Choosing the Right Doctor to Treat AMD

BrightFocus Foundation
Choosing the Right Doctor to Treat AMD
April 27, 2016
Transcript of Teleconference with Milam A. Brantley, Jr., MD, PhD (Vanderbilt Eye Institute)

Please note: This Chat was edited for clarity and brevity.

MICHAEL BUCKLEY: Hello, and welcome to our monthly BrightFocus Chat. This month’s topic is “Choosing the Right Doctor to Treat Your AMD.” My name is Michael Buckley, and I am with BrightFocus Foundation.

For people who are new to this Chat, I would like to take a moment to tell you more about BrightFocus and how the Chat today will work. BrightFocus funds research around the world to find cures and treatments for macular degeneration, glaucoma, and Alzheimer’s. We share the findings of this research free of charge through materials that we make available to families that are impacted by these diseases.

Today’s Chat is an extension of that, where we have the opportunity to talk to an expert in the field of vision disease and an opportunity to answer questions.

Today’s guest is Dr. Milam Brantley from the Vanderbilt Eye Institute. Dr. Brantley specializes in retinal degenerative diseases, like macular degeneration. We are also proud to have supported his research on some of the environmental and genetic factors affecting the progression of macular degeneration. Dr. Brantley, thank you so much for being with us today. I would like to start off with some basic details on the different kinds of macular degeneration.

MILAM BRANTLEY: Hi, Michael; thank you for having me on the call. You started with the best question, I think. It is often very difficult for folks to understand exactly what kind of macular degeneration they have. I am going to refer to it as AMD, or age-related macular degeneration. People most often hear the terms “dry” and “wet.” In some cases these are helpful terms, but they can also be confusing. First of all, wet has nothing to do with how your eyes feel. Patients will often say, “Yeah, my eyes are watering, I must have the wet kind.” It really doesn’t have anything to do with that. The wet refers to whether or not there is fluid in, or underneath, the retina. It might be blood, it might simply be fluid.

In general, people know that wet macular degeneration—or wet AMD— is the one that can be treated, and dry, not so much. Again, it is a little bit more complicated than that. The way I like to think of it—and like to tell my patients to think of it—is instead of just dry and wet, think of it as early, intermediate, or advanced. Those are kind of the severity stages of macular degeneration. The way that we figure out what somebody has is basically to take a look on an eye exam. Sometimes we do a little bit of testing. The hallmark of early AMD is little tiny waste deposits, little yellow posts, on or underneath the retina. These are called drusen. People can look these up and see pictures of them. If people have just a few drusen, that is early AMD. This person probably has not had their vision impacted at all. Everything looks fine to them, and they have no idea they have early AMD. But, the chance of it becoming advanced at this point is really pretty small. Later on they may develop more drusen or larger drusen. We call these soft drusen. That is intermediate AMD.

At this point, that person is at risk for progressing over time to the advanced form of AMD. That comes in two types. The first is wet; that is the one we hear about, that is the one with fluid and where people get injections in their eyes. The other type is advanced dry AMD, which is often called geographic atrophy. Atrophy just means things have lost their shape. So, the cells that used to help you see are gone in the center part of the retina, called the macula. Advanced AMD can be wet or it can be dry, meaning geographic atrophy. We sometimes call that GA. You can see that if someone says it is wet AMD, we know that is advanced, but if someone says dry AMD, that can be anything from a few small drusen and it’s early AMD to pretty advanced AMD with vision loss and geographic atrophy.

I encourage people, when their doctor tells them they have dry AMD, to say, “Can you tell me a little bit more about that? Are we talking about early AMD? Are we talking about intermediate or advanced?” to get just a little bit of a better idea. I really like to show patients pictures so they get a bit of a better idea about how severe the condition is at this time. Then we can talk about what possibilities are for progression or not.

MICHAEL BUCKLEY: Great, thank you very much, Dr. Brantley. That is a very nice overview. We frequently hear about how important it is to get eye exams and treat diseases like macular degeneration and glaucoma. One of the questions we get asked a lot at BrightFocus is, “How do I know the difference between different types of eye professionals?” Like an optometrist, an ophthalmologist, a retina specialist. I think I can speak for many people where, that is a tough question—and not only what’s the answer, but, “How do I know which particular one meets my needs?” I was wondering if you could explain a little bit about optometrists, ophthalmologists, and retina specialists.

