The discussion features Edward Marcus, MD, a leading ophthalmologist in New York. Dr. Marcus specializes in medical and surgical management of retinal diseases, including diabetic retinopathy, macular degeneration, and retinal detachment. He also specializes in treating inflammatory and infectious eye diseases.
BrightFocus Foundation
Keeping Your Eyes Healthy in the New Year
January 27, 2021
1:00 p.m. EST
Please note: This Chat may have been edited for clarity and brevity.
MICHAEL BUCKLEY: Hello, I’m Michael Buckley with the BrightFocus Foundation. Welcome to today’s BrightFocus Chat, “Keeping Your Eyes Healthy in the New Year.” If this is your first time on a BrightFocus Chat, welcome. Let me tell you a little bit about who we are and what we are going to do today. BrightFocus funds some of the top scientists in the world trying to find cures for macular degeneration and glaucoma and Alzheimer’s, and what we’d like to do is to share the latest news and best practices from the fields of science and medicine. We offer a number of free publications and materials on our website, BrightFocus.org, and today’s Chat is an example of that. We’re going to spend a little over a half-hour today discussing macular degeneration and answering some of your questions. Let me tell you about today’s Chat—again, “Keeping Your Eyes Healthy in the New Year.” Our guest is Dr. Edward Marcus. He’s an ophthalmologist in the New York City area, and we had him on about a year ago, right before the pandemic started, and so, we thought it was a great opportunity to bring him back and hear what he has to say. As we enter 2021 and people take stock of their health and make plans to be a little healthier in the new year, we thought it would be a great opportunity to bring him back. So, again, Dr. Marcus, welcome back. I was wondering, for those missed your last Chat, if you could just tell us a little about yourself and how did you end up being an ophthalmologist?
DR. EDWARD MARCUS: Great. Well, thank you for having me. I appreciate it, again, and it’s great having a chance to connect with all of you on the call here. I am an ophthalmologist and, specifically, a retina specialist—vitreoretinal surgeon—in the New York area. I work as the head of retina in a relatively large—now multistate—ophthalmology practice called SightMD. We have offices spanning from Pennsylvania, to New Jersey, New York, and Connecticut, mostly in lower New York state. We treat all areas of eye disease—obviously, me specifically treating the retina. I got into ophthalmology … there’s a short answer and a long answer. I think the long answer is more interesting.
I wanted to enter a field of medicine that had both medicine and surgery. In other words, there was an opportunity to be in the OR and to do surgical procedures but not be the entirety of the profession. I want to see patients. I want to do small procedures. I want to meet people and treat chronic diseases, as well. Ophthalmology—specifically retina—was a great opportunity for that sort of practice. There’s a lot of technology involved, and treating retinal disease is always on the forefront of every pharmacological breakthrough. It’s just been an exciting feedback loop. It’s an area of medicine that I can treat severe disease and make people better, so it’s a real chance every day to take people who can’t see and then make them see. It’s really rewarding in that way. So, that’s essentially the journey.
MICHAEL BUCKLEY: It’s great to hear the motivators that send people into this type of work. We talked to you just before the pandemic started in the winter of 2020, so we wanted to check back with you. How has your practice changed since the pandemic started?
DR. EDWARD MARCUS: It’s been a progression. At the very beginning, most of our larger practice was completely shut down because people were very afraid and, essentially, limited everything to only essential and emergency visits and treatments. For the aforementioned reasons, almost everything I do is urgent and emergency, so we were still up and running during the total lockdown period. My practice was running basically normally except not at full capacity because some people, although they should have come in, were afraid to at first. We had all sorts of very new and interesting precautions that people hadn’t done before—people are still feeling their way through—but I think what we’ve largely learned over the past year as a society and as a practice is what’s safe, what’s important, and what really isn’t. I think people have learned over the months of the pandemic that going to the doctor is very safe and there’s little to no spread of COVID in doctors’ offices. You can go to your appointments and feel like you did before. Yes, there is something covering your face, but other than that, your appointment is as it has ever been.
We’ve really come down to understand how to make the visits safe and normal. People, unfortunately at the very beginning, didn’t come in for their visits because they didn’t feel that going out was safe and doing their everyday activities was a possibility, and some people, unfortunately, lost a lot of vision and ended up in a pretty bad way because of that, but since then, both the importance of saving your vision and getting your regular treatments and the relative safety of just coming to your appointments was realized simultaneously, and we’ve been running at full normal capacity ever since.
