 2.2%

Letter CS for Type 2 diabetics (n=20): 3.6%

Approximate 2-line difference in groups is significant!Letter CS (but not VA) was reduced with min/no DR/no DME vs controls

CONCLUSION:Measuring letter CS can be an effective screening tool

for identifying and monitoring decreased visual function in diabetic patients

DO PATIENTS WITH DIABETES RESPONDTO MACULAR CAROTENOID SUPPLEMENTS?

“Application of Lutein and Zeaxanthin in non-proliferative diabetic retinopathy”• 3 Month Intervention Study published in 2011 from Tianjin, China• Comparing serum carotenoid levels and visual function• 30 diabetics with NDR: 4 type 1 and 26 type 2 were given 6mg L and 0.5mg Z• 30 diabetics with NDR: DR control group and 30 participants without DM included

Baseline serum carotenoids were much higher in non-diabetic controls but after 3 months in the treated group:

Higher serum carotenoids than either of the other groupsContrast sensitivity at 1.5, 3.0, and 6.0 cpd increased significantly

Hu BJ, Hu YN, Lin S, Ma WJ, Li XR. Application of Lutein and Zeaxanthin in nonproliferative diabetic retinopathy. Int J Ophthalmol. 2011;4:303–6

THE ROLE OF MACULAR CAROTENOIDS AND OMEGA-3 IN THE RETINA

“The presence of L and Z throughout the neural retina and brain supports the possibility that L might play a role in preserving long-chain polyunsaturated-rich neural tissue and

ultimately enhance the transmission of visual impulses to the brain”1

1. Mares, Julie. “Lutein and Zeaxanthin Isomers in Eye Health and Disease.” Annual review of nutrition vol. 36 (2016): 571-602.

IS THERE A CORRELATION BETWEEN SERUM CAROTENOID LEVELS

AND THE INCIDENCE OF

DIABETIC RETINOPATHY?

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SERUM CAROTENOIDS IN DIABETES

• Previous studies have demonstrated lower serum carotenoids in diabetes• This study looked at relationship of serum carotenoids to DR• 111 Type 2 diabetic men participated, ages 44-77, no history of supplementation

Brazionis, Laima, et al. “Plasma Carotenoids and Diabetic Retinopathy.” British Journal of Nutrition, vol. 101, no. 02, 2008, p. 270.

RESULTSA higher combined plasma concentration of L, Z, and lycopene vs beta carotene and other carotenoids was associated with a

66% lower odds ratio of having diabetic retinopathy

Plasma Carotenoids and Diabetic Retinopathy

IS THERE A CORRELATION BETWEEN SERUM CAROTENOID LEVELS AND THE INCIDENCE OF DIABETIC RETINOPATHY?

CONCLUSIONSIndependent Synergies Between Plasma Carotenoids

Related To DR Appear To Exist

Study does not prove a cause and effect relationship - more studies are needed

Brazionis, Laima, et al. “Plasma Carotenoids and Diabetic Retinopathy.” British Journal of Nutrition,vol. 101, no. 02, 2008, p. 270.

However, it does provide support for the concept of recommending carotenoid-rich foods and supplements

containing L, Z, and lycopene to reduce the risk of DR

No relationship has been found between plasma levels of

Vitamin C or Vitamin E and Diabetic Retinopathy

Millen, A. E. “Relations of Serum Ascorbic Acid and -Tocopherol to Diabetic Retinopathy in the Third National Health and Nutrition Examination Survey.” American Journal of Epidemiology, vol. 158, no. 3, 2003, pp. 225–233.

.

DOES A TRIPLE CAROTENOID SUPPLEMENTIMPROVE MACULAR FUNCTION IN

PATIENTS WITH DIABETES?

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FUNCTIONAL ASSESSEMENT OF MACULAR FUNCTION WITH ERG IN DIABETES

Multifocal ERG (mfERG)• Best for diabetic macular disorders1

• Detects localized retinal dysfunction• Indicates photoreceptor and outer

plexiform-bipolar layer response

1.Pescosolido, Nicola, et al. “Role of Electrophysiology in the Early Diagnosis and Follow-Up of Diabetic Retinopathy.”Journal of Diabetes Research, vol. 2015, 2015, pp. 1–8.,

.

Moschos, Marilita M., et al. “Effect of Carotenoids Dietary Supplementation on Macular Function in Diabetic Patients.” Eye and Vision, vol. 4, no. 1, 2017.

Retrospective 2017 Study of 120 eyes (60 individuals) with non-insulin dependent Type 2 Diabetes

10MZ-10L-2Z taken for 2 years

The Patients Had No Diabetic Retinopathy

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After: 193 nV/deg2Before: 169 nV/deg2

Electrical responses in the central 13 degrees were significantly enhanced with nutritional intervention

From Moschos, Marilita M., et al. Effect of Carotenoids Dietary Supplementation on Macular Function in Diabetic Patients. Eye and Vision, vol. 4, no. 1, 2017

↑ ELECTRICAL RESPONSE = ↑ RETINAL FUNCTIONWITH TRIPLE CAROTENOID THERAPY

FUNCTIONAL ASSESSEMENT OF MACULAR FUNCTION WITH ERG IN DIABETES

SUMMARY- IN DIABETIC PATIENTS

1) Retinal Oxidative Stress Is Increased 2) Macular Pigment And Macular Carotenoids In

The Serum Are Typically Low3) Contrast Sensitivity Is Often Reduced

MACULAR CAROTENOIDS REDUCE OXIDATIVE STRESSRESEARCH SUPPORTS THE USE OF SUPPLEMENTATION

TO IMPROVE VISUAL PERFORMANCE AND ENHANCE RETINAL FUNCTIONIN TYPE 2 DIABETIC PATIENTS

ARE OMEGA-3 LEVELS IMPORTANT IN DIABETIC PATIENTS?

WHAT ARE OMEGA-3 FATTY ACIDS?

OMEGA-3s: PolyUnsaturated Fatty Acids (PUFAs)-ESSENTIAL FATS1) EPA- eicosapentaenoic acid (long-chain PUFA)- anti-inflammatory

2) DHA -docosahexaenoic acid (long-chain PUFA)- “brain food”

3) DPA- docosapentaenoic acid (long-chain PUFA)

4) ALA- alpha-linolenic acid (intermediate-chain PUFA) from plantsCan be elongated to longer-chain omega-3 in humans- BUT inefficient

Atlantic Bluefin Tuna

Byelashov, Oleksandr A et al. “Dietary sources, current intakes, and nutritional role of omega-3 docosapentaenoic acid.” Lipid technology vol. 27,4 (2015): 79-82.

Most Predominant Omega-3 Found In The Brain And Retina• Major component of outer segment cell membranes • Essential nutrient for seeing in varying light conditions• Important source of anti-inflammatory mediators

Dietary Considerations• Triglyceride (TG) form better absorbed than ethyl ester (EE)• Dietary ratio of omega-6/omega-3 at least 11 / 1 • Excess omega-6 within the diet may displace DHA

OMEGA-3: ROLE OF DHA IN THE BRAIN AND RETINA1,2

1.Bradbury, Joanne. “Docosahexaenoic acid (DHA): an ancient nutrient for the modern human brain.” Nutrients vol. 3,5 (2011): 529-54.2.Giuseppe Querques, Raimondo Forte, and Eric H. Souied, Retina and Omega-3, Journal of Nutrition and Metabolism Volume (2011):1-12

THE BODY’S HIGHEST CONCENTRATION OF DHA IS FOUND IN THE RETINA!

Omega-3 and Vision

DHA Constitutes Half Of The Mass Of The Retinal Neuronal Membrane

Singh M. Essential Fatty Acids, DHA and Human Brain. Indian J Pediatr 2005;72:239-242

Slide Courtesy William S Harris, Ph D

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OMEGA-3 INTAKE IN DIABETIC RETINOPATHY

IMPORTANT CLINICAL STUDY OF DIABETIC MEN AND WOMEN• Study from 2003-2009 included nearly 3500 individuals >age 55 with Type 2 diabetes • Individuals were part of a larger study in Spain of dietary influences on cardiovascular disease

Goal: to determine the effect of dietary omega-3 levels on the incidence of sight-threatening DR

Intake of at least 500 mg/d of dietary long-chain omega-3 was

associated with a 48% reduced risk of sight-threatening DR.

This can be achieved with 2 servings of oily fish per week.

Sala-Vila, Aleix, et al. “Dietary Marine ω-3 Fatty Acids and Incident Sight-Threatening Retinopathy in Middle-Agedand Older Individuals With Type 2 Diabetes.” JAMA Ophthalmology, vol. 134, no. 10, 2016, p. 1142.

FISH (3 OZ COOKED, DRY HEAT) EPA DHA EPA + DHA % DHA

PACIFIC HERRING 1056 751 1807 42

ATLANTIC SALMON (wild) 349 1215 1564 78

BLUEFIN TUNA 309 970 1279 76

MACKEREL (canned) 369 677 1046 65

SOCKEYE SALMON (wild) 451 595 1046 57

RAINBOW TROUT (farmed) 284 697 981 71

SARDINES (canned) 402 433 835 52

ALBACORE TUNA (canned) 198 535 733 73

SEA BASS 175 473 648 73

TILAPIA 4 111 115 97

ORANGE ROUGHY 5 21 26 81

STD FISH OIL 1000 MG CAP (EE) 180 120 300 40

THE AMOUNT OF OMEGA-3 IN FISH VARIES GREATLY!

Table adapted from Harris et al. Current Atherosclerosis Reports 2008;10:503-509. Values based on USDA Nutrient Data Lab values

The International Society for the Study of Fatty Acids and Lipids( ISSFAL-2004) looked at multiple epidemiological studies

and recommended for cardiovascular health a minimum intake of EPA and DHA combined of

500 mg/day

HOW MUCH OMEGA-3 SHOULD BE INGESTED DAILY?

ISSFAL. Intake of PUFA in healthy adults. http://www.issfal.org/statements/pufa-recommendations/statement-3. Accessed April 3, 2019

Is this the ideal amount for everyone?

HOW MUCH OMEGA-3 DO WE NEED?

THERE IS HIGH VARIABILITY IN INDIVIDUAL UPTAKE

FACTORS INCLUDE:1) Diet2) Supplement form-TG Vs EE3) Heredity4) BMI5) Smoking habits

Dosages of EPA/DHA (TG) Bottom to Top:0, 300mg, 600mg, 900mg, 1800 mg1

1.Flock, Michael R., et al. “Determinants of Erythrocyte Omega‐3 Fatty Acid Content in Response to Fish Oil Supplementation: A Dose–Response Randomized Controlled Trial.” Journal of the American Heart Association, vol. 2, no. 6, 2013.

The Omega-3 Index: Biomarker and Risk Factor

The Omega-3 Index (EPA+DHA as a % of erythrocyte fatty acids) is a marker of tissue levels of EPA and DHA

Having an Omega-3 Index in the desirable range (8%-12%) has been associated with improved heart, brain, eye, and joint health.

