Why AMD Is on the Rise-and What Can be Done

BrightFocus Foundation
Why AMD Is on the Rise and What Can Be Done
February 22, 2017
Transcript of Teleconference with Sandra S. Block, OD and Christina Morettin, OD
1:00–2:00 p.m. EDT

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

MICHAEL BUCKLEY: Hello, I am Michael Buckley from BrightFocus Foundation. I welcome you to today’s BrightFocus Chat, “Why AMD Is on the Rise and What Can Be Done.” If this is your first time on a BrightFocus Chat, welcome. Let me take a moment to tell you a little bit about BrightFocus and what we will do today. BrightFocus funds some of the top scientists in the world. We support researchers who are trying to find cures for macular degeneration, glaucoma, and Alzheimer’s. We share the latest news from these scientists with families that have been impacted by these diseases. Today’s BrightFocus Chat is another way of sharing this information as widely as we can.

Today we are going to discuss a new report from the National Academy of Sciences on vision health in America. The study found, and I quote, “Despite the importance of eyesight, millions of people grapple with undiagnosed or untreated vision impairments—ranging from mild conditions to total blindness—and eye and vision health remain relatively absent from national health priority lists.“ The study found that age-related macular degeneration, often called AMD, is particularly on the rise. The authors noted a dramatic increase over the last decade, and they predicted the number of Americans with advanced forms of AMD could more than double by 2050.

A little background—the National Academy of Sciences is an independent advisory council created in 1863 by President Abraham Lincoln. We are fortunate to be joined today by a member of the Academy’s vision panel, as well as one of her colleagues at the Illinois College of Optometry. Today’s guests are Dr. Sandra Block, OD, a professor at the Illinois College of Optometry and a member of the National Academy of Sciences study panel “Making Eye Health a Population Imperative: Vision for Tomorrow.” Also joining us today is Dr. Christina Morettin, OD, an assistant professor at the Illinois College of Optometry and Chief of Urgent Eye Care Services. Her interests include urgent eye care, primary eye care, ocular disease, and retinal disease.

Today we will discuss more about vision health in America and what can be done, and we will take your questions as well. We don’t always have time to answer all the questions during today’s Chat, but we do save them to ask for future Chats. Turning to our guests today, I was wondering if we could start off with Dr. Block. What was your panel at the National Academy of Sciences charged with doing, and what did you recommend?

DR. BLOCK: The panel was an interesting group. There was a statement of tasks that was put together by a group of organizations that represent vision and vision issues around the country, including the National Institutes of Health, the CDC, Prevent Blindness, the American Academy of Ophthalmology, the American Academy of Optometry, and Research to Prevent Blindness. These individuals got together and decided we needed to bring vision to a higher level within the political climate, which is the government and the budget, as well as the nongovernmental people, such as the public health arena and medical professionals. The reality is that vision is a significant problem, and our population is changing drastically, as we all know. There is an aging issue going on where we will see a lot more people who are at the older level of the age group rather than the younger. We do not see as many large groups of babies being born, as primarily we are living longer and hopefully living healthier lives.

The committee was made up of a group of doctors and diverse people: three ophthalmologists, three optometrists, a physician, a patient with a visual impairment, and some public health folks that were really there to keep us on track. The whole purpose of us sitting together in a room for many hours over a year and a half was to talk about the fact that vision is an issue that oftentimes is ignored. Many problems that the American public faces are problems that, if diagnosed, can easily be treated, such as glasses for far or near sightedness. However, there are many vision problems that don’t have that simple fix, problems that are diseases that we don’t have a treatment for, or if they are not caught early enough, the outcomes are poor. With aging we are looking at things like diabetic retinopathy, hypertensive retinopathy, glaucoma, age-related macular degeneration.

The committee felt very strongly that we needed to bring these topics to a higher level and not only talk about them as being issues to the public but what can be done. The things brought out by the committee included the need to know how large the problem is—what is the true number of people [suffering from these diseases] in the United States? Much of the numbers we have are based on populations that were incomplete. They used to disregard data about people in nursing homes or mental health institutions, but if you think about it, people who have vision problems oftentimes are at the end of life and end up in those facilities, so our numbers were never really that good, and that is one of our recommendations.

