Reception areas at ophthalmologists’ offices today are overflowing from morning until evening, and so thinking about being a member of an extended health care team for every patient can be mind-boggling in terms of sheer numbers — yet in light of new studies on genetics and age-related macular degeneration (AMD), team-based thinking is becoming especially pertinent in managing lifestyle factors such as higher alcohol use and smoking.
“I think that addressing lifestyle choices with patients is very important,” says Mehul Patel, MSc in Global Health, assistant professor of ophthalmology at University of Central Florida and clinical provider at UCF Health. He suggests of the family medicine doctor and internist, “they’re like the quarterbacks, if you will, in terms of the patient’s overall health, so I absolutely believe ophthalmologists contribute to that, and when appropriate, can chime in and both inform and educate, but also encourage patients to make those healthy lifestyle choices.”
Alcohol consumption has long been known as a neurotoxin that can potentially cause oxidative stress on retinal tissues, but a recent study published in JAMA Ophthalmology using Mendelian randomization established genetic predisposition to higher weekly alcohol use was strongly associated with geographic atrophy (GA).1 Therefore, ophthalmologists now have more evidence that alcohol specifically has detrimental effects on AMD.
In an invited commentary on the Mendelian randomization analysis, Xinyi Su, MB, BChir, PhD and Tien Yin Wong, MBBS PHD suggest, “perhaps, the best way forward is through a holistic approach” with healthy lifestyle choices both advised and supported in patient education and a spirit of co-mentorship by the “entire health care community,” including eye care doctors, dieticians, and general practitioners.2
The Health Care Village
Allen Ho, MD, attending surgeon and director of retina research at Wills Eye Hospital in Philadelphia, and professor of ophthalmology at Thomas Jefferson University concurs that ophthalmologists play a crucial role both in a patient’s ocular health and general health as part of the full care team.
“Eye care specialists have unique leverage into a patient’s general health habits since people value their vision highly and are motivated to keep their vision,” he explains. “I talk about a foundation of good general health, for example avoiding smoking, and a good healthy diet rich in colorful fruits and vegetables and natural sources of omega-3 fatty acids like tuna and salmon as being important for their eye health and general health.”
Dr Ho also brings up specific factors in addition to diet, alcohol, and smoking. “We talk about blood pressure control and regular cardio exercise like walking 30 minutes daily.” Dr Patel adds that a patient’s healthy choices which make the ophthalmologist happy will also make the primary care provider (PCP) happy.
The partnerships between ophthalmologist and PCP that these 2 physicians express makes Melissa Deadmond, PhD, MPH happy. She is associate dean of assessment & planning and accreditation liaison officer at Truckee Meadows Community College, the largest community college in Northern Nevada.
“Health care is already becoming more of a team care approach, and I support continued dialog between specialists and primary care physicians that result in comprehensive care for patients,” she explains. “I do think eye care specialists should be talking to their patients who are at risk for lifestyle-related eye conditions, but the message should be the same as when the patient speaks with their primary care physician, and the message should be based on accumulated evidence.”
Impact of Genetic Studies
Dr Deadmond adds the strength of the Mendelian randomization analysis is that it used genetic variants to show a strong and stable link between the trait of starting to smoke and AMD. Genetic predisposition data can uncover information about disease risk without the confounders that sometimes affect observational epidemiological studies. “A positive to this study design is that it can more clearly establish the direction of causality,” Dr Deadmond says.
In the study, researchers in the UK assessed data from 7 major genome-wide association studies (GWAS), and summary-level genetic association data gathered by the International AMD Genomics Consortium (IAMDGC) — its 2016 data set represents 16144 patients with AMD and 17832 control individuals.1 Data was evaluated from July 2020 to September 2021. Investigators found smoking and alcohol have different kinds of effects.
Genetic predisposition to start smoking was not meaningfully connected with risk for GA, but it was significantly associated with advanced AMD (P <.001). Tendency for lifetime smoking also showed a significant association (P =.004). Conversely, genetic predisposition to smoking cessation was linked to a lower chance for onset of advanced AMD (P =.003).