Harris WS and von Schacky C. Prev Med 2004;39:212-220.


A Desirable Omega-3 Index Is >8%

Harris WS and von Schacky C. Prev Med 2004;39:212-220.

Typical for US Typical for Japan

Red Blood Cell EPA+DHA (% of total fatty acids)

4% 6% 8%2% 10% 12%

Slide Courtesy William Harris, Ph D

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Circulating EPA+DHA levels taken from:

• 24,129 individual subjects

• 54 countries

• 398 data sets

• Converted to Omega-3 Index equivalents based on Stark et al2

2 Stark et al. PLEFA 2016;104:1–10

1 Stark et al. Global survey of the omega-3 fatty acids, DHA and EPA in the blood stream of healthy adults. Prog Lipid Res. 2016;63:132-152.

GLOBAL OMEGA-3 INDEX1

Meta-Analysis: Omega-3 Index as a Predictor of Risk for Fatal Coronary Heart Disease

(10 studies worldwide - over 27,000 subjects)

Harris WS, et al. Atherosclerosis 2017;262:51-54

Risk for fatal CHD was 35% lower in

persons with an

Omega-3 Index of

8% compared

with those with an Index of 4%

OMEGA-3 INTAKE -IMPORTANT IN REDUCING RISK OF HEART DISEASE


Multivariable-adjusted risk for death from any cause between age 70 and 85 in 6501 post-menopausal women was 31% lower with an Omega-3 Index of >8% vs <4%

Harris WS, et al. J Clin Lipidol 2017;11:250-259

RELATIVE RISK FOR DEATH FROM ANY CAUSE AND THE OMEGA-3INDEX: THE WOMEN’S HEALTH INITIATIVE MEMORY STUDY


“The presence of diabetic retinopathy was associated

with a twofold higher risk of incident CHD events …

and a threefold higher risk of fatal CHD….”1

DIABETIC RETINOPATHY IS ASSOCIATED WITH INCREASED RISK OF CARDIOVASCULAR DISEASE

A Middle-aged Cohort Of Over 1500 Type 2 Diabetics Without Coronary Heart Disease (CHD) Were Followed For Over 7 Years…

1. Diabetes Care 30:1742–1746, 20072. Nasser Shoeibi and Shokoufeh Bonakdaran, “Is There any Correlation Between Diabetic Retinopathy and Risk of Cardiovascular Disease?”, Current Diabetes Reviews (2017) 13: 81.

More Recent Study: Is There Any Correlation Between Diabetic Retinopathy And Risk Of Cardiovascular Disease (CVD)?

“After adjustment for traditional risk factors for CVD,

the risk for CVD remained markedly increased in the presence of DR.”

RISK OF CARDIOVASCULAR DISEASE

Even Without DR, the Risk For CVD DOUBLES When Diabetes And Hypertension Are Both Present (A Common Occurrence)

More than 70% of patients with type 2 diabetes die of cardiovascular causes1

1.Laakso, Markku. “Cardiovascular disease in type 2 diabetes from population to man to mechanisms: the Kelly West Award Lecture 2008.”Diabetes care vol. 33,2 (2010): 442-9 BMJ 2016;355:i5953

IS THERE INCREASED RISK FOR CARDIOVASCULAR DISEASE IN PREDIABETES?

EXTENSIVE REVIEW AND META-ANALYSIS

• 53 prospective studies • Average duration of studies 9.5-years

• Included >1.6 million prediabetics

Found increased risk of up to 30% in CVD even with HbA1C as low as 5.7%

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OMEGA-3:Recent Randomized Clinical Trial

REDUCE-ITReduction of Cardiovascular Events with EPA- Intervention Trial

• RCT: Results of 5-year study released in 2018 • > 8000 patients already on statin with average LDL 75 and TG of 216 • Participants had a history of CVD or diabetes• Treatments: 4 g/d of EPA (Vascepa, Amarin Corp) or placebo (4 g/d)

Primary Study Outcome:Incidence Of Major Adverse Cardiovascular Events

Bhatt et al. NEJM Nov 10, 2018 DOI: 10.1056/NEJMoa1812792.

REDUCE-IT

Bhatt et al. NEJM Nov 10, 2018 DOI: 10.1056/NEJMoa1812792.

Cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina in the icosapent ethyl group and the placebo group, in a time-to-event analysis.


REDUCE-IT

A HOME RUN FOR OMEGA-3!

25% REDUCTION IN COMPOSITE RISK OF SERIOUS CARDIOVASCULAR EVENTS1

The Calculated Omega-3 IndexIn The Treated Group: ~7%2

THE ADA HAS NOW OFFICIALLY RECOGNIZED THE ROLE OF VASCEPA FOR SOME DIABETICS IN THE

2019 ADA STANDARDS OF CARE1.Bhatt et al. NEJM Nov 10, 2018 DOI: 10.1056/NEJMoa1812792.https://investor.amarincorp.com/news-releases/news-release-details/new-updates-american-diabetes-associationsr-2019-standards2. Harris, William S, Jackson, Kristina H, Translating plasma eicosapentaenoic acid (EPA) concentrations into erythrocyte percentages of EPA plus 2 docosahexaenoic acid (DHA) during treatment with icosapent ethyl, J Clin Lipidol, in press

AS HEALTHCARE PROVIDERS--WE MUST CONSIDER THE OVERALL HEALTH OF THE PATIENT

Omega-3

Risk for DR / CVD

TAKE HOME MESSAGE:The average American is consuming ONLY ~1/5th of the

MINIMUM dietary omega-3 recommended for cardiovascular health or if diabetic to reduce the risk of severe retinopathy!

Monitoring omega-3 levels will inform recommendations on intake.

Actual:100-150 mg EPA/DHA per day

Recommended:Min 500 mg EPA/DHA per day

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Logistics Of The Omega-3 Index Test

Collect SampleSimple finger prick – only 1-2 drops of blood needed

Mail to LabUses pre-paid return envelope and standard mail

LearnIn 1-2 weeks a report is sent with the test results

CorrectSimple dietary changes can improve results in as little as

a few weeks

OMEGAQUANT.COMSLIDE COURTESY WILLIAM HARRIS, PH D

Metabolic

Disorder

In Diabetes

Lutein,

Zeaxanthin,

Meso-zeaxanthin,

DHA, EPA

OX

IDA

TIO

N/I

NFL

AM

MA

TIO

N

OX

IDA

TION

/INFLA

MM

ATIO

N

RATIONALE FOR USING MACULAR CAROTENOIDS WITH OMEGA-3 IN DIABETES

USE OF OCT ANGIOGRAPHY IN DIABETIC PATIENTSWe are still in the infancy stage with this technology

CASE STUDYMark W. Roark, OD, FAAO

Diabetic Retinopathywith Reduced Contrast Sensitivity

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASEDIABETIC RETINOPATHY WITH REDUCED CS IN A 48 YEAR-OLD MALE

Mark W. Roark, OD, FAAO

History• Retinopathy noted OU on routine exam 6 years prior- referred to PCP• Diagnosis: Type II diabetes, started on oral med, now diet-controlled• History of mild macular edema 3+ years ago OS>OD which resolved • History of low Macular Pigment and family history of AMD

Why is there a 3-line difference in CST despite equal Visual Acuities?

OD: VA 20/20

CST 1.6%OS: VA 20/20

CST 3.2%


Dilated fundus exam shows NPDR OS>OD; no macular edema in either eye on 90D stereo view

FAF shows heme L>R

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OCT OF THE MACULA • No macular edema OU• Why is CS reduced OS?

OS

OD


MORE INFO NEEDED: PERG ORDERED


MACULARISCHEMIA!

AbnormalPERG OSConfirmsMacular ischemiaCST 3.2%

NormalPERG OD

CST 1.6%

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASEDIABETIC RETINOPATHY WITH REDUCED CS IN A 48 YEAR-OLD MALE- A YEAR LATER

OCT A IMAGES

APPROXIMATELY ONE YEAR LATER- NO SUPPLEMENTS BEING USED• OCT A ordered for additional macular evaluation to study capillary plexus blood flow• Foveal Avascular Zone larger OS, consistent with findings of macular ischemia with reduced CS

AREA OF FAZ 32% LARGER OS THAN OD!

OD-CST 2.0% OS-CST 5.0%


SUMMARY• Visual acuity normal- but patient now notes subjective decrease in vision OS• Non-proliferative DR without macular edema noted OS>OD• Contrast sensitivity testing alone uncovered need for additional diagnostic testing

-PERG abnormal OS, consistent with macular ischemia and correlated with CST-OCT A showed larger FAZ OS and reduced blood flow, consistent again with CST Result:• Diagnosis of macular ischemia • Better understanding of the risk for proliferative disease• Closer observation to reduce risk of vision loss• Nutritional intervention indicated

-≥500 mg omega-3s daily to reduce risk of DR progression-Triple carotenoid indicated: low MPOD, family history of AMD

SUMMARY WHAT WE KNOW:

NUTRITIONAL SUPPLEMENTSMacular Carotenoids And Omega-3 Appear To Improve Retinal Function And Health

Increased Contrast SensitivityIncreased ERG responseReduced Inflammation

DIABETIC RETINOPATHYEarly Recognition With Advanced Technology May Reduce Risk Of Advanced DiseaseRisk of Severe Retinopathy Reduced With Increase in Omega-3 Linked to Increased Risk Of Cardiovascular Disease and Sudden Fatal Heart Attack

DIABETES MELLITUSIncreasing Incidence Due To Several Factors Including Poor Diet And Physical InactivityMost Common Cause Of Vision Loss In Patients Ages 20-74Associated With Increased Risk Of CVD Including Sudden Cardiac Death

SUGGESTED ACTIONS FOR DIABETIC PATIENTS RECOMMEND THE FOLLOWING:

TRIPLE CAROTENOID MACULAR PIGMENT SUPPLEMENTShown To Enhance Visual Performance And Retinal FunctionImportant To Reduce Oxidative Stress

TRIGLYCERIDE FORMULA OMEGA-3 SUPPLEMENTMinimum Daily Dosage Of 500 Mg Should Be Given And Omega-3 Index MonitoredHigh DHA Supplement Likely Preferred Based On Higher Amounts In The Retina/Brain

MONITORING OF RETINAL HEALTH AND VISUAL FUNCTIONOCT And OCT Angiography // Widefield Retinal Photography ImportantContrast Sensitivity Testing – Find And Understand Changes In Visual Performance

HEALTHY DIET AND LIFESTYLEEat Plenty Of Dark, Leafy Greens, Colored Fruits And VegetablesEat Minimum of 1-2 Healthy Servings Of Oily Fish Per WeekIncrease Physical Activity, Control Weight, Monitor BSL, BP, Lipids

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THANK YOU!