The other issue is early prevention, a good recommendation to the public as to how often they should be seen for eye exams. We didn’t make that statement as to when they should be seen, but what we did was ask everyone to come together to agree on some recommendations so the American public understood very clearly how often they should be seen for an eye exam, just like a routine dentist appointment every 6 months.

One of the other pieces that is really an important piece is that there are a lot of people with vision problems that leave them visually impaired or blind, and the focus needs to be on ensuring that population has resources that aren’t necessarily out of pocket but are potentially covered by a health care program. This allows them to maintain their independence; as you may know, as we get older, we become more dependent on our families or the community at large. So the report came up with eight recommendations. We are having our first workshop next month to translate those recommendations into actual operational pieces.

MICHAEL BUCKLEY: That is great. Thank you very much, Dr. Block. It sounds like the report really highlighted the gaps in knowledge and gaps in awareness. Related to public awareness, I read an article the other day in the newspaper about how a study at Johns Hopkins found that most Americans regard losing their eyesight as the worst ailment that could possibly happen to them—more so than loss of limbs, loss of memory, or loss of hearing or speech. Yet as you mentioned, it seems like people do not always take their eye health as seriously as other types of health. I was wondering—do you or the panelists have observations about those potential contrasts or disconnect there?

DR. BLOCK: You know, Michael, it was nice to see the authors actually published that. This is not the first time that people have investigated whether people fear vision loss or physical loss versus mental health issues, and they all come down to the same information—that a loss of vision is the scariest as it oftentimes forces people to become more dependent and less independent, and that can lead to various complications, whether with their mental health issues or lack of access to appropriate health care. To me that is really one of the scary things—that people do not realize that if they do not take care of their vision it does lead to the loss of vision down the road. I am not quite sure how the American public will respond when we talk about that.

Many times vision problems have no pain or discomfort. This is not an acute issue that can send you to the emergency room. You may not even realize that you lose vision in one eye, because the other eye is probably seeing quite well, and it’s only when you lose vision in that second eye that you are even aware that there is a loss of vision. Our goal is to really make people aware of the fact that sometimes they may not be aware of the steps leading to a loss of vision so that we can do the intervention before the disease takes its toll on the visual system.

MICHAEL BUCKLEY: It’s interesting, it seems to me that maybe one of the misunderstandings is that if your vision isn’t perfect, you can go out and get it corrected by getting a pair of eye glasses or contact lenses. How do we as a country provide awareness that vision may be something that can be lost—and perhaps irreparably—as opposed to something that with just a trip to a doctor can be improved?

DR. BLOCK: We certainly hope we can correct most things, and glasses certainly are an easy fix, but many times people are afraid that the vision loss can’t be treated or the people that they are dealing with—their health care providers don’t understand the new techniques or the processes that can be used to treat some of these current problems, including glaucoma and macular degeneration. I really defer to Dr. Morettin for that information, as that is more of her area of expertise.

MICHAEL BUCKLEY: Great, thank you. Dr. Morettin, I know that the report talked about a number of conditions that are on the rise. One is particularly age-related macular degeneration. I was wondering, in your practice in your opinion, why do you think macular degeneration is on the rise?

DR. MORETTIN: Thank you for having me. That is an excellent question, and I think the number one reason, as Dr. Block pointed out, is that people are living longer now, and we also hope that people are living a healthier lifestyle, as well. With macular degeneration, one of the biggest risk factors is age. As we have an aging population, as Dr. Block again alluded to, we want to make sure that we are screening people earlier, so if there is something we can do, we want to intervene earlier to prevent vision loss if we can.

MICHAEL BUCKLEY: Thank you. Beyond aging, are there population groups that are more at risk for AMD than others?

DR. MORETTIN: Yes, that is an excellent question. Genetics have a huge role to play with macular degeneration. They have isolated at least 20 genes right now that play a role, although we don’t know 100 percent how or why these genes makes someone more susceptible. Therefore, if you have someone in the family, especially your immediate family, who has had macular degeneration, you are more at risk. Secondly, Caucasians seem to be more at risk than other populations, although any ethnicity can develop macular degeneration, Caucasians are more at risk. The other biggest and modifiable risk factor is smoking; they have done many studies, and smoking always appears to be the biggest modifiable risk factor. Therefore, that is a big conversation to have with your doctor and if you are smoking, how to quit smoking, because it is such a big risk factor.

