When it comes to age-related macular degeneration (AMD), most eye care specialists are focused on the primary goal: reduce the risk of progression and its associated vision loss for patients. But while a physician has the tools and knowledge required to take the lead on this challenge, deputizing the patient can help keep their disease at bay.  

Currently, no cure for AMD is available. But physicians can empower patients to make healthy lifestyle changes. The academic literature shows that patients’ actions really do affect the likelihood of progression from non-neovascular (dry) AMD to neovascular (wet) AMD. It is incumbent upon the ophthalmologist to explain to patients who have AMD that their dietary choices, eyewear, and self-monitoring practices can each play a role in preserving their vision. By recommending changes and ensuring patients understand the power they have against this intimidating diagnosis, we can help them reduce their risk of moderate to advanced AMD progression and take control of their eye health.

When meeting with a patient recently diagnosed with the condition, take the time to have a thoughtful discussion about these specific steps they can take everyday to help combat progression.


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Encourage a Healthy Diet and Daily Exercise

One of the most important things patients can do to help reduce their risk of AMD progression is to adopt a diet that includes specific foods and nutrients known to help support eye health. Two large European studies — one of which spanned a period of 21 years — found that participants with AMD who closely follow a Mediterranean diet, one that is rich in fruits, vegetables, fish, whole grains, legumes and olive oil, were 41% less likely to develop advanced AMD.1

While patients may not be familiar with eating these types of foods so frequently, they should do their best to incorporate them into their diet as frequently as possible and in combination, rather than relying on one single food, to derive the greatest eye health benefit. Foods they should avoid include fast food, trans fats, tropical oils like palm oil, lard, margarine, high-fat dairy foods and fatty meats like beef and lamb. 

In addition to prioritizing a healthy diet, exercising daily can also help reduce the risk of AMD progression. Incorporating aerobic activity can increase available antioxidant levels in the eye, as well as boost the overall emotional state of patients. Most patients tend to experience some level of concern, anxiety or fear following an AMD diagnosis and sudden vision loss, so this is an important factor to consider.2,3

If patients aren’t currently active, suggest they ease into it by doing activities that won’t stress their joints such as brisk walking, cycling, swimming, water aerobics or even yard work. 

Explain the Need for Protective Eyewear

Patients should ensure they are using protective eyewear, especially when they spend time outdoors. Unprotected exposure to the sun’s ultraviolet rays can permanently damage structures in the eye and speed the progression of AMD.4 Recommend patients with AMD wear sunglasses with lenses that filter 90% to 100% of both UVA and UVB light.4-6

Additionally, while no research has conclusively pointed to blue light as a factor in AMD, some patients may find comfort in using blue-blocking computer glasses or sunglass tints, particularly if they are heavy digital device users. 

Connect Smoking Cessation to Vision Preservation

Patients who smoke have up to 4 times the risk of developing AMD compared with nonsmokers.If your patient smokes, chances are they are more than aware of the benefits of quitting. However, it is worth reiterating these benefits and explaining what could occur if their smoking continues.

For instance, if a patient continues to smoke and only has dry AMD in 1 eye, they could increase their likelihood of developing AMD in their other eye. They can also increase their chances of developing a more advanced stage of the condition such as progressing from dry to wet AMD. Treating wet AMD is challenging, and it is even more so for smokers since smoking decreases the effectiveness of some treatments that are aimed at slowing damage in the eye.7

As a trusted eye health resource for your patients, you can take an active role in encouraging them to quit smoking by having program referrals on hand in your office. Refer patients to a smoking cessation counselor or provide them with a free telephone counseling service such as the National Cancer Institute’s Smoking Quitline: 1-877-44U-QUIT. 