[email protected]

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VISUAL PERFORMANCE:BEYOND 20/20 WITH ENHANCED

MACULAR NUTRITIONIncluding Case Studies

• Mark W Roark, OD, FAAO

• Allisonville Eye Care Center

• Fishers, IN



Allisonville Eye Care Center– Fishers, Indiana YOU DON’T KNOW HOW TO BEST HELP YOUR PATIENTS UNTIL YOU UNDERSTAND HOW THEY SEE!

GOALS:

1) Look at the latest research showing the value of Contrast Sensitivity (CS) testing to measure and monitor visual performance

2) Appreciate the role of Macular Pigment (MP) in eye health and visual performance

3) Observe through Case Studies that patients with excellent VA may have poor visual quality as determined with CS testing and may benefit from nutritional or other intervention

CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL VA PATIENTS23-YEAR-OLD MYOPIC FEMALE WITH COMPLAINTS OF GLARE

• 23-YEAR-OLD MYOPIC FEMALE• Patient with chronic night glare OU, worse over the last 6 months• Paternal GF blind from AMD, Paternal Aunt with AMD• Takes Fioricet for migraines / No ocular pathology present• Persistent symptoms despite new eyeglasses with good quality AR

OD: -1.25-0.50 x 085 / 20+ OS: -1.00-0.25 x 077 / 20+


How would you handle this patient in your practice?

A) Reassure the patient that nothing is wrong

B) Perform additional diagnostic or medical testing

C) Refer to another provider for a second opinion

D) Recommend a nutritional supplement

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20/20 (6/6) or smaller is only ~9% of our visual world!2

• Sloan designed a uniform

series of 10 letter optotypes

• Letters are C, D, H, K, N, O,

R, S, V and Z (no serifs)

• ETDRS chart chosen for

research uses Sloan letters.

Stroke width= 1/5th of the letter height

HOW SHOULD WE MEASURE VISUAL PERFORMANCE?

1Wood JM, Owens DA. Standard measures of visual acuity do not predict drivers’ recognition performance under day or night conditions. Optometry and Vision Science 2005;82(8):698-705

2Personal communication: Jim Stringham, PhD

The ability to function in activities of daily living cannot be reliably predicted based on visual acuity alone1

OTHER WAYS TO MEASURE VISUAL PERFORMANCE

VISUAL FIELDS

• Show sensitivity to light presented

across a large spatial area

Limitations

• Time-consuming and often difficult test

OTHER MEASURES

• Include color vision testing,

binocularity, glare recovery

time, dark adaptation

CONTRAST SENSITIVITY- IMPORTANT MEASURE OF VISUAL PERFORMANCE

DEFINITIONS:

• Contrast Sensitivity Threshold (CST) is the minimumdifference between the luminance of the target andthe background required to recognize the target.

• Contrast Sensitivity (CS) is the reciprocal of this.

!

- Photopic CS: background luminance ~85 cd/m2*- Mesopic CS: background luminance ~3 cd/m2*

*https://www.aaojournal.org/article/S0161-6420(16)31336-7/pdf

We are measuring the border between the visible and the invisible.

LOW CONTRAST SITUATIONS ARE COMMON

The human visual system can detect a single candle flame at a distance of ___?

1.6 miles (2.5 km)!*

We are sensitive to changes in luminancethat vary by a factor of more than

*Shown by Kevin Krisciunas and Don Carona in the astrophysics department at Texas A&M in 2015.

CONTRAST SENSITIVITY FUNCTION

The Contrast Sensitivity Function (CSF) typically consists of the contrast thresholds at about 5 spatial frequencies.

The CSF is dependent on physiologic, neural and optical factors.

20/20

20/100

FAINTER

SMALLER

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20/20 = 30 cpd

20/100 = 6 cpd

UNDERSTANDING SPATIAL FREQUENCY NOTATION

20 Foot Testing Distance20/20 Letter

CONTRAST SENSITIVITY TESTING WHAT TARGET SIZE SHOULD BE MEASURED?

STUDY: Owsley and Sloane: “Contrast Sensitivity, acuity,

and the perception of ‘real-world’ targets” (BJO 1987)

Overall, 20/100 is the best target size for predicting the ability to identify and recognize faces, signs, and objects.

TESTING CONTRAST SENSITIVITY WITH PHYSICAL LETTER CHARTS

PELLI-ROBSON MARS

8 ROWS OF 6 LETTERS 8 ROWS OF 6 LETTERS

LETTER TRIPLETS INDIVIDUAL LETTERS

0.15 logCS STEPS 0.04 logCS STEPS

1 OR 3 M DISTANCE 40-50 CM DISTANCE

PELLI-ROBSON CHART VS HARRIS CONTRAST TEST ON LCD SCREENS

2013 Comparison Study published in the Journal of Ophthalmology showed similar results for both normal and diseased eyes. (262 eyes)Conclusion: LCD testing using the Harris Contrast Test with individual Sloan letters is an alternative to the Pelli-Robson gold-standard for measuring Contrast Sensitivity

CONTRAST SENSITIVITY USING ELECTRONIC LCD CHARTSHARRIS CONTRAST TEST

“Old School” “New School”… and Cool!

Rapid assessment can easily be performed through the latest refraction at 20’

HOW TO MEASURE PHOTOPIC LETTER CONTRAST SENSITIVITY

1) Measure CS monocularly with best distance prescription and with non-dilated pupils2) Turn the room lights OFF3) Isolate a 20/100 (6 cpd) Sloan letter on a properly calibrated electronic chart4) Next, project a 5% contrast letter and ask the patient to identify the letter5) Decrease (or increase) the contrast level by one step as needed 6) Proceed slowly, allowing time for the letters to come into view7) Record lowest CST where the patient can correctly identify 2/3 random letters8) Document OD or OS: (Example - OD@6cpd 2.5%)

5%-Poor1.25%-Good 6.3%-Impaired Driving

- CATARACT REFERRAL-

8.0%-Very Poor 10%- Severe Impairment

2.5%- Average

COMPARISON OF VISUAL ACUITY TO CONTRAST SENSITIVITY

YOU CANNOT PREDICT CONTRAST SENSITIVITY FROM VISUAL ACUITIES

For example, it is possible to see 20/20- or better with a CST from 0.80% to at least 8.0%.

Good VA with poor CS = POOR QUALITY VISION!

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

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CONTRAST SENSITIVITY TESTING IN PRIMARY EYE CARE

Just check Visual Acuity AND Photopic Contrast Sensitivity at 20/100.

You will gain valuable information quickly about your patient’s true visual performance to guide your treatment recommendations.

USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL PERFORMANCEFINANCIAL CONSIDERATIONS

H53.72 Impaired Contrast SensitivityH53.71 Glare Sensitivity

Coding By Time • 99212 (10 min)• 99213 (15 min)• 99214 (25 min)• 99215 (40 min)

>50% of time spent in face-to-face counseling with the patient regarding the condition

PHOTOPIC LETTER CONTRAST SENSITIVITY THRESHOLDSWHAT IS NORMAL?

When no ocular pathology is present, clinical studies and experience suggest that at 20/100

(6/30), the expected letter CST will most often measure an average of 2.0% - 2.5%.

Pelli-Robson Letter Chart

CSTs of 1.5-2.5 % for young subjects and 2.5-

3.2% for older subjects (above age 60) is the

normal range*

CREST Normal Clinical Trial Observations

Baseline letter CST of 2.0 to 2.1% for both

active and placebo groups at 6 cpd

Validation of LCD Based CS Testing Method

(2015 SCO Poster)

Mean binocular testing of 53 healthy adults

ages 23-65 at 6 cpd was 2.3%

*Mäntyjärvi, Maija, and Tarja Laitinen. “Normal Values for the Pelli-Robson Contrast Sensitivity Test.”Journal of Cataract & Refractive Surgery, vol. 27, no. 2, 2001, pp. 261–266

DETERMINE BCVA

NORMAL EYE HEALTH CONFIRMED

CHECK LETTER CONTRAST SENSITIVITY @ 20/100 (6/30)

0.8- 1.6%- GOOD 2.0- 2.5% - AVERAGE ≥ 3.2% - POOR

USING CONTRAST SENSITIVITY TESTING IN PATIENTS WITHOUT OCULAR DISEASE

0.8- 2.0%- GOOD 2.5- 3.2% AVERAGE ≥4.0% - POOR

PATIENTSAGE 20-60

PATIENTS> AGE 60

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

MEASURING VISUAL QUALITYMark W Roark, OD, FAAO

10.0% 4.0%8.0% 6.3% 5.0% 3.2% 2.5% 2.0% 1.6% 1.25% 1.0%

CONTRAST SENSITIVITY THRESHOLDS (20/100 target, 0.1 LogCS steps)

SEVERELY IMPAIRED----------------------------POOR-----------SUBOPTIMAL ---------AVERAGE------------------------------------EXCELLENT

CONTRAST SENSITIVITY GUIDE UNDERSTANDING THE VISUAL IMPACT OF CHANGES IN CONTRAST SENSITIVITY

VA @ 100% Contrast0.1 LogMAR Steps

Letter CST @ 20/1000.1 LogCS Steps

Roark Model for Assessing Visual Impact of Letter Contrast Sensitivity Threshold Changes @ 20/100 Compared to Visual Acuity Changes*

0.8% 20/10

1.0% 20/12.5

1.25% 20/16

1.6% 20/20

2.0% 20/25

2.5% 20/32

3.2% 20/40

4.0% 20/50

5.0% 20/63Poor Visual

Performance

Poor Visual Performance

Assuming Limiting Letter CST of 0.8% and Peak BVA of 20/10

Constant CPD WithDecreasing Contrast

Sensitivity

Constant Contrast With Decreasing Letter

Resolution

The visual impact ofbeing able to identify aletter one step fainter onthe CS chart can becompared to the abilityto identify letters one linesmaller on the VA chartwhen both are measuredin an equal logarithmicincrement.

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Corroboration of this Model: The Salisbury Eye Evaluation• 2520 older Americans from Salisbury, MD assessed in the mid-90s• Patient ages 65-84, part of a larger project • Association of various visual impairments with self-reported visual disability• Visual disability assessed with Activities of Daily Vision Scale (ADVS) questionnaire

UNDERSTANDING THE VISUAL IMPACT OF CHANGES IN CONTRAST SENSITIVITY

SAMPLE ACTIVITIES RATED WITH THE ADVS1) Driving at night with or without oncoming headlights2) Driving in unfamiliar areas 3) Reading street signs in daylight or nighttime4) Walking down steps during daylight or in dim light 5) Watching television 6) Reading directions on medicine bottles 7) Writing checks 8) Preparing meals

RESULTS


A Reduction In Contrast Sensitivity Of 0.3 LogCS-OR-

An Increase Of 0.3 LogMAR (decrease in VA)

Showed A Similar Association With Reported Difficulties In VisuaI Function

Rubin GS1, Bandeen-Roche K, Huang GH, Muñoz B, Schein OD, Fried LP, West SK, The Association of Multiple Visual Impairments with Self-Reported Visual Disability:SEE Project, Investigative Ophthalmology & Visual Science 2001;42(1):64-72

But can we make a difference in visual performance in patients with

20/20 and no signs of ocular disease?