MICHAEL BUCKLEY: Related to that, we have two questions that will be suited for you, Dr. Morettin. Rawlins from Wyoming is wondering—is it true that blue-eyed Scandinavians are one of the more at-risk populations for AMD?

DR. MORETTIN: Yes, they are more at risk. Studies have shown that people with blue eyes are more at risk for developing macular degeneration. Again, the understanding of the “why” is still unknown. It could be the underlying genetics, and it could also be the role of pigmentation in the eye itself.

MICHAEL BUCKLEY: Interesting. Another question related to a modifiable risk is from Kathy from California. She would like to know the balance of how much of the risk is environmental influence, such as diet and exercise and smoking, versus how much of the risk is genetic.

DR. MORETTIN: That is an amazing question—it is something that we are still striving towards. We do know that there is a genetic component, and we also know that there are environmental components. If you are more at risk, or someone in your family is at risk, we do recommend that you start [addressing] the modifiable risk factors early to prevent disease and prevent progression of the disease.

MICHAEL BUCKLEY: Makes perfect sense. Next question can go to either Dr. Block or Dr. Morettin, or perhaps both—do you see any risks or lifestyles in youth or middle age that lead to problems? I know you mentioned smoking a moment ago. But do either of you see parts of American lifestyle that could lead to these problems later down the road?

DR. MORETTIN: An interesting area of research right now is in blue light. We know that blue light has some harmful effects in the back of the eye called the retina, and we also know that it has some healthy benefits like maintaining rhythm and when we go to sleep and when we wake up. It is not 100 percent sure what type of tints might be beneficial; some companies are coming out with yellow tints, because we see blue lights from a lot of technology like iPads and iPhones and computer screens, so that is one thing that may put people at risk later down the road. It is too soon to really know, but many companies have invested in the yellow tinted lenses that hopefully will prevent people from developing these types of diseases if they are at risk. The other thing is diet. People that have diets that are elevated in fats; high cholesterol; and high glycemic index foods like white rice, pasta, and breads can be more at risk as well.

MICHAEL BUCKLEY: Dr. Block, is there anything you would like to add to that?

DR. BLOCK: To me the biggest issue is to make sure people have regular eye exams, because oftentimes some of the earlier risk factors are identified before things become a problem, so I feel it’s really important that everyone understands the value of a dilated eye exam to be a part of their annual eye exams.

MICHAEL BUCKLEY: That is great. Let us expand on that. Dr. Block, you said that your study group looked at the question of how often should one get an eye exam. Is that a simple answer or is there more than one answer depending on the individual?

DR. BLOCK: There is more than one answer depending on who responds. There is a lot of question about who should get an exam every year. There is an agreement that people who have any type of risk factor—such as a family history of amblyopia or glaucoma—those kinds of people should be seen for regular eye exams on a regular basis from childhood to adulthood. It is the people who don’t have a family history that there is some sort of disagreement, such as—oftentimes children don’t need an eye exam until they complain or fail a screening. That would be fine if our vision screening process was a good process and they were able to ensure that anyone who failed accessed eye exams later on.

The age group between 18 and 40, which is typically a pretty healthy age group—there’s lots of controversy whether it should be every year, every other year or every 3 years. It really depends on who you talk to, but we need research to know what the most cost-effective way is. Oftentimes people who have vision problems may need their glasses tweaked, or if something bothers them they will go in anyways. It is really the ones who have no complaints that typically don’t have a clear-cut idea of when to go. I have to say that oftentimes some of our students in optometry school say, “Oh yeah, this is my first eye exam ever.” You wonder, how did they come to optometry school if they have never had an eye exam? Those are some of the surprises we have.

Over the age of 40, we all can pretty much agree that every year is probably good, and once you hit close to 65 annual eye exams are really important.