MICHAEL BUCKLEY: As people start turning their attention to the vaccine, is there anything that people that have AMD or other vision disease … are there any questions or concerns that they should have about the COVID vaccine?
DR. EDWARD MARCUS: The only question would be how to get it sooner than soon. I think that this is an absolute blitz to get as many people vaccinated as soon as possible and as well as possible. This is the only chance we have in fighting this pandemic. It does not affect macular degeneration. As far as we know, it doesn’t affect any other disease state in existence. The only real precautions that have come up have been allergic reactions, which for better or for worse, you can’t really predict who’s allergic and who isn’t to anything before they actually experience it, but there hasn’t been any other health concern that’s come up. I guess there was a report of pregnancy being a potential factor, but I don’t know how many people who are pregnant have age-related macular degeneration. But that’s sort of been the only safety signal. Essentially, it is imperative for as many people to be vaccinated as soon as humanly possible across the globe, because that’s our only real chance. We need 80 percent of the population immune at the exact same time for this to go away, and getting the disease and getting over it doesn’t provide immunity for more than 3 months, really, unless you are really, really sick, in which case you may have a year or so of immunity on board.
MICHAEL BUCKLEY: Certainly great advice. Dr. Marcus, have you noticed with your patients during the pandemic … have you noticed signs of isolation or loneliness, or did your patients seem different during this time?
DR. EDWARD MARCUS: Yeah. We’ve seen a lot of it. We, unfortunately, have a lot of patients who’ve lost a family member. We hear about it all the time, and we haven’t stopped hearing about it, unfortunately. There are people who are in states of grief at various visits because of that, and clearly, that’s the most traumatic thing that can happen, but there are certainly elderly people who have not been in contact with their children or their grandchildren because they are too afraid or, conversely, their children and grandchildren are too afraid to be with them. There are people who have just missed visits because or missed months of visits because their family that usually spends time with them or takes them just isn’t around. They are in other states. They can’t travel. They can’t come to help out with certain tasks.
The isolation has absolutely affected us in a very noticeable way from day to day. Even in the office, people are isolated from the people they come with because we can’t have family members with patients. We don’t want to overpack the waiting rooms in the office, so we have lots of patients who usually come with a spouse or with a child that writes things down and accompanies them. They are not able to come with that person, so there is some miscommunication because their partner at the visit is not there. So, we’ve had some issues just why that the visit with … the temporary loneliness of just not being with your spouse who’s waiting for you in the car. Absolutely, we face this on a daily basis.
MICHAEL BUCKLEY: Any tips for patients that are understandably troubled when they can’t bring a care partner in with them?,
DR. EDWARD MARCUS: Yeah, usually we’ll have patients notify our staff if they need for someone to be with them in order to write things down or for them to remember the details of the visit, and they may not accompany them for the whole visit, but when they’re finally called in to see me, then their significant other or children would be called into the room from the car of the parking lot so they can partake in that last part of the visit. I guess the essence of it all, being in the exam room, if there are three people in the room when we all have masks on, we’re pretty safe. We just don’t want to have 100 patients plus their husbands and wives making 200 people in the waiting room. We want to just … again, like everything else, we’ve adapted. We’ve found ways to make it as safe as possible.
MICHAEL BUCKLEY: Pivoting to AMD, in general, we’ve received a number of questions already today for people looking for updates on how AMD is treated, so I was wondering if we could just start with dry AMD and geographic atrophy. Is there anything new or coming down the line in how to treat dry AMD?
DR. EDWARD MARCUS: Sadly, the most promising thing, which was brimonidine—or some people with glaucoma may know it otherwise as Alphagan®—the compound was found to be neuroprotective, and there was an investigational drug from Allergan, which was a Depo shot of Alphagan—or brimonidine—in the eye, but when Allergan merged or became a part AbbVie, some of their products were dropped, and this was also around the time of the pandemic when they were streamlining their product line, so actually, the most promising thing was dropped from the lineup, and the research was halted. There are a couple of other things that were under investigation, some monoclonal antibodies—which are similar to Eylea® or Lucentis® but to treat geographic atrophy—were look at and were not very successful. Really, the only thing that seems to have any sort of promise, unfortunately, was stopped in its tracks, so we’re essentially left with our old armament of AREDS vitamins, careful monitoring with either the Amsler grid or some of the newer products—like the Notal Vision ForeseeHome™—and just keeping on top of monitoring as closely as possible.