Finally, remind patients that even living with someone who smokes can increase the risk of AMD development or progression.7

Advise on a Daily AREDS2 Formula Eye Vitamin

The National Eye Institute (NEI) AREDS2 10-year follow-up study results were published in JAMA Ophthalmology in June. They demonstrate continued efficacy in reducing the risk of moderate to advanced AMD compared with the original formula. Built on more than 2 decades of data, this new publication provides added support for the benefits of the NEI’s specific eye vitamin formulation recommendation: vitamin C (500 mg), zinc (80 mg), copper (2 mg), vitamin E (180 mg), lutein (10 mg) and zeaxanthin (2 mg).8  

Many patients are unaware that eye-specific vitamin formulas even exist, let alone the benefits and extensive research that has been conducted on their efficacy and safety. In fact, 64% of patients with moderate to advanced AMD are not taking an AREDS2 formula eye vitamin, according to the Age-Related Eye Disease Study clinical trial data (ClinicalTrials.gov Identifier: NCT00000145).9 Emphasize the importance of the specific levels of nutrients researched in these studies. They cannot be obtained from diet alone. Therefore, an AREDS2 supplement should be recommended twice daily, in addition to any other multivitamins or supplements patients use.

Patients with mild AMD were not studied in the AREDS and AREDS2 clinical studies. For patients presenting with symptoms of mild AMD, consider an eye vitamin formula that includes lutein, zeaxanthin and other antioxidants.

Explain At-Home Monitoring and Follow-Up Scheduling

Providing patients the tools they need to personally track their AMD progression can also help them stay focused on their eye health. Offer take-home materials that explain key terminology about AMD and outline the suggested lifestyle changes and supplements. Additionally, you can emphasize the value of daily or weekly home monitoring through the use of an Amsler grid, which can be provided to patients as part of their visit. 

Schedule routine, 6-month follow-up appointments to properly monitor and track patients’ AMD progression. During these appointments, patients may ask more follow-up questions on their diagnosis since they have had time to process their condition. This is a good opportunity to review the lifestyle changes and resources discussed at their previous appointment. These conversations can help alleviate the fear and anxiety patients may experience by providing them with concrete, actionable steps they can put into practice to reduce their risk of losing their sight.   

Arming patients with the knowledge and support they need to make lifestyle changes following an AMD diagnosis, and throughout their AMD journey, is a critical element that should be considered as part of a care plan for patients. 

Rishi P. Singh, MD, is a staff physician at the Cleveland Clinic in Florida and president of Cleveland Clinic Martin hospitals.

References

  1. Merle BMJ, Colijn JM, Cougnard-Grégoire A, et al, for the EYE-RISK Consortium. Mediterranean Diet and Incidence of Advanced Age-Related Macular Degeneration: The EYE-RISK Consortium. Ophthalmol. 2019;126(3):381-390. doi:10.1016/j.ophtha.2018.08.006
  2.   Lombardo M, Serrao S, Lombardo G. Challenges in age-related macular degeneration: from risk factors to novel diagnostics and prevention strategies. Front Med. Published online June 6, 2022. doi:10.3389/fmed.2022.887104. 
  3. ​​Loprinzi PD, Swenor BK, Ramulu PY. Age-related macular degeneration is associated with less physical activity among US adults: cross-sectional study. PLoS ONE. Published online May 1, 2015. doi:10.1371/journal.pone.0125394
  4. Ultra-violet and blue light aggravate macular degeneration. American Macular Degeneration Foundation. https://www.macular.org/about-macular-degeneration/risk-factors/ultra-violet-and-blue-light. Accessed August 1, 2022.  
  5. Ratnayake K, Payton JL, Lakmal OH, Karunarathne A. Blue light excited retinal intercepts cellular signaling. Scientific Reports. Published online July 5, 2018. doi:10.1038/s41598-018-28254-8
  6. Abdouh M, Lu M, Chen Y, et al. Filtering blue light mitigates the deleterious effects induced by the oxidative stress in human retinal pigment epithelial cells. Exp Eye Res. 2022;217:108978. doi:10.1016/j.exer.2022.108978. 
  7. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol. 2001;119(10):1417-1436. doi:10.1001/archopht.119.10.1417
  8. Chew EY, Clemons TE, Agrón E, et al. Long-term outcomes of adding lutein/zeaxanthin and ω-3 fatty acids to the AREDS supplements on age-related macular degeneration progression. JAMA Ophthalmol. 2022;140(7):692-698. doi:10.1001/jamaophthalmol.2022.1640