HOW MUCH IMPACT CAN WE MAKE IN HEALTHY PATIENTS?

???

But can we make a difference in visual performance in patients with

20/20 and no signs of ocular disease?

HOW MUCH IMPACT CAN WE MAKE IN HEALTHY PATIENTS?

???

CONTRAST SENSITIVITY TESTING IN PRIMARY EYE CAREVISUAL PERFORMANCE AND NUTRTION

June 2016 Investigative Ophthalmologyand Visual Science (IOVS)

CREST Normal- Landmark Study

Level 1 evidence!

AVERAGE BASELINE LETTER CST @ 6CPD: 2.0-2.1%

The study used a supplement containing:-10mg of Lutein-10mg of Meso-Zeaxanthin-2 mg of Zeaxanthin

YES!

20/100

CONTRAST SENSITIVITY TESTING IN PRIMARY EYE CAREVISUAL PERFORMANCE AND NUTRTION

QUESTIONS ABOUT THE RESULTS OF THE CREST NORMAL STUDY

We know supplements have been shown in some studies to reducerisk of disease but why would a nutritional supplement improve vision?

Why was a triple carotenoid supplement chosen for the study?

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https://www.ncbi.nlm.nih.gov/pubmed/?term=Rubin%20GS%5BAuthor%5D&cauthor=true&cauthor_uid=11133849

https://www.ncbi.nlm.nih.gov/pubmed/?term=Bandeen-Roche%20K%5BAuthor%5D&cauthor=true&cauthor_uid=11133849

https://www.ncbi.nlm.nih.gov/pubmed/?term=Huang%20GH%5BAuthor%5D&cauthor=true&cauthor_uid=11133849

https://www.ncbi.nlm.nih.gov/pubmed/?term=Mu%C3%B1oz%20B%5BAuthor%5D&cauthor=true&cauthor_uid=11133849

https://www.ncbi.nlm.nih.gov/pubmed/?term=Schein%20OD%5BAuthor%5D&cauthor=true&cauthor_uid=11133849

https://www.ncbi.nlm.nih.gov/pubmed/?term=Fried%20LP%5BAuthor%5D&cauthor=true&cauthor_uid=11133849

https://www.ncbi.nlm.nih.gov/pubmed/?term=West%20SK%5BAuthor%5D&cauthor=true&cauthor_uid=11133849

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Macula Lutea:

“YELLOW SPOT”

MACULAR PIGMENT

Timeline- Macular Pigment (MP)

• 1866- Schultze suggested vision benefit and protection from blue-light

• 1945- Wald demonstrated thepresence of carotenoids

• 1985- Carotenoids shown to belutein (L) and zeaxanthin (Z)

• 1993- Third carotenoid-meso-zeaxanthin (MZ)- found

WHY IS YELLOW PIGMENT PRESENT IN THE MACULA?

• Leaves stop producing chlorophyll (source of green color)

• Other pigments normally presentare then revealed

• Yellow and orange colors comefrom carotenoids

• Function to protect leaves from sundamage and degeneration

CAROTENOIDS IN NATUREOVER 700 DIFFERENT CAROTENOIDS

FALL FOLIAGE

PUFFERFISH AND CAROTENOIDS

PUFFERFISH – 120 Species• Double layer of skin (some with spines)

but no scales so can inflate

• Contain a toxic substance that is deadly to other fish and to humans

• Active in daytime and at night with a “PHOTOCHROMIC CORNEA”

✓ Cornea is clear in the dark but becomes yellow during the day

✓ Carotenoids are released to protect from light damage, improve vision

TOADFISH AND CAROTENOIDS

TOADFISHLight Dark

Occlusable corneas in toadfishes: Light transmission, movement and ultrastruture of pigment during light- and dark-adaptation - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/Fig1-A-The-common-toadfish-Tetractenos-hamiltoni-B-The-weeping-toado-Torquigener_fig2_10739642 [accessed 15 Nov, 2018]

DISTRIBUTION OF CAROTENOIDS IN THE HUMAN MACULA

1:1:1

• L, Z, and MZ work best as a team!

• MZ is most central and the strongest anti-oxidant

• MZ is part of the food chain but not as prevalent in our food

• From 12- 30% of the population appear not to be able to convert L to MZ

The “Blue Light Hazard”

*Lutein, Zeaxanthin, and Mesozeaxanthin in the retina (macular pigment) absorb

wavelengths in the visible spectrum with the highest potential to do damage

lutein zeaxanthin

meso-zeaxanthin

macular pigment

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Central Macular Pigment

Central Macular Pigment

Macular Pigment Volume

Macular Pigment Volume

CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTINGUNDERSTANDING THE LIMITS OF MPOD TESTING

• Useful, but imperfect method of determining macular pigment• Measures 1 point at 0.5 degree eccentricity

Limitations of Testing Macular Pigment:Similar central pigment peaks with large differences in Macular Pigment Volume can occur.

*Graphs courtesy of John Nolan, PhD

Heterochromic Flicker Photometry

Dual-wavelength Autofluorescence- Measures Macular Pigment Volume• Objective measurement using digital subtraction of 2 images• Measures entire spatial profile across all macular eccentricities• Used in research

Macula without Macular pigment Macula with Macular pigment

Healthy Photo Receptors Macular Pigment

SHORT-WAVELENGTH (BLUE) LIGHT FILTRATION

Free Radicals

Blue Light

Courtesy Jim Stringham Ph D

Average Glare Disability Improvement From Low MP to High MP is About 40%

Images: TJTP Van Den Berg.

Increased straylight 40%

High MPOD Low MPOD

Based on data from Stringham & Hammond (2007)

IMPROVEMENTS IN VISUAL PERFORMANCE- REDUCTION OF GLARECAROTENOIDS ARE PRESENT THROUGHOUT THE EYE AND VISUAL SYSTEM

~50 in

diet

~20 in serum Only lutein, zeaxanthin,

and meso-zeaxanthin

found in the eye

(concentration over

1000X serum)1



1Landrum JT, et al. Arch Biochem Biophys. 2001; 385:28-40.

*Courtesy Jim Stringham Ph D

BRAIN AND OCULAR NUTRITION RESEARCH



.

• Strong correlation between MP in retina and brain

• Correlations of MP with cognitive function

• Research is continuing

University of Cambridge, Downing Collegebonconference.org

:

MECHANISMS FOR IMPROVEMENTS IN CONTRAST SENSITIVITY

Mechanisms for Contrast Sensitivity Enhancement• Macular carotenoids are present throughout most of the visual pathway

• Serum carotenoid levels improve significantly with supplementation

• The neurophysiology of the retina and visual system likely improves, leading to better contrast sensitivity through enhanced lateral inhibition*

*Stringham JM, O’Brien KJ, Stringham NT. Contrast sensitivity and lateral inhibition are enhanced with macular carotenoid supplementation. Invest Ophthalmol Vis Sci. 2017; 58(4): 2291-2295.

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Better Contrast Sensitivity enablesthings that are faint to appear darkerso that they are more easily recognized

SOURCES OF MACULAR CAROTENOIDS

The typical American dietary intake is only about 1.6mgof lutein and zeaxanthin combined per day for adults!

WE LIVE IN AN ERA OF NUTRIENT-DEFICIENT FOODS AND POOR DIETARY HABITS

• About 25% of the vegetable intake in the US consists of french fries.• We need a rainbow of colorful fruits and vegetables in our diet.

Top Three:❑Spinach❑Kale❑Orange Bell Peppers

Supplementation is often needed to achieve optimal macular pigment accumulation

RESEARCH SUPPORTING MACULAR PIGMENTOVER 400 PEER-REVIEWED PUBLICATIONS TO DATE

What about Meso-Zeaxanthin?

CONTRAST SENSITIVITY TESTING IN PRIMARY EYE CAREVISUAL PERFORMANCE AND NUTRITION

MOST STUDIES- 8 trials from 2008-2015Meso-Zeaxanthin Ocular Supplementation Trials

This study reported increases in serum concentrations of MZ and L following

supplementation with all three macular carotenoids (in a MZ:L:Z [mg] ratio of 10:10:2) and a increase in MP,

after two weeks of supplementation.significant

Subjects supplemented with all three macular carotenoids (in a MZ:L:Z [mg] ratio of 10:10:2) exhibited significant

increases in serum concentrations of these carotenoids and a subsequent increase in central MP. Pathology

analysis suggested no adverse clinical implications of consuming these carotenoids.

The formulation containing all three macular carotenoids (in a MZ:L:Z [mg] ratio of 10:10:2) was the most efficacious in terms of

achieving the highest combined concentration of the three MP constituent carotenoids in serum, thereby potentially optimising the bioavailability of

these compounds for capture by the target tissue (retina).

Serum MZ response is positively related to MP following supplementation in AMD subjects, and a

formulation containing equal amounts of L and MZ (10 mg of each) appears to result in a greater augmentation of MP across the measured spatial

profile, when compared with formulations lacking MZ.

2010 2011 2012 2014

M.O.S.T TRIALS: EXPLORATORY STUDIES

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CONTRAST SENSITIVITY TESTING IN PRIMARY EYE CAREVISUAL PERFORMANCE AND NUTRITION

Loughman, J., et al. “The Impact of Macular Pigment Augmentation on Visual Performance Using Different Carotenoid Formulations.” Investigative Ophthalmology & Visual Science, vol. 53, no. 12, 2012, pp. 7871–7880., doi:10.1167/iovs.12-10690

“The Impact of Macular Pigment Augmentation on Visual Performance Using Different Carotenoid Formulations.”-2012

Change in mesopic CS across supplementation groups6 Month Study

“The current study demonstrates a novel and important effect of MP augmentation on visual performance among healthy subjects without ocular disease. Across a broad range of testing modalities and

conditions, visual performance improved significantly among subjects who exhibited a significant rise in MPOD. Specifically, improvements in

contrast sensitivity (across virtually all spatial frequencies, under daytime and nighttime conditions, with and without glare conditions), and improvements in VA, were demonstrated in subjects

supplemented with all three macular carotenoids, but no such observations were seen in the placebo control subjects or in subjects supplemented with L and Z

(but not MZ)….”

Group 1: high L group (L = 20 mg/day, Z = 2 mg/day); Group 2: combined carotenoid group (MZ = 10 mg/day, L = 10 mg/day, Z = 2 mg/day); Group 3: high MZ group (MZ = 17 mg/day, L = 3 mg/day, Z = 2 mg/day);

We report that the typical central peak of

MP can be realized in subjects with

atypical spatial profiles, following

supplementation with a preparation

containing all three macular carotenoids,

but not with a supplement lacking MZ.