MICHAEL BUCKLEY: I’d like to just save that point for another minute or two. In terms of monitoring your eye health in between visits—and, as you said, some people, that in-between time might be a little bit longer than prudent—but during that time, how does an Amsler grid and the ForeseeHome monitor … how do those work?
DR. EDWARD MARCUS: The Amsler grid essentially is boxes on a piece of paper. It’s the old graph paper, basically, and you’re looking at it one eye at a time. You want to ensure that the lines you are seeing are straight. If the lines start to look bent or wavy, that’s something called metamorphopsia or just changing shapes of things, which indicates that there is either subretinal fluid or some sort of disturbance of the retinal photoreceptors that they’ve moved around by some force—usually subretinal fluid—that causes a straight line to look wavy, so distortion of straight lines is one of the earliest signs of trouble in macular degeneration. That’s something that obviously requires patient participation and understanding, but on the other hand, it’s extremely simple and easy to understand, so it rarely ever fails. The only problem with the Amsler grid is people get bored with them, and they just fall into a drawer somewhere and never get looked at. If it’s somewhere prominent and noticeable, then people will see it and do it all the time.
The ForeseeHome is a step above that, which is basically using a computer-generated algorithm that a patient looks into a little binocular-type device on their desk, and it measures a patient’s metamorphopsia or lack thereof, and a computer analyzes it and sends us a report, and if there is any sudden change in someone’s ability to see straight, we’ll be notified and call them in for a visit right away.
More on the horizon but not quite commercially available yet is the home OCT, or the more sophisticated home monitoring where we’re taking the interpretation of the patient’s own experiences out of the equation and basically taking an OCT, or a scan of the retina, at home and analyzing that and sending that to us on a regular basis. That’s obviously the real future, which basically takes our office and puts it in the patient’s home, but that’s not there yet. That’s being commercially developed. It’s being marketed, and we’re not quite at that stage yet, but that’s really the future.
MICHAEL BUCKLEY: No, that great! I really appreciate covering the range of that. To our listeners, BrightFocus provides an Amsler grid, which Dr. Marcus just spoke about. BrightFocus provides these free of charge, and they’re magnetic, so the concern that Dr. Marcus mentioned of people not using them will go away if you put them on your refrigerator and you look at it every day.
DR. EDWARD MARCUS: What I noticed, I’m sorry to jump in for one second here …
MICHAEL BUCKLEY: Yes, go ahead.
DR. EDWARD MARCUS: … an interesting trend is the rapid decline in the presence of magnetic refrigerators in this country, that there are so many people that have either a stainless steel refrigerator or some kind of wood-paneled refrigerator, that people are … the kitchen is a much more common place to dress up these days in a person’s home, so people don’t have magnetic fridges anymore. So, they have this magnetic thing, but they have nowhere to put it, so it ends up right back in the drawer because there is nothing to stick it to.
MICHAEL BUCKLEY: We will try to maybe get some that that could go up a different way. I appreciate that point. Getting back to the treatment, is there anything new regarding treating wet AMD?
DR. EDWARD MARCUS: There is always something new regarding treating wet AMD, and I’ll simplify it by saying that the goal or the incremental goal of all these new medications is to lengthen the time in between injections. It’s still all injections, but the idea is to reduce the amount of injections needed in a given amount of time. So, there are drugs coming out that have the treatment interval going to every 8 weeks or every 16 weeks, every 12 weeks. It’s all about the amount of weeks in between in the treatments. About a year ago—a year ago? Yeah, about over a year ago—a year and 3 months ago—we had a new drug that came out called Beovu® (or brolucizumab) from Novartis, and that promised to extend the treatment interval to a pretty consistent every 3 months or every 12 weeks, and that was a big breakthrough because that’s the first thing that really hit the market since Eylea in 2011. Beovu (or brolucizumab) had a major safety signal that came out a couple of months after its release that people are getting severe intraocular inflammation and even sometimes devastating vision loss associated with it—it was rare, but it was enough to give people pause. So, the drug works really well. It’s still on the market, but there are these rare cases where people have severe irreversible vision loss from the treatments and you have no way of predicting who it’s going to be. You kind of just roll the dice each time. That obviously sounds a little scary.