MICHAEL BUCKLEY: Thank you. Related to that, it sounds like what I hear the two of you talking about is a distinction between an eye exam that looks at your eye health and an eye exam that looks at your visual acuity—the ability of my kids to see the blackboard at school. What should you ask for—what is the right balance, or is it an either or both on the eye health versus the visual acuity?

DR. BLOCK: I will be happy to respond to that. An eye exam should always look at a number of things: how well you see with each eye; how well you see with your eyes together; whether you need any type of correction with lenses, such as eye glasses, sunglasses, or reading glasses; and how healthy your eye is, both inside the eye as well as outside the eye. You do not necessarily need to have drops to dilate your eyes every year, but someone should look at the back of your eye often just to make sure that there is nothing going on. The interesting thing is the nerve endings in your eye do not give you pain, so you may not realize that there is a vision problem. It might just be flashes of light, and sometimes people ignore that. So an eye exam should really be all of the above.

MICHAEL BUCKLEY: That’s great. Here at BrightFocus we have a front-and-back card that you can take to your eye doctor called The Top Five Questions to Ask Your Eye Doctor. It is free of charge and can fit in a bag or coat pocket. Kind of related to that, what should someone ask for—for instance, I have heard the phrase “comprehensive eye exam”—what should a person walking in the door to their appointment make sure they are getting or know what to ask for?

DR. MORETTIN: Like Dr. Block mentioned, I think the biggest thing that people should make sure of is that they are getting a look in the back of their eye. Sometimes if you need to adjudicate for yourself, this would be the area of biggest concern, whether that is through dilation or through imaging.

DR. BLOCK: The imaging is oftentimes by machines that are computer-designed that will be able to look at the back of the eye to see how healthy it is without having to put the drops in your eyes. It’s non-invasive but it is often very helpful, important.

MICHAEL BUCKLEY: Thank you. Generally speaking, in terms of Medicare/Medicaid or private insurance, what seems to be covered and not covered at an eye exam appointment?

DR. MORETTIN: Concerning Medicare, for example, I deal a lot with that population. An annual dilated eye exam is covered every year. If there is special imaging that needs to be acquired, most of the time it’s covered, as well. Make sure to talk to your health care provider to ask those questions.

DR. BLOCK: To add to that, glasses are not necessarily covered as often as a medical exam, so depending on your insurance, every insurance plan is written a little bit differently. Your age and the coverage you have will determine whether you are entitled to a pair of glasses under your plan.

MICHAEL BUCKLEY: Great, thank you. We just received two questions—I’d like to go back to the risk factors. Elizabeth in Massachusetts says that growing up she played tennis and was outdoors a lot. Is that something that would put her at risk for AMD as she gets older?

DR. MORETTIN: That is a great question. Many studies are looking at effects of UV light. If she was wearing goggles or protective eye wear, that generally reduces your risk. Nowadays, when especially young people are coming in who are very active, or even older people, we do recommend tinted sunglasses or ski goggles to reduce the risk—not only for macular degeneration, but UV light has been shown to cause even advancement of cataracts in the eye over time.

MICHAEL BUCKLEY: Great. Related to that, Diane from Texas is wondering—can AMD be something that is caused by other health problems in your body as you get older?

DR. MORETTIN: A great question as well. You know, many studies have looked at the lifestyle that we have and its effect on AMD, and they have looked at the Mediterranean diet. This goes alongside our overall cardiovascular health—not just our eyes, but they have shown that a diet rich in dark leafy green vegetables, nice healthy fresh fish versus a lot of carbohydrates and dairy can actually reduce your risk of macular degeneration. That does not just help your eyes but your cardiovascular system. They do find that people who live a more sedentary lifestyle, who aren’t getting exercise or the proper nutrients, are at risk.

MICHAEL BUCKLEY: That is very helpful. I just want to remind our listeners that we have a free publication to expand on the doctor’s point there. It’s called Healthy Living and Macular Degeneration. It includes tips to protect your eyesight, such as recommended lifestyle choices. Related to that, Dr. Morettin, we hear people mention something called—a treatment for AMD called AREDS or AREDS 2. Would you be able to expand on that a little bit?