However, the investigation demonstrated a significant link between predisposition to high alcohol use and GA (P =.001). Prior research exploring the relationship between drinking and AMD has shown a range of results — from high alcohol consumption increasing the risk, to the difficulty of removing confounding impacts of smoking, to the possibility that moderate intake may be protective. Ultimately, public service information “and clinical advice regarding the harms of excessive alcohol intake should include the risk of blindness, especially given that there are currently no effective treatments for GA,” according to the investigation.1
Dr Deadmond cautions that public health messages are best when coordinated, due to the current climate of mistrust originating from politicization of COVID-19 health information. “I would advocate for public health professionals and ophthalmologists to collaborate so that the messaging to patients around this subject is clear and unified,” she explains. Mistrust can arise when individuals without a science background perceive conflicting messages. “Science is always subject to change based on new accumulating evidence and can thus be messy and contradictory at times,” she adds.
What is the Ophthalmologist’s Role in Giving Advice?
For Dr Ho, the role of ophthalmologists in educating patients about healthy lifestyle choices depends on the individual clinician. He mentors his patients because, “we not only preserve vision and ocular health, but can also impact patients positively in their general health.”
Dr Patel agrees. “If we’re looking at macular degeneration, we would focus on the reason for why they’re here with us as the first line, because when they go to their primary care doctor, the primary care doctor would not be able to advise how they’re doing in terms of macular degeneration — whether we need to talk about, you know, therapy for wet macular degeneration or the amount of geographic atrophy they might have,” he explains. “Those are the things that they’re coming to me for.”
Although, in his view, it may not always be best for eye care providers to delve into specific cessation screening tools, such as the 4-item CAGE questionnaire (Cutting down, Annoyance by criticism, Guilty feeling, Eye-openers). “These are things that I think are generally better suited in the hands of a primary care doctor who probably sees the patient more frequently than the ophthalmologist does,” Dr Patel says.
Approaching the subject of smoking and alcohol intake may be a challenging task. Dr Ho finds it useful to refer to smoking as an addiction, and at the same time, imposing no judgment. However, he is unequivocal. “I explain that smoking increases the risk of vision loss and blindness,” he says.
Dr Ho also believes in a stepwise approach to reducing smoking. “For example, if someone smokes a pack a day or 20 cigarettes daily, I recommend that they go down to 19 a day for the next seven days and then 18 a day for the following seven days, and so on. Every week they can reduce their smoking by gradually tapering and they will have some days where they go back up to higher numbers. If they are a pack a day smoker and do this weekly reduction plan, they can be cigarette free in less than 6 months.”
Models to Create Motivation Are Available
Clinicians can use prediction models to shape personalized recommendations for patients. Researchers in a number of European nations who contribute to the EYE-RISK Consortium have developed a machine-learning-based (ML) model that helps patients estimate their risk for developing advanced AMD.3 The tool uses genetic, phenotypic, and lifestyle variables, as well as pulse pressure and Mediterranean diet score. Data to inform the ML algorithm was gathered from two large population-based cohort studies; The Rotterdam Study 1 and the Antioxydants, Lipides Essentiels, Nutrition et Maladies Oculaires (ALIENOR) Study.
This online tool for providers and their patients can be found at www.macutest.net, where there is also a section describing the 2 primary stages of AMD, strategies to prevent the disorder, and a listing of ingredients for a recommended diet.
Other tools, models, and strategies are increasingly available, such as an article published July 2017 in Journal of the American Academy of Physician Assistants, “Smoking cessation: Identifying readiness to quit and designing a plan”.4 That research highlights a tool known as the 5As Model: ask, advise, assess, assist, and arrange. “Tobacco users should be urged to quit in a clear, strong, and personalized message that highlights the benefits of cessation,” the report explains. One example is that a clinician can restate a problem the patient has mentioned, such as shortness of breath interfering with quality family time, and then highlight the benefits of quitting.
A Dietician Lists Additional Motivators
Lorraine Fye, registered dietitian nutritionist, RDN, at Mayo Clinic in Arizona, Phoenix. She explains that there are more advantages to reducing alcohol intake than most patients may know about. For one, alcohol, a nonnutritive substance, loads up the calories in an individual’s diet, but has no nutritional benefit. Over-consuming alcohol does not increase the feeling of fullness, but increases hunger signals, which can lead to weight gain. So, a small 5 ounce glass of wine or 12 ounce mug of beer include more than 125 calories, and mixed drinks with juice or soda contain an even greater calorie count — and may leave an individual still hungry.