See definitions in paper for each group for

each figure.

High L Group Combined Carotenoid

Group

High MZ Group

2012

REBUILDING CENTRAL DIPS

We believe that a Central Dip is found in about 30% of the population. This may be the percentage of peopleunable to convert L to MZ because of lack of the enzyme needed for this conversion.

This study confirmed the presence of MZ in nature, and in the human food chain.

SOURCES OF MACULAR CAROTENOIDS

Is Meso- Zeaxanthin Necessary?

1) We cannot determine who is able to convert L to MZ2) Little MZ is available in commonly consumed foods

Yes!

CASE STUDIES

1) Normal Visual Acuity and Apparent Healthy Eyes 2) Normal Visual Acuity after LVC3) Cataracts- Cortical, NS, PSC4) Secondary Cataract5) Macular Degeneration6) Pattern Dystrophies7) Premium IOLs8) Post-Op Complications9) Medication Toxicity10) Glaucoma11) Corneal Disease12) Diabetic Retinopathy13) Corneal Hypoxia from CL wear

Contrast Sensitivity Testing and Nutritional Intervention:better patient care across many different diagnoses:

Contrast Sensitivity:• Reduced with poor Macular Nutrition • Reduced in numerous disease states• Non-specific - so you must consider this when evaluation CS

• Indicates level of visual impact

CONTRAST SENSITIVITY CAN BE REDUCED IN MULTIPLE CLINICAL CONDITIONSCLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL VA PATIENTS

23-YEAR-OLD MYOPIC FEMALE WITH COMPLAINTS OF GLARE

• 23-YEAR-OLD MYOPIC FEMALE• Patient with chronic night glare OU, worse over the last 6 months• Paternal GF blind from AMD, Paternal Aunt with AMD• Takes Fioricet for migraines / No ocular pathology present• Persistent symptoms despite new eyeglasses with good quality AR

OD: -1.25-0.50 x 085 20/20+ OS: -1.00-0.25 x 077 20/20+

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CST@ 6cpdc 3.2% CST@ 6cpd 3.2%

RMS 0.24D

RMS 0.39D

Excellent optical system- no significant aberrationsHistory of very poor diet the last few years Low Macular Pigment Optical Density (MPOD)-0.27

RMS 0.18D

RMS 0.17D

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%


OD: CST 1.25% OS: CST 1.6%

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

REPEAT TESTING PERFORMED 8 WEEKS LATER and AGAIN AT 3 MONTHS• Triple carotenoid supplement taken every day• MPOD improved to 0.30

• Patient notes much less glare at night- IMPROVEMENT RATED 6/10!


The patient reported a very healthy diet in early childhood, but this changed during college. Her CS improved quickly and dramatically after high levels of a triple carotenoid supplement were taken.

Testing CS – even in patients with normal VA and no eye disease– often uncovers unaddressed visual problems and brings the important topic of ocular nutrition into the exam lane.


How would you handle this patient in your practice?

A) Reassure the patient that nothing is wrong

B) Perform additional diagnostic or medical testing- CST

C) Refer to another provider for a second opinion

D) Recommend a nutritional supplement- Triple Carotenoid

CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS:47-YEAR-OLD MYOPIC FEMALE WITH REDUCED CST OU

47-Year-Old Science Teacher

• DW Single use SCL wearer

• 20/20 VA and healthy eyes

• Notes vision not sharp with daily activities

• Also c/o poor vision at night

• Takes Prozac, Zyrtec

• Systemic diagnosis of Sarcoidosis

• Good ocular health

Refraction: OD -6.50 -0.75 x 005 20/20OS -7.00-0.75 x 012 20/20

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

What else should we do?

CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS:47-YEAR-OLD MYOPIC FEMALE WITH REDUCED CST OU

47 Year-Old Science Teacher

Refraction:

OD -6.50 -0.75 x 005 20/20 OS -7.00-0.75 x 012 20/20

“

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

CST 4.0% CST 4.0%

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CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS47-YEAR-OLD MYOPIC FEMALE WITH REDUCED CST OU

• No signs of corneal or other abnormality

• Large pupils but minimal Higher Order Aberrations

• CST expected to be at least 2 lines better

• Potential improvement with enhanced Macular Pigment

RMS 0.16D

RMS 0.23D

Patient started on 10-10-2 triple carotenoid formula; rec medical recheck in 6 months

RMS 0.12D

RMS 0.09D

CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS47-YEAR-OLD MYOPIC FEMALE WITH REDUCED CS

Exam 12 months Later- January 2019• Ocular health and VA stable OU• Took 10-10-2 macular supplement part-time initially but now faithfully over

the several months• Notes she is no longer bothered by glare at night

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

OD: CST 2.0% OS: CST 2.0%

CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS47-YEAR-OLD MYOPIC FEMALE WITH REDUCED CS

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

IMPLICATIONS:This patient can now see things at one-half the

contrast necessary a year prior

Or, put another way—

A significant part of the previously invisible visual world has now become visible to her!

CONTRAST SENSITIVITY TESTING CASE STUDY

- .

25-Year-Old Male Truck Driver- October 2017Complains of loss of vision OS over last 2-3 weeks

OD: VA 20/20 OS: VA 20/25 CST 6.3% CST 12.5%

• No ocular pain, no general health problems except some recent HA

• Slit lamp and fundus exams normal OU

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

CONTRAST SENSITIVITY TESTINGCASE STUDY

- .

VF defects noted on screening VF and confirmed with threshold 24-2 OU

Threshold VF with SITA-Std: • OD: Temporal defect

extending from the blind spot and S/N defect

• OS: Generalized depression mostly S/T and dense nasal defect


- .

• VA dropped to CF@5’ OS 12 days later

• Complete workup including MRI and Spinal Tap

• Diagnosis: MS with Optic Neuritis Hospitalized with IV steroids x 5 days

Then started on Gilenya (fingolimod) po daily(watch for macular edema)

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

Evaluation By Neuro-Ophthalmology

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- .

Annual Exam- 1 year later• Occupation: Truck Driver

• Has recovered VA but complains of excessive daytime glare

• Refraction: OD: Pl - 0.25 x 065 /20OS: Pl - 0.25 x 150 /20

• Unusual recovery?No- 87% recover to 20/25 or better 5 years after episode of Optic Neuritis

• MPOD 0.39

Visual Function 5 Years After Optic NeuritisExperience of the Optic Neuritis Treatment Trial. Arch Ophthalmol. 1997;115(12):1545–1552. doi:10.1001/archopht.1997

CONTRAST SENSITIVITY TESTINGCASE STUDY

OD: 20/20 OS: 20/20CST 4.0% CST 5.0%

Treatment: Counseling, Triple Carotenoid, Monitor


- .

20/20

20/100

A (normal) and B (MS) both see 20/20 but do not have the same visual quality!

NORMAL

MS

Kalloniatis, Michael. “Visual Acuity.” Webvision: The Organization of the Retina and Visual System [Internet]., U.S. National Library of Medicine, 5 June 2007, www.ncbi.nlm.nih.gov/books/NBK11509/.


- .

QUESTION-

If this young patient is placed on macular carotenoids, is there reason to believe that glare disability (photophobia) could be lessened?

2008 Study1: Changes in Macular Pigment (MP) and Disability glare ---Subjects took macular carotenoids for 6 months---Increased approximately 0.16 log units in MPOD

RESULT: IMPROVED VISUAL PERFORMANCE!After supplementation, subjects on average could withstand 58% greater glare intensity before losing sight of the target!

1.Stringham JM, Hammond BR., Jr. Macular pigment and visual performance under glare conditions. Optometry and Vision Science. 2008;85(4):82–88.

CLINICAL OBSERVATIONS WITH CS TESTING IN PATIENTS WITH NORMAL VISUAL ACUITY52-YEAR-OLD MALE WITH APPARENT LOW MPOD

52-Year-Old Male – Compliant with Annual Exams• Family history of AMD

• 20/20 Visual Acuity OD & OS

• No general health issues

• Small area of drusen and pigmentary change sup/temp fovea OS

• History of inconsistent use of various carotenoid supplements x several years

• MPOD (Macular Densitometry) yearly- apparent poor response

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Mark W Roark, OD, FAAO

Area of Idiopathic RPE Epitheliopathy


Annual ExaminationDec 2017: Changed to triple carotenoid * bid x 6 months, then daily x 6 months

Dec 2018• Reports night glare now less bothersome!

• Significant improvement in CST OD & OS after 12 months of 10-10-2 formula

• Likely Increased Macular Pigment Volume DATE MPOD OD CST % OD/OS

12/2013 0.23

12/2014 0.30

12/2015 0.30

12/2016 0.31

12/2017* 0.32 2.0 / 2.5

06/2018 0.20 2.0 / 2.0

12/2018 0.27 1.0 / 1.0

3-4 Line CSTImprovement!

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL VA PATIENTSMEASURE AND MONITOR

SUSIE- THE COMPLIANT PATIENT• 59-Year-Old Caucasian Female presented for examination 05/2018• BCVA 20/20 OD and OS• Minimal macular changes were noted along with peripheral retinal drusen OU• Dry Eye Disease was present• Medical History: High Cholesterol and Hypertension• Medications: Atorvastatin, Lisinopril, HCTZ• Also on TG Fish Oil: 2.2gm EPA/DHA daily for several years• Pt started on triple carotenoid supplement 05/2014, excellent compliance

CLINICAL OBSERVATIONS WITH CS TESTING IN PATIENTS WITH NORMAL VISUAL ACUITYMEASURE AND MONITOR

Susie

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

2014 2015 2016 2017 2018

CHANGES IN MPOD OVER TIME

MPOD 0.70CST 2.0%

MPOD 0.78CST 1.25%

CONTRAST SENSITIVITY THRESHOLDSOF 50 CONSECUTIVE FULL EXAM PATIENTS

0

2

4

6

8

10

12

Nu

mb

er o

f pat

ien

ts

0.6% 0.8% 1.0% 1.25% 1.6% 2.0% 2.5% 3.2% 4.0% 6.3%

90% WITH VA of 20/20- OR BETTERAGE RANGE 19-87

68%

“Low spatial frequency processing can be diminished by a host of retinal disorders and by ocular media opacities and other optical disorders, often with minimal or no diminution of visual acuity.”1

1.https://studylib.net/doc/7930949/the-mars-numeral-contrast-sensitivity-test


CONTRAST SENSITIVITY TESTING ADDS VITAL INFORMATION!

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CONTRAST SENSITIVITY- IMPORTANT MEASURE OF VISUAL PERFORMANCE PROTECTING MACULAR HEALTH AND OPTIMIZING VISION: WORTHY GOALS

We are the Vision Experts.Let’s optimize each patient’s vision!

Questions Always Welcome!