DR. MORETTIN: Of course. So in the 1990s there was a huge multi-center trial called AREDS, and at that time they looked at what vitamins would actually reduce your risk of progression of macular degeneration. What they found is a multivitamin that has five different items—vitamin C, vitamin E, zinc oxide, copper and the last is beta carotene—which helped to reduce the risk of intermediate to advanced macular degeneration by 25 percent.

Let’s take a step back. There are three basic stages in dry macular degeneration. There are two types of macular degeneration, dry and wet. Ninety percent of people who have macular degeneration have the dry form. This form can range from people who do not know they have it because their vision is still perfect all the way to having significant central vision loss. When they looked at the different distinctions between early, intermediate, and late, they found that the vitamins only help for the intermediate and advanced stage. If you have very early macular degeneration, the AREDS vitamins haven’t been shown 100 percent to help you, but there is no harm in taking these vitamins. Now, the one thing they looked at with the original AREDS vitamins was the beta carotene. In people that smoked, they found that beta carotene actually increases your risk of lung cancer. So if you are at the store and looking at the different forms of vitamins and AREDS, there is a formulation without beta carotene for those who smoke.

A few years back this multi-center trial came out, and it was a huge deal—people couldn’t wait to find out the results, because they looked at the effect of omega-3—because again that’s involved in antioxidation in the body—and lutein and zeaxanthin—those are big words for antioxidants that we have in our retina and in our macula. Interestingly, we found that that omega‑3 didn’t actually help prevent progression of macular degeneration, but what they found was that lutein and zeaxanthin actually do help to reduce your progression as well, especially in those who couldn’t have the beta carotene, as they were current or former smokers.

MICHAEL BUCKLEY: Well thank you, I appreciate that. You mentioned a multivitamin. If someone went to their local pharmacy, would it be labeled as AREDS 2, or would be it labeled as different vitamins needed to be taken together?

DR. MORETTIN: That is another good question. I know sometimes when we go to the pharmacy, it is overwhelming with the selection that we have—not only for vitamins but for eye drops, like for artificial tears. Most of the vitamins are labeled AREDS or AREDS 2. If you need any help, I suggest you talking to your eye care provider or local pharmacist to help you with the brands they carry in office or at the pharmacy. Again, it can be labeled AREDS 2. If you are a current or previous smoker, make sure that there is no beta carotene in that formulation. They do have the recommended amounts in most of the labeled AREDS 2 or AREDS formulation.

MICHAEL BUCKLEY: I appreciate that. Additionally, our website at www.BrightFocus.org has the AREDS information on it for people’s reference, as well. Dr. Block, I want to get a big picture on vision disease on the rise. Is there anything that communities can do to be supportive of the aging population, particularly as aging-related diseases increase?

DR. BLOCK: There are a number of things that were recommended within the report; some of them were related to the physical environment that people are in. There are many modifications to buildings that can be made to ensure that those who have visual impairments are able to get around safely. Oftentimes the communities are unaware—as they make changes within their facilities in the community—that those things are available. The report really wanted to advocate that our goals were to educate the government on all different levels, all the way down to the local community. Therefore, they were aware that there is a growing problem and that individuals with visual impairment live in the communities. It really was their responsibility to ensure that when they start to look at modifications of the buildings, they need to consider it. Simple modifications to the environment that can be made so someone could maintain their independence even with the vision loss.

MICHAEL BUCKLEY: Great. As you mentioned earlier, such a key part of healthy aging is that sense of independence. Did the report address whether there were any areas that need more research on vision disease?

DR. BLOCK: One of the biggest recommendations is that—everyone sitting at the table when we were discussing vision indicated that there are so many gaps in the research. Much of the research that has taken place over the past 10 years has really focused on bench science, which isn’t necessarily going to help the U.S. population for another 10 to 15 years.

We really felt it was important that the National Institutes of Health, the National Eye Institute, and the CDC—they can do a better job on how we can ensure that there are better screening techniques and to ensure that people actually access health care services and what are the barriers and drawbacks for people, such as money, transportation, or a fear of going to the doctor and being diagnosed with something.