MILAM BRANTLEY: Sure, that is a fantastic question, too. An optometrist is someone who attends optometry school. It is 4 years of optometry school and they do some clinical rotations in this. Optometrists are fantastic at checking for refractive error and prescribing glasses. They may do contact lenses and low vision. We have all of those specialties in our Optometry Department here at Vanderbilt, and many places have that. Optometrists are typically the folks you would find at Target, or Walmart, or someplace like that. Optometrists are not medical doctors so they cannot perform surgery, but they can prescribe some drugs to treat glaucoma and things like that. Routine eye care? Absolutely, an optometrist is fantastic for that.

An ophthalmologist is a medical doctor so, 4 years of medical school followed by a residency of ophthalmology of an additional 3 years and sometimes a fellowship. A comprehensive ophthalmologist is the type of person who would do your cataract surgery. So, this is someone who performs surgeries—they are all medically trained, so they can prescribe any medication that any doctor can prescribe.

A retina specialist is an ophthalmologist who has then gone on and done specialized training on the retina. Most people do a 2-year vitreoretinal fellowship and do vitreoretinal surgery—things like repair attachments, macular hole surgery, things like that. I myself did a medical retina fellowship where I don’t do surgeries, but I see diseases of the retina that can be treated outside of the operating room—which is actually most of them, such as macular degeneration, vein blockages, diabetic retinopathy, that sort of thing.

Now, you asked a very key question to follow up on that which is, “Who do I need to follow to treat my AMD?” It really depends a lot on two things. The first one is, how severe is your AMD? The second one is, how easily accessible are these people to you?

We talked about that early AMD. If you have a few drusen and you have an optometrist who you really like who is following you and who routinely looks in your eyes and does dilated exams, then I think that is just fine. Once you get into the area of intermediate AMD and you are at a higher risk of progressing to advanced AMD, I think perhaps a comprehensive ophthalmologist who can follow along and have an easy referral to a retina specialist would be very appropriate. Again, the key being having a dilated exam. If you are not getting your eyes dilated when you go in to see your eye doctor, you are not getting a comprehensive exam. That’s easy for us because we are retina specialists, and we dilate everyone who walks in the door, but it is important to remember that if you go see your eye care professional and they take a look, or they need a picture to tell you whether or not you have AMD, I would really prefer seeing someone who puts a few drops in your eyes, takes a look 15 to 20 minutes later, and says, “You’ve got AMD and it is at this stage.”

Now, having said that, sometimes in order to really understand whether it is a very subtle type of wet AMD, we need to take some pictures or do specialized tests. Certainly anybody who needs treatment for wet AMD should be seeing a retina specialist for the injections.

MICHAEL BUCKLEY: Great. That is very helpful. For people who found your answer very helpful, but obviously it is a lot of information to take in, I want to remind folks that BrightFocus offers free of charge a publication called “A Guide to Finding the Right Eye Doctor.” You can get that free of charge by going to our website, www.BrightFocus.org or by calling 800-437-2423.

Dr. Brantley, thank you for mentioning the dilated eye exam. I think, to me, dilation and dilating, these are phrases people hear very often. If I am the patient, how do I know that I am going to get one when I make the appointment? How do I know whether I will be receiving one?

MILAM BRANTLEY: I don’t think you probably do unless you ask. If you are going to see the local eye care professional, and maybe that is an optometrist, you would want to make sure they know—I am 73 years old, I am coming in for my regular exam, and ask, “Are you going to dilate my eyes?” And that is what I would encourage you to ask. Hopefully the answer is yes.

Usually, in a full, comprehensive exam, everybody is going to dilate your eyes. Again, in our clinic, we dilate everyone. I think that it is a key portion of it. A lot of times people now will have pictures of the retina taken, and these are pretty fancy these days. A lot of times that can be done without dilating the eyes and is sold as a positive thing. It might be good for screening, but if you want someone to really evaluate whether or not you have AMD and its severity, actually dilating the eye, putting those drops in, and taking a good look with the microscope is the way to do it.

MICHAEL BUCKLEY: One question that has already come in, Dr. Brantley, is hereditary, genetic risk factors. If someone has family members with AMD, what type of risk—if any—are they themselves [facing] to getting macular degeneration?