[email protected]

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CONTRAST SENSITIVITY:GRAND ROUNDS II

• Mark W Roark, OD, FAAO

• Allisonville Eye Care Center

• Fishers, IN



Allisonville Eye Care Center– Fishers, Indiana A KEY COMPONENT TO UNDERSTANDING HOW THE PATIENT SEES:

CONTRAST SENSITIVITY (CS) TESTING

YOU NEED THE BEST TOOLS TO MAKE THE BEST DECISIONS!GOALS1) Briefly review CS Testing concepts, techniques, and action guidelines

2) Understand how CS Testing reveals the Visual Impact of poor macular nutrition and ocular disease through the presentation of Case Studies

3) Review the reasons and methods to implement CS testing and nutritional counseling to help your patients and to grow your practice

WAYS TO MEASURE VISUAL PERFORMANCE

Visual Acuity:

• Measures the ability to resolve high contrast targets

Limitations:

• No standardized Snellen chart

• The ability to function in activities of daily living cannot be reliably predicted based on visual acuity alone*

*Wood JM, Owens DA. Standard measures of visual acuity do not predict drivers’ recognition performance under day or night conditions. Optometry and Vision Science 2005;82(8):698-705

CONTRAST SENSITIVITY- IMPORTANT MEASURE OF VISUAL PERFORMANCE

DEFINITIONS:

• Contrast Sensitivity Threshold (CST) is the minimumdifference between the luminance of the target andthe background required to recognize the target.

• Good Contrast Sensitivity (CS) (the reciprocal of CST) helps us identify edges and borders.

!

- Photopic CS: background luminance ~85 cd/m2*- Mesopic CS: background luminance ~3 cd/m2*

*https://www.aaojournal.org/article/S0161-6420(16)31336-7/pdf

We are measuring the border between the visible and the invisible.

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LOW CONTRAST SITUATIONS- COMMON IN THE REAL WORLD HOW TO MEASURE PHOTOPIC CONTRAST SENSITIVITY THRESHOLDMark W Roark, OD, FAAO

1) Measure monocularly with best distance prescription and non-dilated pupils 2) Turn the room lights OFF and isolate a 20/100 (6 cpd) Sloan letter on a calibrated electronic screen 3) Project a 5% contrast letter and ask “Can you see the faint (letter)?”4) Decrease (or increase) contrast as needed and ask the patient to identify the letter 5) Allow a few seconds for response as you approach the threshold6) Record the lowest level of contrast where 2 of 3 random letters are correctly identified7) Document result for each eye, for example, CST@ 6cpd OD: 2.0% / OS: 2.5%

Tips❑ Unless the background luminance is properly calibrated, results will not be accurate.❑ Encourage the patient to blink and focus only on the center of the screen.❑ Allowing more time for response as you approach the threshold will improve results.❑ CST difference between eyes is typically ≤ one step for patients with no ocular disease.❑ An accurate threshold can normally be measured in about one minute per eye.

CHANGES IN LETTER CONTRAST


Just check Visual Acuity and Photopic Contrast Sensitivity at 20/100.

You will gain valuable information quickly about your patient’s true visual performance to guide your treatment recommendations.

USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL PERFORMANCEFINANCIAL CONSIDERATIONS

Mark W Roark, OD, FAAO

ICD-10 Diagnosis CodesH53.72 Impaired Contrast SensitivityH53.71 Glare Sensitivity

Coding By Time (CPT) • 99212 (10 min)• 99213 (15 min)• 99214 (25 min)• 99215 (40 min)

>50% of time spent in face-to-face counseling with the patient regarding the condition

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WHAT ROLE DOES NUTRITION PLAY IN ENHANCING CONTRAST SENSITIVITY?

CAN WE HELP PATIENTS WITH OCULAR DISEASE AND REDUCED VISUAL ACUITY THROUGH NUTRITION?

CAN WE ALSO HELP PATIENTS WITH HEALTHY EYESAND 20/20 VISION THROUGH NUTRITION?

DISTRIBUTION OF CAROTENOIDS IN THE MACULA

1:1:1

• L, Z, and MZ work best as a team!

• MZ is most central and the strongest • anti-oxidant

• MZ is part of the food chain but not as prevalent in our food as L and Z

12-30% of the population appear not to be able to convert L to MZ

WE LIVE IN AN ERA OF NUTRIENT-DEFICIENT FOODS AND POOR DIETARY HABITS

Less than 10% of Americans consume even 5 servings of vegetables and fruits daily

CASE STUDIESContrast Sensitivity (CS) Testing has led to better patient outcomes across many different diagnoses:

1) Normal Visual Acuity and Healthy Eyes2) Normal Visual Acuity after LVC3) Cataracts- Cortical, NS, PSC4) Secondary Cataract5) Macular Degeneration6) Pattern Dystrophies7) Premium IOLs8) Post-Op Complications9) Medication Toxicity10) Glaucoma11) Corneal Disease12) Diabetic Retinopathy13) Contact Lens Hypoxia

CASE STUDIES

NORMAL VISUAL ACUITYNo History of LVC

WHEN CONTRAST SENSITIVITY TESTING APPEARS ABNORMAL IN A “NORMAL PATIENT“ -NOW WHAT?

June 2016 Investigative Ophthalmologyand Visual Science (IOVS)

Thanks to CREST Normal- we now have a plan based on Science!

AVERAGE BASELINE LETTER CST @ 6CPD: 2.0-2.1%

The study used a supplement containing:-10mg of Lutein-10mg of Meso-Zeaxanthin-2 mg of Zeaxanthin

20/100

100% responded with increase in Macular Pigment Volume!

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CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL VA PATIENTS:ARE YOUR PATIENTS SEEING AS WELL AS YOU THINK?

22-Year-Old College Student Seen Summer 2017

• DW SCL wearer • Admits to poor diet• Notes annoying glare at night • No ocular disease

OD: BCVA 20/20

CST 5.0%

MPOD 0.14 (0.21 one year prior)

Started on daily triple carotenoid formula (10mg Lutein, 10mg Meso-Zeaxanthin, 2mg Zeaxanthin)

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

CLINICAL OBSERVATIONS WITH CONTRAST SENSITIVITY TESTING IN NORMAL PATIENTS:ARE YOUR PATIENTS SEEING AS WELL AS YOU THINK?

12 Month Follow-Up- MPOD now 0.34 but still low• Reports better diet and took the 10-10-2 supplement about 25% of the time• Still notes highly bothersome glare at night, despite excellent optical focus OU• CST has improved but still poor

OD: BCVA 20/20 OS: BCVA 20/20

CST 4% CST 3.2%

After discussion, the patient decided to be more consistent in taking the triple carotenoid (10mg Lutein, 10mg Meso-Zeaxanthin, 2mg Zeaxanthin)

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

CLINICAL OBSERVATIONS WITH CS TESTING IN PATIENTS WITH NORMAL VISUAL ACUITY44-YEAR-OLD FEMALE WITH SMALL DRUSEN AND LOW MPOD

JULY 2016: BCVA 20/20 OD and OS • No family history of AMD• No history of smoking• MPOD 0.20• Several small scattered drusen OU

QUESTIONS:How important are small, scattered drusen in a young patient?Will these patients go on to develop AMD?What is an appropriate plan?

CLINICAL OBSERVATIONS WITH CS TESTING IN PATIENTS WITH NORMAL VISUAL ACUITY44-YEAR-OLD FEMALE WITH IMPROVING CST

“Hard drusen are prevalent in young adults, and having more than 20 drusen per eye is a highly

hereditary feature. Additional research is needed to determine whether the presence of small hard

drusen correlates with the development of age-related macular degeneration later in life and to explore

the relation to AMD genotypes.”

Management• Healthy lifestyle• Sun protection• Nutritional supplementation

"Heredity of Small Hard Drusen in Twins Aged 20–46 Years.“Investigative Ophthalmology & Visual Science 48.2 (2007): 833• Study involved 220 twins • About half identical and half fraternal • 212 were found to have small drusen• Small drusen are easy to miss

CLINICAL OBSERVATIONS WITH CS TESTING IN PATIENTS WITH NORMAL VISUAL ACUITY44-YEAR-OLD FEMALE WITH SMALL DRUSEN BUT IMPROVING MPOD AND CST

BCVA 20/20 OD & OS

• Nutritional intervention started July 2016 and is ongoing

• Excellent response to triple carotenoid formula

MPOD OD CST OD07/2016 0.2007/2017 0.46 2.5%07/2018 0.62 1.6%

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

Contrast Sensitivity TestingIn Ocular Disease

UNDERSTANDING THE VISUAL IMPACT OF THE DISEASE

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE- REFERENCE VALUES

Contrast Sensitivity Threshold (CST) References (Pelli-Robson-NCBI)

How is visual impairment defined in regard to CS?

• 4.0% CST OR WORSE is likely to have significant impact on visual performance

• 10% CST OR WORSE is likely to cause severe visual impairment

CST 0.1 log

steps

0.8%

1.0%

1.25%

1.6%

2.0%

2.5%

3.2%

4.0%

5.0%

6.3%

8.0%

10%

12.5%

16%

20%

CASE STUDIES

Normal Visual Acuity-Poor Contrast Sensitivity

Soft Toric Contact Lens Oxygen Transmissibilityand Contrast Sensitivity

• History of SCL wear for about 25 years including some CW in college• Wears Dk/t (25) single-use toric SCL• No initial visual complaints but does note dryness• General health good and no systemic meds used

Refraction (performed immediately after lens removal):OD: -4.25 -1.50 x 148 20/20 CST 4%OS: -5.00 -1.25 x 025 20/20 CST 5%

SLE:Min non-central corneal but significant conjunctival nafl staining OU~1-1.5 mm corneal neovascularization superiorly > inferior OU

DFE:Fundus exam normal OU

OPD3:Increased HO aberrations centrally OU

Contrast Sensitivity and Contact Lenses42-Year-Old Male Toric Single-Use SCL Wearer


OD OS

• Significant superior neovascularization noted OU • Patient was refit into high Dk/t (129) single-use toric lenses• Mild prescription adjustment R>L


Follow-up visit about one month after wearing lenses with high Dk/t:• Reports significant improvement in both day and night vision• Rates level of improvement at 6-7/10!

OD: VA 20/20 CST 2%OS: VA 20/20 CST 3.2%(TESTING DONE THROUGHTHE PHOROPTOR AS BEFORE)

Summary OU: • Oxygen transmissibility improved ~ 500% with new lenses• Significant subjective improvement in vision reported at one-month visit• CS Thresholds much improved and will be monitored for additional change• Central optical aberrations reduced • No change in visual acuity

CASE STUDIES

AGE-RELATED MACULAR DEGENERATION

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE - AMD

Age-Related Macular Degeneration Overview

The Population is Aging: • ~1 billion people aged 60 and older right now• ~ 2 billion people aged 60 and above by 2050

Prevalence of AMD• ~11 million Americans have AMD (2015)• ~ Projected to double to 22 million by 2050.