We felt very strongly that there are significant gaps in research, and we looked within our recommendations for most people involved from the level of research through clinical providers to take vision into consideration.

The other piece that we often ignore is that vision should not be siloed; you know, we always talked about going to your optometrist separately from going to your health care provider. One of the focuses we had is—we need to educate all health care providers to integrate vision into the basic health care system. We had a geriatric physician on the committee who expressed that anytime she had an individual come in for a health exam, that they talked about their vision and made sure that the recommendation was to get an eye exam, to ensure that their vision is assessed, and if there is any intervention that needs to be done. That it be a part of the holistic view of that patient.

MICHAEL BUCKLEY: That is great advice both individually and from a policy standpoint. We have one question that will get us into our last topic; Colleen from Ontario wants to know at what age children should start wearing sunglasses. Before we get into that, I would like to wrap up today by talking about children and grandchildren and—whether it is Coleen’s question on sunglasses or in general, what type of advice can we give to our children and grandchildren decades before they may be senior citizens?

DR. BLOCK: So there is no age that is too young—we want babies in sunglasses. They have some wonderful sunglasses designed specifically for infants and toddlers. You want to prevent any of that UV light that can hurt the eyes; protect them as early as you can. That being said, as children start to participate in sports activities, you want to make sure that whatever they are wearing is appropriate and protective as well—protection not only from the sun but also from injury in any way. Our goal is to ensure that children have the opportunity to grow and develop fully. That means that we need to protect their vision and their eyesight from infancy all the way to adulthood.

DR. MORETTIN: That is a great point, and I will add that on top of that to make sure you are talking to your family, whether that is your kids or grandchildren, so that they know what their family has. If you have macular degeneration, let them know from an early age that this runs in the family, in order to be taking things like UV protection seriously from when they are at a young age all the way to when they get older. Let them know that, because they have this in their genetics, to make sure that they are going for their annual eye exams and people are looking at the back of their eye, so that the minute we see something that isn’t normal we can take action and do something about it.

MICHAEL BUCKLEY: That is great, thank you. A last question to each of you: in your profession, do you have any big picture advice or concerns that you would want to share with people about their eye health?

DR. MORETTIN: You know, I work in our urgent eye care clinic a lot, and I tend to see many people come in who have not taken care of their eye health until it has become too late, so really the biggest thing for me is prevention in your annual exam. If something is wrong, do not hesitate; go and see your local provider so they can look and take action early if need be. Just like with macular degeneration, the earlier we know about it, the earlier we can intervene and preserve vision.

MICHAEL BUCKLEY: That is great, thank you. Anything else you would like to add?

DR. BLOCK: I would like to share that I am a specialist in pediatrics and special needs patients, and many people who work with special needs patients, whether they are children or adults, don’t realize the value of ensuring that these individuals see well, because oftentimes it allows them to reach a higher level of quality of life. We see it frequently in the Special Olympics. I work with the Special Olympics regularly, and we really want to make sure that everyone has the opportunity to have optimum vision, which means good vision care.

MICHAEL BUCKLEY: That is great. I really appreciate the advice from both of you. I think you both have made a lot of positive and specific points of advice, and at the same time you have done a great job conveying to people the seriousness of vision health.

Dr. Block and Dr. Morettin, I would like to thank you for your generosity and, Dr. Block, I appreciate your service to the country and to the field of science through your National Academy of Sciences work, and I know you have another meeting coming up and wish you all the best. With that, I would like to conclude today’s BrightFocus Chat. Thank you, Dr. Block and Dr. Morettin and all of our listeners.

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

• Information on research funded by BrightFocus
• AMD On the Rise, According to National Academies Report Update on Clinical Trials for Macular Degeneration
• Macular Degeneration: Essential Facts (PDF)
• Clinical Trials: Your Questions Answered (PDF)
• Healthy Living and Macular Degeneration: Tips to Protect Your Sight (PDF)
• The Top Five Questions to Ask Your Eye Doctor
• Tips to Protect Your Eyes from Bright Light 

Treatments or devices mentioned:

• AREDS and AREDS 2 vitamin supplements
• Tinted lenses to cut down on blue light exposure

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.