MILAM BRANTLEY: That is a question that we could have a whole two or three Chats about. Very complicated question, and typically what I tell people—and I am an erstwhile geneticist, and I am very interested in the genetic risk factors of AMD. Really, the most important risk factors are what things look like clinically, and age. There is a lot of information out there about genetics, but the important thing is what your eye looks like and how old you are.

If somebody is 35 and they are concerned about macular degeneration because their mother has it, who is 65, I would just say go get yourself a good comprehensive eye exam, make sure everything is okay, and do the sorts of things we would tell anybody to do such as, don’t smoke—the number one thing you can control related to macular degeneration and any macular disease—and, at that point, I would also say to make sure you are eating healthy. Leafy green vegetables and omega-3 fatty acids, maybe a multivitamin if you feel like you aren’t getting everything like that. Those are the main things to do as a young person who is concerned because of a family history. If you are 63 and mom is 87 and you’ve got some changes in the back of your eye, you’ve already seen a doctor, and that trumps just about anything else.

There is some genetic information that can be obtained to get a genetic risk score, but things are primarily based on what the exam looks like, and do you have mild changes, no changes, or pretty severe changes. The follow-up visits are really based on that at this point.

MICHAEL BUCKLEY: Great. Thank you. We have a question from a Mr. Lee in Missouri who says he has been hearing lately about a medicine called L-DOPA and was wondering if that is something he should be asking his eye care professional about.

MILAM BRANTLEY: I don’t know that there is any clinical trial evidence that L-DOPA is something for macular degeneration at this point. That is really not something that is recommended that I know of. We certainly here a lot about different stuff being tried for different things, but not at this point, no.

MICHAEL BUCKLEY: Sure. Thank you. One thing we often hear about is that doctors will mention clinical trials, ask people if they want to participate. Could you tell us a little bit about what a clinical trial for macular degeneration would be? How should someone ask their doctor for a bit more information on whether it is the right choice for them?

MILAM BRANTLEY: Clinical trials right now for AMD are mostly of two types—and there are not that many. People think that there are all of these clinical trials and that if they go into a big doctor’s office they will get into a clinical trial. There are a few, and primarily there are two types.

One is looking for a better way to treat wet macular degeneration. Standard of care right now is an injection of one of three different drugs into the eye. This can be monthly, or every other month, or every 6 weeks, depending on the patient and how well they respond. What we would love is to be able to do that less frequently, but what patients would love is to be able to come in less frequently to the doctor’s office. Wouldn’t it be nice if they could get three injections per year instead of 10 or 12 injections per year? So, the drug companies are looking for additions or modifications to the types of injections so that things can last longer or be better. There are a couple of trials like that. There are also trials where people have tried drops in addition to the injections, or multiple injections on the same day, which would eventually—maybe—be put together into one injectable drug. That is the one type. There are not that many of those.

The other major type of clinical trial for macular degeneration is to look for things that would try to slow down the progression of dry AMD. Really, what people focus on at this point is the progression of geographic atrophy. Remember, that is the advanced form of the dry, and you’ve already lost some cells. That area of cell loss can expand over time. If you’ve got a blank spot in your vision, that can get bigger and bigger over time. We would all love to slow that progression down.

There are also some injectable drugs into the eye that are being evaluated for their ability to slow down the progression of advanced dry AMD. The thought was that maybe someday you could give somebody something that keeps them from getting to that point. Those really aren’t the things that are under clinical trials right now. That’s hard to look at, because it takes place so slowly over a period of time, it’s hard to study in the space of a clinical trial.

MICHAEL BUCKLEY: I appreciate that. Speaking of the injections and other treatments—if a patient has questions or concerns about whether or not they are currently getting the appropriate treatment, what do you think about patients going for second opinions at another office?

MILAM BRANTLEY: I think any patient, seeing any doctor, has a very reasonable right to seek out a second opinion. If somebody is seeing me and they are deep down wondering if they are getting the right treatment, heck yeah, go ahead—sometimes I will even recommend somebody if they would like for me to. Just to make sure that they are comfortable. I think that the big key is, if you feel like you are being rushed or hurried, if you don’t feel like you understand why you are getting the injections, then I think it is reasonable to say “Well, maybe I will go see somebody else and see if there is anything different.”