There is a medication on the horizon from the makers of Lucentis, which promises to extend the treatment interval to 16 weeks, or every 4 months. Again, it works well in trials, but we don’t know if there’s going to be some strange safety signal that comes out or some warning or if it really works at every 16 weeks, because originally, Eylea (or aflibercept) was supposed to be an every 8-week injection, but we quickly found that it doesn’t always get out to 8 weeks; it could be every 4 weeks, every 6 weeks. It doesn’t quite get to 8 weeks, but it still works better than the other one, and the results are good. So, even though it doesn’t meet its stated goal of being every 8 weeks, it’s still better than what we had before.
Some people are expecting that trend to come out of new medications, as well. There are depot injections, which is basically that a surgeon, like myself, would insert a tiny little reservoir inside the patient’s eye and that reservoir would be filled once a year with medication, such as Lucentis, and it would be slowly released into the eye over the year. Obviously, that is a little bit of a left turn from just getting injections that it’s a surgical procedure with the occasional filling. People are coming up with different ways to do this. There are generic medications hitting the market soon called biosimilars. The landscape is definitely getting more broad and more interesting, but really they’re still just injections, and we’re questioning how often to do them. That’s wet AMD.
MICHAEL BUCKLEY: A lot of things coming down the road. Do any of these have the ability to restore vision loss, or is this more delaying or preventing?
DR. EDWARD MARCUS: Yeah, well, if someone has a lot of subretinal fluid in an acute state of wet macular degeneration, drying up that fluid will improve that vision dramatically. Interestingly enough, though it is a much more severe condition, wet AMD is reversible, whereas geographic atrophy or the end stages of dry AMD are not reversible in any way, so it is the opportunity we have to treat that vision loss from the subretinal fluid and hemorrhage that represents the real improvement of vision that people are looking for.
MICHAEL BUCKLEY: Great. And to our listeners, we provide free-of-charge a written transcript of the BrightFocus Chats, so a lot of the great updates that Dr. Marcus just gave us will be in our transcript free of charge. And some more on the topic of treatments, Dr. Marcus, any tips for patients to have other chronic conditions that they are seeing other physicians? How … we always joke in my house, “I wish we had a general contractor to manage all these things.” Any tips for how patients can best coordinate the care that they might be receiving with you and other specialists?
DR. EDWARD MARCUS: The question I get a lot is, “What if I come in 5 weeks instead of 4 weeks. Is that okay?” or “What if I skipped February because I am down in Florida?” or something like that. And the answer is always, “It’s not okay,” unfortunately. Time is vision, and a lot of the vision … and we’ve learned this from the pandemic because people are afraid to come in and they couldn’t bring themselves to the doctor’s office because they were frightfully afraid of what might happen. So, we’ve learned that the only way to ensure that things go well is to stick to the plan. Getting to the doctor’s office, unfortunately, is the only way you can be treated for wet macular degeneration.
The good news, on the other hand, is if you’re just being monitored and you have dry macular degeneration or kind of a quiet stable state, there’s a lot of opportunity for home monitoring, which is both available and on the horizon, which should keep you at least comfortable with what you’re going through when you can’t come to the doctor’s office because there is a good chance we’d catch something from your home. But, unfortunately, these treatment regimens are fairly strict because that’s the way to best deploy the medications. Obviously, longer-lasting medications—like every 8-week, 12-week-, and 16-week ones—will make it a little bit easier, but it’s still … there is this burden on the patient of coming in all the time to get one eye or both eyes treated, and that’s really the only way to ensure things go okay.
MICHAEL BUCKLEY: I appreciate that. I think through the pandemic … I think in a good way it’s raised more attention to science and clinical trials. I was wondering, do you have advice for your patients on clinical trials in vision health? Is this something that patients should ask you about or try to pursue, compared to how the COVID vaccine got developed? I think it’s just raised people’s awareness, and I was wondering what you think?