“Excess alcohol consumption impairs your immune system, contributes to some of the micronutrient deficiencies like folate, magnesium, thiamine, B12, and zinc, and it can disrupt sleep,” she explains. “Heavy alcohol use increases risk for more serious health issues, such as high blood pressure, liver disease, pancreatitis, and cancers such as breast, liver, mouth and esophagus.”
Ms Fye adds that alcohol intake has benefits including the potential to reduce risks for diabetes and heart disease, but regular physical activity and a nutrient-rich diet can decrease these risks and are backed up by a greater number of studies to reach the same end goal, while also offering additional health benefits.
Patients may not perceive alcohol as a neurotoxin that can interfere with communication between nerves in the brain. This is more of a direct effect, while the indirect effect comprises vitamin deficiencies that may lead to disorders such as neuropathy, including in the eye.
Case Study of Optic Neuropathy
A clinical challenge case posted in JAMA Ophthalmology describes a 44-year-old man who presented with progressing vision loss in both eyes that began approximately 4 months prior. Upon evaluation, he displayed visual acuity of 20/400 OU. He reported that he smoked 1.5 packs of cigarettes, drank 2 to 3 liters of wine, and ate 1 meal each day. Dilated fundus examination showed bilateral telangiectatic vessels on the optic nerve surface, hyperemia, and blurred margins. Humphrey 24-2 Swedish Interactive Testing Algorithm fast visual fields revealed bilateral central scotomas.
The patient’s serum B12 level was normal at 190.4 pg/mL, his folate measured low at 4.3 (compared with the normal >15.0), and red blood cell folate was also low at 1031 ng/mL (compared with normal >3342 ng/mL). He was diagnosed with serum folate deficiency and underwent counseling to reduce alcohol and tobacco use, and entered an alcohol rehabilitation program. B-complex multivitamin with folic acid was prescribed and he began eating 3 nutritious meals a day.
After 3 months, his folate levels returned to normal, and at 12 months, the patient’s visual acuity was substantially better at 20/30 OU. The only remaining sign was slight temporal pallor.
Four Health Practices Linked to AMD
The combined impact of 4 health practices were found to influence the prevalence and 15-year incidence of AMD in an investigation published in 2017 by Scientific Reports.6 This cross-sectional analysis examined the Australian population-based Blue Mountains Eye Study (BMES) starting with baseline evaluations in 1992–1994 of 3654 individuals age 49 or older who returned for assessment after 5, 10, and 15 years. Higher alcohol use was defined as more than 2 drinks daily, poor diet as fewer than 4 servings of fruits or vegetables each day, lower physical activity as less than 3 sessions per week, and smoking as a current habit or quitting for less than 1 year prior to a visit.
After 15 years, data from 1903 surviving participants was analyzed. Higher alcohol consumption was significantly associated with 1.68 odds of prevalence and 1.39 times greater incidence of early AMD. Poor diet was associated with 3.87 times higher prevalence of late AMD only, and poor physical activity was not associated with prevalence or incidence of AMD. Smoking was associated with 1.98 times increased odds for prevalence of early AMD and 5.98 times greater prevalence of late AMD. A slight association was revealed between a higher number of poor health habits and greater risk for incident early AMD (P =.08), after adjustment for confounders.
This investigation recommends patient education on a collective set of healthy behaviors and lifestyle-focused care with co-management by eye care providers, dieticians, and other health professionals.
Here again, messages need to be consistent between the PCP and ophthalmologist. “Conflicting information leads to doubt and mistrust, especially around behaviors that can negatively impact health,” Dr Deadmond says. “If I’m a regular smoker with a higher lifetime smoking index, and my general provider tells me there is no risk for AMD despite my ophthalmologist telling me there is, in the context of AMD I might be less likely to quit smoking because I’ve heard something that already fits my lifestyle.”
Friction Points in Giving Advice
A number of ophthalmologists and optometrists may feel tentative about bringing up topics of smoking and nutrition. Eline Meijer, PhD, MSc Leiden University Medical Center, Public Health and Primary Care, Netherlands, and colleagues conducted a cross-sectional analysis evaluating survey data of approximately 800 diverse health care professionals, such as dentists, general practitioners, internists, ophthalmologists, pulmonologists, and others concerning their attitude on giving advice to quit smoking, with results posted in 2018 on tobaccoinduceddiseases.org.7
The analysis revealed that offering advice to quit smoking was “significantly associated with stronger intentions to use the guideline (Dutch Tobacco-dependence-guideline), stronger role perceptions, and sufficient training in smoking-cessation care.” The investigation added that respondents who viewed smokers “to lack willpower” also were less likely to give the advice to stop smoking. The study concludes that more training should be offered on the topic, including clinicians’ roles in encouraging quitting, and the differences between addiction and willpower for those who smoke.