I do caution people—not a lot of times, but sometimes patients will come, for instance here to Vanderbilt, a large medical center, and they have been treated elsewhere with injections—one of these three commonly used drugs—and are being treated just like the vast majority of all people in the country, either monthly or close to monthly, or monitored very closely and “inject when we need to” type injections. They come to the medical center here and they think, “Well they’ve probably got something different there.” Really we don’t. The standard of care is really pretty secure across the country, and that is monthly or close to monthly—sometimes that is every 2 months or even every 3 months—injections of one of these drugs. So, if you are getting injections, you probably won’t find something that is different or better outside of a clinical trial, and still people are trying to figure those out.

MICHAEL BUCKLEY: Yeah. Well, thank you. We have a few questions related to that. Mary from Illinois wants to know about sunglasses. Is there one type of color that is better than another? Particularly, it is getting to be late spring and summer, what do you recommend for sunglasses for people who may have macular degeneration?

MILAM BRANTLEY: For someone with AMD, typically I will just recommend sunglasses. I don’t have a super-specific type. A lot of times, a low-vision specialist for someone with a particular issue will be able to zone in on a particular wavelength. I think, in general, sunglasses that block the UV light are acceptable and good. They get the job done. A lot of times, as we get older, we need more light. If we block out all of the light then we are not seeing quite as well. So, the lighter tints and the amber colors sometimes will benefit patients so that they have the UV protection, while still not blocking off all of the light. Getting into very specific wavelengths, I would leave that to an individual person.

MICHAEL BUCKLEY: Sure. I want to make people aware that BrightFocus has a nice short card that could fit into your bag or coat pocket called the “Top 5 Questions to Ask Your Eye Doctor.” It helps you prepare ahead of time to help you best manage your vision health. That is available free of charge at www.BrightFocus.org, or you can call 800-437-2423, and we will get you a copy of “Top 5 Questions to Ask Your Eye Doctor.”

Sharon from Tennessee has a question that she would want to ask her doctor: What are the warning signs of macular degeneration?

MILAM BRANTLEY: I think this question could be asked by two different kinds of folks, but the answer is very similar either way. One is somebody who knows they have early AMD, and they are looking for those warning signs of it becoming more advanced and vision threatening. The other type of person is somebody who doesn’t have any history of AMD and they are concerned and want to know what to lookout for in case they start having some signs of AMD.

Really what it boils down to is blurriness, waviness, and distortion of vision. For example, if somebody has these drusen that I talk about, and they have either early or intermediate AMD, their vision is 20/20, and everything seems just fine, and one day they are driving down the road and realize, “Hey, that center stripe is a little bit weird today, it is kind of wavy and I am having trouble making sure that I am driving on the right side.” And then I realize, “It isn’t in my left eye at all, it is just my right eye, and that is weird, it wasn’t like that yesterday.” That is the sort of thing. That is exactly the sort of thing that can go along with AMD going from intermediate to advanced wet AMD, because suddenly there is fluid underneath the retina that distorts the shape of the retina and that then distorts what we are seeing.

So, distorted vision—we have a fancy word for it, metamorphopsia, meaning the shape is off—that is the sort of thing that people will see on their Amsler grids that they might have been given by their doctor to take a look at—that checkerboard pattern of straight and up-and-down and back-and-forth lines, if those become wavy, that is the same sort of thing. People will notice it in door frames. They will notice it on poles. They will notice it on lines in the street. Things become wavy. That is the sort of thing that “Huh—they said that if anything is different I should call my doctor.” These are the types of things we are talking about.

MICHAEL BUCKLEY: I appreciate that, and two things. First, BrightFocus has free Amsler grids. You can call 800-437-2423, and we can send you a free Amsler grid. It is magnetic and can go on your fridge or elsewhere. One of the questions submitted in advance from Joanne from Florida had to do with the Amsler grid. She was wondering, if she were to notice that distortion that you just spoke of, is it too late? Is there irreversible vision loss at that point? How bad are things when you notice distortion?

MILAM BRANTLEY: Don’t know yet. The thing to do is to make that call. What we don’t want is for somebody to say, “Oh yeah, my vision got distorted about 2 months ago, and I knew I had an appointment with you so I decided to wait.” Also, you don’t necessarily want to rush to the emergency room. If you have a doctor that you know and you are hooked in somewhere, you call them and tell them what your symptoms are and ask them when they think you need to be seen. That little distortion may mean that you are finding it very early, that may mean you start getting injections in your eye and in a short period of time things are considerably better. So it certainly is not a, “Wow, everything is over because I have seen distortion.” At the same time, there is not a guarantee that because you get treatment your vision will get back to normal or even improve tremendously. The only way that you can know is if you get a good evaluation and see if there is blood, if there is fluid, or something that needs to be treated…or if it is even AMD.