Impact of AMD• Effects the quality of vison and the quality of life of the patient• Involves other family members• Huge financial impact for the health care system- $2.3 Billion MC 2013

METABOLISM AT THE MACULA

• Highest metabolic rate in the whole body!!

• About 10% of the approximately 1000 outer segment discs in each photoreceptor cell are shed daily, and then regenerated.

• THE MACULA NEEDS PROTECTION

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE - AMD

Age-Related Macular Degeneration

.

IMPORTANT STUDIES

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE - AMD STUDIES

MESO-ZEAXANTHIN OCULAR SUPPLEMENTATION TRIAL (MOST)-AMD (2015)

After 36 months:. At 20/100 (6/30):Baseline CST ~5.0%36 Month CST ~3.2%

There was no change in VA.0.00

0.20

0.40

0.60

0.80

1.00

0.25 0.5 1.0 1.75

Change in MPOD

Supplements with Meso-Zeaxanthin were more effective than competing formulas in improving macular pigment volume and contrast sensitivity in patients with early AMD.

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE - AMD STUDIES

CREST AMD

Results:75% (24 of 32) of vision related outcome measures in both groups (e.g. contrast sensitivity, glare disability, photostress recovery) exhibited significant improvements.

A higher percentage of patients in the group with all threemacular carotenoids showed improvements in Contrast Sensitivity.

• Group 1, 10mg/day meso-zeaxanthin [MZ], 10mg/day lutein, 2mg/day zeaxanthin plus 500mg/day vitamin C, 400 international units [IU]/day of vitamin E, 25mg/day zinc and 2mg/day copper• Group 2, 10mg/day lutein, 2mg/day zeaxanthin plus 500mg/day vitamin C, 400 international units /day of vitamin E, 25mg/day zinc and 2mg/day copper

Omega-3 and Vision

DHA Constitutes Half Of The Mass Of The Retinal Neuronal Membrane

Singh M. Essential Fatty Acids, DHA and Human Brain. Indian J Pediatr 2005;72:239-242


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The Omega-3 Index: Biomarker and Risk Factor

The Omega-3 Index (EPA+DHA as a % of erythrocyte fatty acids) is a marker of tissue levels of EPA and DHA

Having an Omega-3 Index in the desirable range (8%-12%) has been associated with improved heart, brain, eye, and joint health.

Harris WS and von Schacky C. Prev Med 2004;39:212-220.Slide Courtesy William S Harris, Ph D

1837 participants at moderate-to-high risk for advanced AMD

Sangiovanni JP, Agrón E, Meleth AD, et al. {omega}-3 Long-chain polyunsaturated fatty acid intake and 12-y incidence of neovascular age-related macular degeneration and central geographic atrophy: AREDS report 30, a prospective cohort study from the Age-Related Eye Disease Study. Am J Clin Nutr. 2009;90(6):1601–1607

THE 12-YEAR INCIDENCE OF CGA AND NV AMD IN AREDS (Report 30)

National Eye Institute, National Institutes of Health

Those reporting highest vs. lowestOmega 3 intake (FFQ):

↓ 30% incidence of Central GA and Wet AMD

NUTRITIONAL AMD TREATMENT 2 STUDYChoroidal Neovascularization (CNV)

Souied, et al. Ophthalmology 2013;120:1619–1631

Conclusion (Referenced in NIH Review)“In patients with unilateral exudative AMD, 3 years of oral DHA-enriched supplementation had the same effect on CNV incidence in the second eye as did the placebo.”

“However, RBCM fatty acid measurements revealed that CNV incidence was significantly reduced in DHA-supplemented patients showing a steadily high EPA plus DHA index over 3 years.”

NUTRITIONAL AMD TREATMENT 2 STUDYChoroidal Neovascularization (CNV)

Souied, et al. Ophthalmology 2013;120:1619–1631

0

2

4

6

8

10

12

T1 T2 T3

Om

ega

-3 I

nd

ex (

%)

Tertiles of Omega-3 Index at 3 yr

14.3%*

32.5%*

*Incidence of CNV at 3 years

Hazard Ratio for developing CNV at 3 years comparing the highest to the lowest tertile of the Omega-3 Index

n=300 / DHA 840 / EPA 270 /55-84 yo/ CNV one eye

Risk was 68% lower for incident CNV in patients who achieved an Omega-3 Index in tertile 3 (8.7%) vs placebo group (olive oil)

77-YEAR-OLD FEMALE WITH MACULAR DISEASEMark W Roark, OD, FAAO

December 2017- Initial Exam

77-Year-Old Female with History of AMD• Pseudophakic OU • Former Smoker• History of AMD – Started Triple Carotenoid 6 Months Prior to Initial Exam• Fundus Exam: Drusen, Pigmentary Migration--- Intermediate Dry AMD OU• Clinical Appearance with Possible Pattern Dystrophy Component• Changed to modified AREDS2 formula with 25mg Zinc and Triple Carotenoid

BASELINE FINDINGSOD: BCVA 20/25+CST 2.5%

OS: BCVA 20/20-CST 2.0%

CST 0.1 log

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December 2018- Annual ExamMacular Disease and VA Stable OUOD: +0.50-1.00 x 090 /25+ OS: -1.75-0.75 x 095 /20-

CST 1.6% CST 1.6%

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OD OS

IntraretinalHyperreflective Foci (HRF)


SUMMARY• Intermediate Dry AMD- stable OU

• HRF indicate increased risk of advanced AMD 1

• Contrast Sensitivity improved with modified AREDS2 supplement with MZ

• Improvement in visual performance consistent with CREST AMD TRIAL 2

• Recent O3I = 7.1% so rec increase in fish intake or increased supplementation

• Will Monitor with repeat OCT and Photos / FAF q 3-4 months

2.Akuffo KO, Beatty S, Peto T, Stack J, Stringham J, Kelly D, Leung I, Corcoran L, Nolan JM. The Impact of Supplemental Antioxidants on Visual Function in Nonadvanced Age-Related Macular Degeneration: A Head-to-Head Randomized Clinical Trial. Invest Ophthalmol Vis Sci. 2017;58(12):5347-5360.

1. Nassisi, Marco, et al. “Quantity of Intraretinal Hyperreflective Foci in Patients With Intermediate Age-Related Macular Degeneration Correlates With 1-Year Progression.” Investigative Opthalmology & Visual Science, vol. 59, no. 8, 2018, p. 3431., doi:10.1167/iovs.18-24143.

• -Patient on triple carotenoid formula for several years with improving MPOD• -Also has POAG and mild cataract OU

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASEDRY AMD OD AND WET AMD OS IN A 67-YEAR-OLD FEMALE

OD: VA 20/25+ OS: VA 20/40-

How well is this patient really seeing?

OD: VA 20/25+CST 2.0%

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASEDRY AMD OD AND WET AMD OS IN A 67-YEAR-OLD FEMALE

OS: VA 20/40-CST 12.5%

• OD shows good CS despite Dry AMD and Glaucoma• OS has impaired CS as expected with active Wet AMD and Glaucoma

CST 0.1 log

steps

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASEUSE IN CATARACT PATIENTS

The prevalence of cataract is increasing with the aging of the population. Below are projections for the US. (NEI)

The Role of Nutrition in Cataracts

• Lutein and Zeaxanthin are the only carotenoids found in the lens

• AREDS 2 showed no overall effect on cataract development except for those with the lowest dietary levels of carotenoids*

• In this group there was a 30% reduction in development of cataract

*Chew, Emily Y. “Lutein/Zeaxanthin for the Treatment of Age-Related Cataract.” JAMA Ophthalmology, vol. 131, no. 7, 2013, p. 843

WHEN SHOULD I REFER MY PATIENT FOR CATARACT SURGERY??

.

1) How symptomatic is the patient--no longer driving at night?2) How does the cataract look at the slit lamp?3) What is the patient’s VA?4) How much aberration is in the visual system of the patient?5) What is the patient’s Contrast Sensitivity (CS) threshold?

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CONTRAST SENSITIVITY IN OCULAR DISEASE- REFERENCE VALUES

FOR OLDER ADULTS WITH CATARACTS:

A CST of 6.3% OR WORSE is associated with an increased risk of driving accidents!

Crash-involved drivers were 6 times more likely to have this level of impairment in both eyes

(or 3 times more likely if only one eye impaired) compared to crash-free drivers (1)

For older drivers, a possible but weak association between visual acuity and crash involvement may exist 2

1) Owsley, Cynthia. “Visual Risk Factors for Crash Involvement in Older Drivers With Cataract.” Archives of Ophthalmology, vol. 119, no. 6, Jan. 2001, p. 881

2) Owsley, Cynthia, and Gerald Mcgwin. “Vision Impairment and Driving.” Survey of Ophthalmology, vol. 43, no. 6, 1999, pp. 535–550

CST 0.1 log

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POOR CONTRAST SENSITIVITY INCREASES RISK OF FALLS IN THE ELDERLY

Among Older Adults

• Falls are the leading cause of accidental injury and death

• One in three adults over the age of 65 falls each year

• Impaired Contrast Sensitivity is one of the strongest visual risk factors for falls1

1.Lord, Stephen R., and Julia Dayhew. “Visual Risk Factors for Falls in Older People.” Journal of the American Geriatrics Society, vol. 49, no. 5, 2001, pp. 508–515

2.Palagyi, Anna, et al. “Visual and Refractive Associations with Falls after First-Eye Cataract Surgery.” Journal of Cataract & Refractive Surgery, vol. 43, no. 10, 2017, pp. 1313–1321..

POOR CONTRAST SENSITIVITY INCREASES RISK OF FALLS IN THE ELDERLY

“

“Provision of single lens glasses significantly reduced falls in older wearers of multifocal glasses who take part in regular outside activities”

Haran, M. J., et al. “Effect on Falls of Providing Single Lens Distance Vision Glasses to Multifocal Glasses Wearers: VISIBLERandomised Controlled Trial.” Bmj, vol. 340, no. may25 1, 2010, pp. c2265–c2265., doi:10.1136/bmj.c2265

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE

A GREAT TOOL FOR UNDERSTANDING THE REAL-WORLDVISUAL IMPACT OF CATARACTS ON THE PATIENT

LEADING TO CONFIDENT DECISIONS ON WHEN TO REFER FOR SURGERY!

DETERMINE BCVA

CATARACT CONFIRMED

CHECK LETTER CONTRAST SENSITIVITY @ 6 cpd

2.5% OR BETTER 3.25-5.0% ≥ 6.3%

ACCEPTABLE BORDERLINE INTERVENTION NEEDED

USING CONTRAST SENSITIVITY TESTING IN MANAGING OCULAR DISEASESUGGESTED GUIDELINES FOR CATARACT MANAGEMENT

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USE OF CONTRAST SENSITIVITY TO ASSESS VISUAL PERFORMANCE78 YEAR-OLD MALE WITH PSC CATARACT R>L

OD: +2.25-1.00 X 165 /30- OS: +1.50-1.50 X 170 /25-

Patient complains of worsening vision mainly in the Right Eye.