In an earlier cross-sectional study of ophthalmologists and optometrists in the UK, 1414 optometrists and 54 ophthalmologists returned an online survey regarding giving advice about diet, nutritional supplements, and smoking to patients with, or at risk for AMD.8 Results are posted in BMC Public Health. Of total respondents, a majority offered diet recommendations to those diagnosed with or at risk for AMD, and 93% recommended supplements for patients with advanced AMD in one eye. In a sub-analysis contrasting optometrist with ophthalmologist responses, ophthalmologists were considerably more apt to ask about smoking status — 70% to 80% often describe the link between smoking and ocular disorders and recommend cessation.
It’s Never Too Late
Dr Patel says one of the greatest challenges in any specialty is that there’s only so much time in a day. “Even if you go to visit your primary care doctor, they may say ‘Look, we’re going to address these 2 issues today’ and so I think, as it pertains directly to eye health, we all do our best to inform patients of how we think that these things are going to help them.”
The eye can recover from some disorders, and not progress in others. Ocular diseases caused by nutritional deficiencies from a poor diet or significant alcohol use have a definite potential for turnaround and improvement in vision. Established cataracts, though, are not as correctable with changes in health behaviors, but he would still urge his patients to quit smoking for general health. For patients with macular degeneration who are still smoking, he recommends quitting to improve their long-term prognosis.
Dr Patel follows the lead of primary care physicians in the technique of empowering patients so they feel control over their health, improve it, and possibly slow progression of some disorders. He would like a patient to feel that even with an existing dense cataract, or an optic neuropathy due to prolonged alcohol use to know it is never too late to choose healthy life practices.
“I think as human beings, we all want to feel like we have some control and I think it’s really awesome, regardless of what specialty you’re in; giving a patient the sense that they can make choices that positively impact their health,” Dr Patel adds.
1 Kuan V, Warwick A, Hingorani A, et al. Association of smoking, alcohol consumption, blood pressure, body mass index, and glycemic risk factors with age-related macular degeneration: a mendelian randomization study. JAMA Ophthalmol. Published online November 4, 2021. doi:10.1001/jamaophthalmol.2021.4601
2 Su X, Wong TY. Revisiting the alcohol consumption association with age-related macular degeneration: what should we tell patients in 2021? JAMA Ophthalmol. Published online November 4, 2021. doi:10.1001/jamaophthalmol.2021.4602
3 Ajana S, Cougnard-Grégoire A, Colijn JM, et al. Predicting progression to advanced age-related macular degeneration from clinical, genetic, and lifestyle factors using machine learning. Ophthalmol. 2020; 128(4):587-597. doi:10.1016/j.ophtha.2020.08.031
4 Olenik A, Mospan CM. Smoking cessation: Identifying readiness to quit and designing a plan. JAAPA. 2017;30(7):13-19. doi: 10.1097/01.JAA.0000520530.80388.2f
5 Ma J, Micieli JA. Severe vision loss in a man with heavy tobacco and alcohol consumption. JAMA Ophthalmol. 2020;138(8):915-916. doi:10.1001/jamaophthalmol.2020.0900
6 Gopinath B, Liew G, Flood VM, et al. Combined influence of poor health behaviours on the prevalence and 15-year incidence of age-related macular degeneration. Scientific Reports. Published online June 28, 2017. doi:10:1038/s41598-017-04697-3
7 Meijer E, Van der Kleij R, Chavannes N. What keeps healthcare professionals from advising their patients who smoke to quit? A large-scale cross-sectional study. Tobacco Induced Diseases. 2018;16(1):514. doi:10.18332/tid/83858
8 Lawrenson JG, Evans JR. Advice about diet and smoking for people with or at risk of age-related macular degeneration: a cross-sectional survey of eye care professionals in the UK. BMC Public Health. 2013;13:564. doi:10.1186/1471-2458-13-564