MICHAEL BUCKLEY: Yeah, that is a great point. We got a question via email from a listener in Ohio who was wondering if there is a specific type of vision change that could indicate that you are turning from dry to wet AMD.

MILAM BRANTLEY: Yeah, I think that it is the distortion thing that you are looking for. Typically, AMD when it goes from the dry to the wet is not going to be total loss of vision, it is not going to be no vision, usually it will be missing vision. There are a couple of exceptions. You could have a hemorrhage that actually blocks off the central part of your vision. The hallmark of going from dry to wet—or going from intermediate to that advanced wet—is that it can happen relatively suddenly. You could wake up one day or just happen to notice that things are a little bit different. It could be something as subtle as that waviness or the door jambs being distorted, or it could be everything is wavy and really weird—like if you look at a person’s face it is fine with one eye and distorted with the other. That is another thing I want to encourage everyone to do. Whenever you feel like your vision may be off a little bit, close one eye, close the other eye, take a look, and try to determine in which eye things are happening so you can tell your doctor. 

MICHAEL BUCKLEY: Don from New Jersey is wondering, “Is there any value to having zinc in your diet in terms of macular degeneration?”

MILAM BRANTLEY: Well, if we look at the Age-Related Eye Disease Study, the AREDS, and then later on the AREDS 2 study, both of these showed that a combination of antioxidants and zinc helped slow the progression of AMD over a 5-year period. AREDS looked at beta-carotene and vitamins C and E. AREDS 2 looked at several different combinations but led with the idea of replacing the beta-carotene with lutein and zeaxanthin. In all of those studies, zinc was found to be an important part of those studies to slow things down. In the context of those two very large clinical trials, the answer is yes.

MICHAEL BUCKLEY: Great! And how would I get more zinc in my diet?

MILAM BRANTLEY: I don’t know off of the top of my head. There is not a study, if we are practicing evidence-based medicine here, there is not a large study, and there probably have been some studying specifically zinc. But the studies that I really go with are the two 4,000-patient studies (or almost 4,000) that say that a combination of antioxidants and zinc slowed things down.

MICHAEL BUCKLEY: I have just a few more questions. Carol from Ohio was wondering, “Is there a typical timeframe in the progression of dry AMD turning into wet?”

MILAM BRANTLEY: Not at all. First of all, you can have dry AMD for a long time and not know about it—you think you just got it last week, but you’ve actually had it for 5 years. The other thing is some people get to the point where they have intermediate AMD, they’ve got a bunch of soft drusen, they are at risk for progressing, and things look exactly the same for the next 20 years. It just never progresses. Those people are very fortunate, and that is great.

There are other people who seem to progress through the stages very quickly. We really don’t understand why some people go the first way and some people go the second way. There is a lot of research going on trying to figure out how we can identify those people who are at risk of quickly progressing, but right now we don’t know. Is there a timeframe that you can hang your hat on? No, not really at all.

MICHAEL BUCKLEY: Thank you. I appreciate that. I think it underscores the value of staying in regular contact. This is very interesting.

Before we conclude, Dr. Brantley, do you have any final observations or comments about what our listeners should be doing to best monitor their eye health or any other topics that we have touched on today?
MILAM BRANTLEY: Well, I think they have already done the main thing, and that is to sign up for something like this to try to understand the disease better. We see a wide variety in patients’ understanding of AMD. I’ve always felt that, if I was a patient, I want to know everything there is to know about my condition, naturally. Patients who understand and can talk about it a little bit better with their doctors and ask questions—“What kind of dry AMD do I have?” “Can you show me the pictures?” “Can you go over the pictures with me and help me see it?”—I really think that an informed patient is going to do a better job of looking for things, is going to do a better job of understanding, “You know, things are a little bit more distorted in that eye. I am going to check that out and make sure that is okay.” But, if you are thinking about it, you’ve got it on your mind, and you’ve done some things like this to understand it better, I think that is very key in just taking care of yourself.