DR. EDWARD MARCUS: Yes, well, the FDA has an extensive database of ongoing clinical trials that if you are internet-savvy, you can easily search them by disease, so you could see exactly what’s being investigated, what stage it’s at, and if there are results. It’s fairly easy to read even if you’re not super medicine-savvy. Unfortunately, people who are armed with both a computer and a telephone can also find endless amounts of garbage and fake news, too. For every patient or every family member who brings in wonderful questions about pipeline drugs and things like that, I also have clippings out of newspapers of—I don’t know if you guys are fans of The Music Man, but as it comes to mind, Professor Harold Hill was selling the band uniforms—all these fake wannabe vitamins and supplements and things that are named like “Bright Health” or “Sunrise” or “Vista” or these things that sound like extremely well-marketed but end up just basically taking your money and doing nothing. There’s a lot of in … just like in every part of life, there’s a lot of fake news and a lot of people trying to take your money out there, so I think that a good thing would be to become familiar with the FDA’s clinical trials’ website. The information is out there. It’s very readily available to anybody, so it’s great because you can ask all the right questions when you come to your visit, and you’ll even know what’s coming down the pipeline, when is this going to be available, when can I sign up.
MICHAEL BUCKLEY: That’s great. In about the 10 or 12 minutes we have remaining, I wanted to pivot to diet and lifestyle. What types of foods are best for your vision health? And conversely, what types of food should someone stay away from if they’re concerned about age-related vision disease?
DR. EDWARD MARCUS: Sure. Fruits and vegetables tend to be high in antioxidants. I guess coffee and red wine also have antioxidant content. Those tend to be protective, and those reflect what’s contained in the AREDS preservation vitamins. Just like in any other part of the body, fatty fried foods that contribute to blood vessel disease and atherosclerosis are also damaging to the eye. Those should be avoided … I mean not avoided—no one can avoid fried foods altogether—but anything that contributes to heart disease and the like would also be detrimental to the eye itself.
There’s a lot of research out there but nothing conclusive about blue light. So, a lot of people have started wearing blue-light glasses when they are on the phone or the computer for long periods of time because there is some thought that blue-light exposure can lead to retinal damage over the long term. I don’t think there is anything conclusive though, so this is a theory. It sounds plausible, but there’s not been anything proven. I mean it certainly doesn’t hurt to put on blue-light glasses, so this is the kind of thing that you can treat as evidence and not hurt yourself by protecting yourself. That’s something that’s been out there. Obviously, sunlight and sun exposure are detrimental to folks with macular degeneration, so wearing sunglasses when you’re outside for long periods of time.
The biggest one is smoking. Smoking is bad or every reason on earth, but this is yet another reason why smoking is bad. It can lead to more aggressive and more end-stage forms of macular degeneration. You can’t change your genetics, but that’s up there. Really, keeping a healthy diet full of fruits and vegetables and avoiding smoking is the one-liner.
MICHAEL BUCKLEY: A couple of minutes ago, you talked about vitamins and supplements. We have a number of questions today that relate to what are the best vitamins? I know people hear AREDS, but when you go to the store, it seems like you have a lot of different products that maybe mention eye health or AREDS. Can you just tell us a little bit about how you guide your patients on the topic of vitamins and supplements?
DR. EDWARD MARCUS: Of course. AREDS was the original trial, and AREDS2 was the second trial examining the exact composition of vitamins that were shown to prevent progression of macular degeneration and geographic atrophy in vision loss. Anything that is not AREDS was not studied, so we know AREDS works in that exact formulation that’s on the box, and anything that differs from that is completely unproven and, at best, a guess. People deal with patents all the time, so if they come up with something slightly different …
I know that people talk about saffron. People talk about all kinds of natural supplements. If you go into the vitamin store, there are hundreds of different things that say, like, “lutein” on it or something like that or have the word “eye” on it, and there is no way I can tell you that it is bad for you. Certainly, taking some antioxidant vitamins isn’t going to hurt you, but the only thing that we know for a fact is going to help is the Bausch + Lomb AREDS2 PreserVision®. The reason for AREDS2 is that in AREDS1, there is something called beta carotene, which in people who were smokers or are smokers has been shown to increase the risk of lung cancer. That is in AREDS1 and applies only to people who were or are smokers, but AREDS2, which is what you’ll find everywhere, AREDS2—that’s the blue, green, and white box—that does not pose any risk to anybody.
MICHAEL BUCKLEY: I appreciate that because we get a number of questions about that. You mentioned you have different tinted glasses; we have a few questions today from people who are wondering about that and driving. Is that something that … are there special tinted glasses that could help them with driving in the winter or any advice for people that have any driving concerns?