Patient needs CE OD. Does he need it OS as well?

CST4.0%CST 6.3%

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YES!

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASECORTICAL CATARACTS IN A 50 YEAR- OLD MALE

• Complains of glare with difficulty seeing in bright sunlight and notes starbursts at night

• Had PRK in 2005 OU with good result

• Has noted worsening vision gradually over the last 2-3 years

• Exam shows significant central cortical cataract, mainly anterior OU.

• No other ocular disease

Does this patient need cataract surgery?

OD (dilated) OS (dilated)

OD OS+0.75-0.75 x 005 /25+ +1.00-0.75 x 180 /20


OD (dilated) OS (dilated)

OD: +0.75-0.75 x 005 20/25+ OS: +1.00-0.75 x 180 20/20

Does this patient need cataract surgery?

CST 0.1 log

steps

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CST 8% CST 6.3%

YES!


OD OS+0.25-0.25 x 143 20/15 +0.75-2.00 x 063 20/15CST 2.0% CST 2.5%6 line improvement in CS! 4 line improvement in CS!

Successful Cataract Surgery -A Happy Patient!

Pt taking 10-10-2 triple carotenoid to build MP: 02/17 MPOD 0.35; 10/17 MPOD 0.52; 01/19 MPOD 0.67

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Patient is taking triple carotenoid supplement daily to enhance macular pigment due to increase in blue light exposure and oxidative stress on the macula following cataract removal

ONE-PIECE ASPHERICMONOFOCAL IOL

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE77-YEAR-OLD FEMALE WITH CATARACT AND HISTORY OF BRVO OS

OD: BCVA 20/40- OS: BCVA 20/40

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• History of BRVO OS with Avastin injections and LASER treatment 2011-2012• Now developing significant NS, some cortical opacity OU

Based on this information, would you counsel the patient about post-surgical expectationsor make any recommendations to the surgeon?

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE77-YEAR-OLD FEMALE WITH CATARACT AND HISTORY OF BRVO OS

OD: BCVA 20/40-CST 6.3%

OS: BCVA 20/40CST 12.5%

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Based on this information, would you counsel the patient about post-surgical expectationsor make any recommendations to the surgeon?

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE77 YEAR-OLD FEMALE WITH CATARACT AND HISTORY OF BRVO OS

• OCT shows thinner inferior macular subfields and GCC OS• Patient informed that testing indicates likely poorer quality of vision after CE OS vs OD despite similar VA • A multifocal IOL is not indicated- perhaps EDOF?

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE77 YEAR-OLD FEMALE POST-OP CE WITH PC IOL AND HISTORY OF BRVO OS

Post-Op 08/21/2018

• Uneventful CE with Monofocal IOL implanted OU- 06/20 OD and 06/06 OS• Subjectively notes better vision OD than OS with or without correction• CST much improved OU but still with 3-line difference in CST

OD: +0.25-1.25 X 102 20/20CST 2.5%

OS +0.25-0.25 X 090 20/20-CST 5.0%

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE77 YEAR-OLD FEMALE WITH POST CE WITH PC IOL AND HISTORY OF BRVO OS

CASE STUDIES

Secondary Cataract

• Occurs in 20-30% of post-CE patients• May take significant time to become visually significant

• Sometimes challenging to decide when YAG LASER needed

• CS testing a useful tool• Timing and necessity of referral

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE51 YEAR-OLD FEMALE WITH PCO OD

CST 6.3% CST 2.5%

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE71 YEAR-OLD FEMALE WITH BILATERAL PSEUDOPHAKIA AND SECONDARY CATARACT OD

• Patient notes mild blur OD with some glare at night• IOLs implanted in 2011 OU and had YAG LASER OS in 2014

• On 10-10-2 carotenoid formula for several years• No signs of macular disease in either eye

BCVA OD 20/20 BCVA OS 20/20

How much is the PCO OD affecting vision? Does she need YAG OD?

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE71 YEAR-OLD FEMALE WITH BILATERAL PSEUDOPHAKIA AND SECONDARY CATARACT OD

BCVA OD 20/20CST@ 6cpd 4.0%

BCVA OS 20/20CST@ 6cpd 2.0%

YES!

CST 0.1 log

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Comments:

• Visual performance OD impaired with significant asymmetry• YAG LASER indicated OD and patient referred• Good visual performance OS after supplementation • 10-10-2 triple carotenoid formula restarted -preferred over the AREDS2 here

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE71 YEAR-OLD FEMALE WITH BILATERAL PSEUDOPHAKIA AND SECONDARY

CATARACT OD

BCVA OD 20/20CST 2.0%

BCVA OS 20/20CST 2.0%

HAPPY PATIENT AT ONE MONTH S/P YAG LASER OD

• Notes significantly better vision in daily activities!• Contrast Sensitivity improved, symmetrical OU

CST 0.1 log

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CASE STUDIES

POST-OP COMPLICATIONS

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE88-YEAR-OLD FEMALE S/P CE WITH PC IOL OU

• Patient seen 05/2017 complaining of reduced vision due to significant cataracts OU

• BCVA 20/30 OD with CST@ 6cpd 10%; BCVA 20/40- OS and CST@ 6cpd 12.5%

• Also diagnosed with Dry Eye Disease, possible Sjogren’s and treated prior to cataract surgery

• Returned for post-op after successful surgery with monofocal Intraocular lenses OU➢ OD: post-op 7 weeks➢ OS: post-op 5 weeks

• Pt pleased with vision in each eye

Post-Op Refraction: OD +0.25 -0.50 x 100 20/20-2 OS +0.25-0.75 x 075 20/20-2 CST 6.3% CST 3.2%

Why is CS reduced by 3 lines OD?

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE88-YEAR-OLD FEMALE S/P PC IOL OU

CST 6.3% CST 3.2%The IOLs look great!

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE88-YEAR-OLD FEMALE S/P PC IOL OU

Subtle abnormality noted at the central macula OD on R/G and FAF photos.

CONTRAST SENSITIVITY TESTING IN OCULAR DIISEASE88-YEAR-OLD FEMALE WITH CME OD

OCT makes the diagnosis easy!

OD

OS

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE88-YEAR-OLD FEMALE WITH CME OD

Pseudophakic CME

• Angiographic studies indicate an incidence of 20-30% following ECCE/Phaco• Symptomatic in about 1-5% of patients following ECCE/Phaco• Usually presents within 4-12 weeks of surgery• Spontaneous resolution occurs up to 80% of the time• The longer it persists, the less likely to spontaneously clear • If chronic (>6 months), can lead to permanent reduction in vision

A decrease in contrast sensitivity occurs across a wide spectrum of spatial frequencies at8 weeks and may cause persistent visual difficulties despite good Snellen visual acuity. (Ibanez et al 1993)

*Update on pseudophakic cystoid macular edema treatment options; Levin, Darrin S et al.Ophthalmology Clinics , Volume 15 , Issue 4 , 467 – 472*.Cystoid macular edema following extracapsular cataract extraction and posterior chamber intraocular lens implantation. Bradford JD, Wilkinson CP Bradford RHRetina 1988;8:161-164.

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASE88 YEAR-OLD FEMALE WITH CME OD

FOLLOW UP VISITS OD(Using Durezol bid & Ilevro bid)Placed on 10L-10MZ-2Z alsoOD: VA: 20/25+CST 2.5%

10 Weeks Post-Op

13 Weeks Post-Op

Good response to treatment OD

7 Weeks Post-Op

CST 0.1 log

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CONTRAST SENSITIVITY TESTING IN OCULAR DISEASECHANGES OVER TREATMENT PERIOD OD

0.00%1.00%2.00%3.00%4.00%

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CS Threshold

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Central Subfield Fluid

Patient reported improvement in vision as CSTimproved even though little change occurred in VA.

CONTRAST SENSITIVITY TESTING IN OCULAR DISEASEPOST CE WITH IOL AND CME

RECENT EXAM 08/21/2018

• Now ~9 months post-surgery• Stopped Ilevro 1 month prior • Emphasized how well she is seeing (volunteered)• No signs of recurrent CME• Taking daily macular supplement (10-10-2)

OD: BCVA 20/15 OS: BCVA 20/15CST 2.0% CST 2.0%

CST 0.1 log

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CONTRAST SENSITIVITY THRESHOLDSOF 50 CONSECUTIVE FULL EXAM PATIENTS

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0.6% 0.8% 1.0% 1.25% 1.6% 2.0% 2.5% 3.2% 4.0% 6.3%

90% WITH VA of 20/20- OR BETTERAGE RANGE 19-87

68%Reasons to Implement CS Testing and Nutritional Intervention1) Better understanding of visual complaints will improve patient care2) This is not just for a select few patient with a specific diagnosis3) Performing the test can be delegated and takes little time4) Minimal capital investment is needed5) The medical side of your practice will increas56) The revenue stream from supplements can be significant.7) You will become a true vision expert which requires understanding “real-world” visual performance

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Steps for Implementing CS Testingand Nutritional Intervention

1) Make sure you have a properly calibrated electronic system2) Use reference guides to interpret the results

3) Test and educate your staff4) Begin testing your patients- start with symptomatic patients and

those with cataracts at a minimum5) Be ready to recommend appropriate nutrition or other intervention

Testing CS – even in patients with normal VA and no eye disease– often uncovers unaddressed visual problems and brings the important topic

of ocular nutrition into the exam lane.

Questions are always welcome!

Thank You!

[email protected]

ADDITIONAL CASE STUDY

Corneal Disease

63-YEAR-OLD FEMALE WITH POOR VISION

63-Year-Old Female with Visual Complaints• Pt complains of blurred vision and difficulty in seeing at night• Previous told she has cataracts and dry eyes causing blur• Desires new glasses to improve vision

Refraction (No significant change)OD: +1.25-1.00 x 100 /30-OS: +1.50-1.00 x 075 /30

Fundus Unremarkable OULens with 1+ NS and trace cortical cataracts OUSLE shows mild DED without central corneal staining OU

OD: CST 6.3%OS: CST 5.0%

CST 0.1 log

steps

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63-YEAR-OLD FEMALE WITH FUCHS’ DYSTROPHY

OD: BCVA 20/30CST 6.3%


OS: BCVA 20/30+CST 5.0%

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CST Testing• Didn’t line up with mild cataracts and DED• Helped with understanding the patient’s visual complaints• Improved patient counseling: recommend not driving at night• Explained treatment options available including DMEK

Providing the best patient care requires understanding the patient’s “real-world” vision

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financial disclosures · 1.ola, mohammad shamsul, et al. “role of oxidative stress in diabetic...

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