MICHAEL BUCKLEY: If you don’t mind, one more question before we wrap up. I would like to talk about driving and macular degeneration. When you talk with your patients, how do you address the driving question? I think that would get to your point about patients knowing important questions to ask about day-to-day life. How does macular degeneration affect someone’s ability to drive?

MILAM BRANTLEY: Sure. Well, the answer to that is as varied as what macular degeneration looks like in people. Someone who has early, say, a few changes, and their vision is not affected—truly their vision is not affected—that, in and of itself, does not really impact their ability to drive. Certainly, too, when you are talking about the AMD population you are talking about a population that is getting older. It is a little bit more of a challenge in general to drive when you are 85 than it was when you were 55.  And reflexes—everybody is aware of this. They need to make sure that they are driving well. A little slip in vision could be a significant thing. Remember, of course, that what we have to go by is visual acuity and where that distortion might be. Because AMD effects central vision, it can be a big player. If vision is significantly distorted, such that visual acuity goes beneath a certain number—and that kind of varies a little bit depending on what state you are living in—then it can become the sort of thing that can affect one’s ability to renew a driver’s license. That, too, varies from state to state, how people can renew their driver’s license.

Whether or not you have a license, it is still a decision that needs to be made, often with the patient and perhaps their son or daughter who is with them in the office and is driving them to the appointment. It is something to talk about. The key thing about driving is that—and I have this conversation with anybody no matter what their vision challenge is, whether it is AMD or something else—you have to remember that when you are driving it is not just you out there by yourself. If you are not safe to drive, you’re not just risking yourself but also those around you, and you’ve got 2 tons of motor vehicle underneath you. If you’re not really seeing well enough, then you are putting other people at risk, too.

So we have very frank conversations. Many times, patients’ kids are going to come in begging that I tell that patient that they can’t drive anymore. Really, that is a decision for the patient and the family, but I lay out all of the information—here is what your visual acuity is, here is what visual acuity needs to be in the state of Tennessee, yours is not that. So, even though your license may have 2 more years on it you do not currently have vision good enough that the Department of Motor Vehicles thinks you should be able to drive—just so you know that. I think that is very important to put all together. If your vision is okay but you are beginning to wonder, there is certainly a difference between driving in downtown Nashville at night in the rain and driving on a nice country road on the way to the grocery store in an outlying county on a bright sunny day where you can see well and have driven it 400 times this year. That needs to be taken into consideration too.

MICHAEL BUCKLEY: I can appreciate that. I know that these must be very difficult conversations for everyone in the room. Related to that, one of our most requested publications is called “Safety and the Older Driver,” and it has some sample scenarios and wordplay for having some of those difficult conversations. Again, that is something at www.BrightFocus.org.

We are running out of time, Dr. Brantley. I just want to thank you so much for being with us today. I think you really helped our listeners understand the different types of eye care professionals, a lot of the right questions to ask about dilation, clinical trials, and treatment. I very much appreciate what you helped us with today.

MILAM BRANTLEY: It was my pleasure. Thanks for having me.

MICHAEL BUCKLEY: About a week from now, we will have a transcript of this call on our website, www.BrightFocus.org. The audio will be up on iTunes and SoundCloud, or people can call in at any time and we can send you a written transcript of this call if you do not use the internet on a regular basis.

Building off of today’s Chat, next month’s is going to be “Macular Degeneration: How to Keep Your Eyes at Their Healthiest.” That will be coming up on May 25, 2016. You can call 800-437-2423 to register for that and also submit some questions.

Thank you, Dr. Brantley, and thank you for everyone who joined with us today. I appreciate everyone who joined us and appreciate the very thoughtful and interesting questions. This concludes the BrightFocus Chat for April of 2016, and thank you very much!  

BrightFocus Foundation: 1-800-437-2423 or visit us at www.brightfocus.org. Available resources include:

• Resource lists for people with macular degeneration
  • A Guide to Finding the Right Eye Doctor
  • Top 5 Questions to Ask Your Doctor
  • Safety and the Older Driver
• Information on research funded by BrightFocus (www.brightfocus.org/mdr-research)
• Information on L-DOPA (www.brightfocus.org/ldopa)

The information provided in this transcription is a public service of BrightFocus Foundation and is not intended to constitute medical advice. Please consult your physician for personalized medical, dietary, and/or exercise advice. Any medications or supplements should be taken only under medical supervision. BrightFocus Foundation does not endorse any medical products or therapies.