DR. EDWARD MARCUS: The question of driving and glasses is really very nuanced, because I guess it depends on what your deficiency is. Some people may people find that they have a lot of glare, especially after they’ve had cataract surgery or especially if they’re driving at night, and for these people, a polarized lens or specific driving glasses might be best. There are people who may just need sunglasses. There are some people who may need certain kinds of telescopes or more sophisticated glasses if they have central vision loss. The real question would be more for the optometrist who makes the glasses, because they would have to know your specific deficit or what exactly is bothering you to tailor the glasses to your needs, but certainly, all sorts of things can be addressed with different types of glasses.
MICHAEL BUCKLEY: We’ve got a final question related to about driving. How … in your experience, how can a family best handle what just seems like a really difficult, sensitive question about when someone … when it’s time to put the keys down? In your experience or observation, what helps a tough conversation like that go okay?
DR. EDWARD MARCUS: Well, obviously, getting a feel for the person and knowing what’s going to speak to them the most, and sometimes it’s a matter of just firing the biggest cannon you can, saying what you’re doing is against the law, and you could go to jail for doing this. This is … not only is this not a good idea, but you could actually end up in jail for this. You could kill someone. You may think you can see, but if you give someone the idea that … they may not know. They may not know that what they’re doing is illegal, or once you put the idea of seriously hurting or killing another person, that really speaks very deeply to them. And then, what I always try to end with is acceptable alternatives, like telling someone, “Well, this doesn’t mean you can’t go to the supermarket, it just means you need someone to go with you,” or “Here is your daughter. She lives 10 minutes away. If you need to go to the supermarket, go with her,” or “Let’s … why don’t you teach mom here how to use Amazon or whatever supermarket is in your area?” They probably deliver, so just learn or immediately focus on adapting. Don’t focus on the negative of, “You can’t get into car and drive whenever you want,” but, “What are some of the things you can do to adapt pretty easily?”
MICHAEL BUCKLEY: That’s good advice across a number of settings. Dr. Marcus, when I think about today’s conversation and how last time we were able to do this was right before the pandemic, I think a big takeaway that I have from our conversation today is that it is okay to continue to see your eye care professional on the regular recommended basis, and it really sounds like you and other practices have really taken a lot of great steps to ensure that people are able to continue their prescribed care. I think that was very reassuring for all of us to hear that today.
Just to conclude, Dr. Marcus, I was wondering, as sort of a big-picture thought you want to leave us with—maybe that’s something you’ve learned in your career or one recurring piece of advice you give your patients or one piece of advice you give yourself as you approach your work—I was wondering whether you have any concluding thoughts for us today.
DR. EDWARD MARCUS: Yeah, I guess that’s especially pertinent to our talk today that progress is always marching forward. There is always something that’s going to do the job better. We have a lot of people focusing on making products and product delivery better, and if you feel like you’re not happy with the way things are going, or you feel like the burden of treatment is too much, then there may be something great just over the horizon for you, or if you feel like the pandemic is too much and you’re lonely or you can’t get to do the things that you do, the pandemic’s going to be one day and also the more we know, the more we adapt to the dealing with the pandemic as it is. You know, humans are very adaptable people—excuse me, humans are very adaptable species—and we’re very good at learning how to make the most of the situation from the very most desperate to the very best, so I think taking everything with a grain of optimism is extremely healthy.
MICHAEL BUCKLEY: I appreciate that. All the challenges in the last 11 months have definitely shown that resiliency of the human spirit and the importance of asking questions. I really appreciate all the great advice you gave us today, and we’re encouraged to hear of progress being made, particularly toward wet AMD. To our listeners, the transcript and audio file will be on our website early in February at BrightFocus.org. Lastly, our next Chat is going to be Wednesday, February 24. It’s going to continue today’s discussion and talk about getting the care you need and the different type of providers that help people on vision. Dr. Marcus, thank you very much. I’m glad we had the chance to catch up. You gave us a lot of good updates and good advice. So, thank you.
DR. EDWARD MARCUS: Thanks for having me.
MICHAEL BUCKLEY: On behalf of the BrightFocus Foundation, this concludes the January BrightFocus Chat. Thanks.
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