Macular Degeneration

Macular degeneration is becoming a very serious problem for people sixty and older. It has now become the leading cause of blindness in the United States for older individuals. (Diabetes is the leading cause of blindness for working age adults.) It is unknown if it is because people are living longer or if there is something else about our life style (diet or environment) that is causing this "epidemic". Most people equate good vision with the ability to read 20/20 letters on an eye chart and it is certainly that - but it is much more. And yes, unfortunately it can prevent you from seeing the faces of your loved ones.

Vision - Your Most Valuable Sense

Think about the fact that you use your vision for nearly everything you do - your ability to earn a living, your ability to enjoy life and see the beauty around you whether it is scenery - the mountains, the oceans, the trees- or a beautiful person, your grandchild perhaps? It allows you to drive and to watch TV and to read, paint, knit, fish or whatever other hobby you enjoy. It allows you to cook and to clean or to take a walk. It allows you to shop and to enjoy lunch or an evening out with friends. It allows you to go to church or synagogue and recognize your friends and to participate fully in the activities. It allows you to keep your balance and avoid falling.

The essential fact - good vision allows you to enjoy life to the fullest and maintain your independence!

Unfortunately it has always been difficult to treat macular degeneration successfully. In just the last few years there is a new treatment called Lucentis that stops the progression of the disease and even some improvement in vision. It is administered by an injection in the eye but needs to be done on a regular basis. If the treatment stops, the macular degeneration flares up again. It is only works for "wet" macular degeneration, the least common type (only about 10-15% of cases). It is also very expensive - the drug itself costs $2,000 per injection. Medicare will usually cover it - but don't think for a moment that means it doesn't cost anything. It never allows you to have normal vision, but at least it may prevent you from going blind. 

Why not prevent or delay the onset of macular degeneration?

Now we are able to diagnose macular degeneration much earlier than before and to initiate steps to slow down or halt its progression. The OCT (Fourier Domain Optical Coherence Topography) test actually measures and images your macula to the accuracy of 5 microns - 1/20 of the thickness of a piece of paper - and allows us to see if any blood vessels are breaking. Broken blood vessels cause "wet" macular degeneration and requires treatment with Lucentis or with pan-retinal photocoagulation - using laser to burn spots into the periphery of the retina. Any thickening of the retina indicates the presence of inflammation. Drusen (early hard fatty deposits that prevent the choroid, the layer of the eye that nourishes the retina from doing its job) can also be detected. 

Macular Pigment Density Testing

Another test is the measurement of macular pigment density. Concentrated in the macula are two pigments - lutein and zeaxanthin. Recent scientific research indicates that they help protect the macula in two ways, both important. The first is as a filter of harmful ultraviolet radiation from the sun. (Wearing a hat that shades your eyes when outside in the sun and to wear a good pair of sunglasses with UV protection also protects from UV damage). The lutein and zeaxanthin (which are yellow and orange pigments) absorb the blue and ultraviolet light and act like "sunglasses" in the eyes and give you a double layer of protection. Many people also notice that they are not bothered as much by glare and that it doesn't take them as long to adapt from light to dark.

The second way that lutein and zeaxanthin protect the macula is by their antioxidant effect. Free radicals are formed in the macula by the presence of UV and can cause damage. Antioxidants prevent free radicals (unpaired electrons) from "stealing" electrons from critical macular tissue and setting off a chain reaction of stolen electrons thereby causing damage.

Is it possible to get the nutrients that you need from your diet?

Eat plenty of brightly colored fruits and vegetables. But it is almost impossible to get an adequate amount of lutein and zeaxanthin unless you eat cooked kale or spinach every day. Fortunately these nutrients are available in capsule form so that one or two capsules a day give you all you need. (We have these available for our patients) I recommend 10 to 20 mg a day of lutein and 8 mg a day of zeaxanthin. All lutein supplements also contain about 5% zeaxanthin since they are found together in nature, but it is much more difficult to get an adequate amount of zeaxanthin from diet alone. Lutein and zeaxanthin also help prevent cataracts and seem to be beneficial for healthy skin.

Omega 3 Fish Oil

Another nutrient that is vitally important for the macula is omega 3 fish oil. The retina and macula of the eye (and the brain) have the highest concentration of any tissue in the body of Omega 3 oils. (Omega 3 oils are commonly referred to as fish oil or flax seed oil) I recommend at least 1000 mg of the active ingredients in fish oil per day, DHA and EPA. Most commercially available fish oil capsules have only 300 mg of the active ingredients in each 1000 mg capsule so it would take approximately 3 or more of these a day to get the beneficial effect. We have a supplement available that is more than twice as potent as well as being more bio-available.

Other Nutrients

Other nutrients such as zinc and copper and vitamin C and vitamin E are also important.

Vitamin C - 500mg/day

Vitamin C is a major antioxidant which is found at an extremely high concentration in the aqueous humor of the eye - at about 15 times higher than in the blood. (Whenever something is normally found at a higher than normal concentration, it must be important.) It gives strength to the blood vessels and is required for the synthesis of collagen, the intercellular cement which holds the tissues of the body together including the sclera and cornea of the eye. It helps the body resist infections.

Vitamin E - 400 IU/day

(Newer recommendations emphasize the importance of delta-tocotrienol, one of the 8 forms of vitamin E.) Vitamin E is an antioxidant especially effective for fatty tissues such as the retina of the eye. It strengthens the blood vessels helping prevent wet macular degeneration.

Zinc 40 mg/day

Zinc is a mineral that is involved in more than a hundred functions in the body. Recent evidence indicates that we need to be careful about getting too much zinc. The first AREDS formula was reformulated with a reduction of zinc for that reason.

Alpha Lipoic Acid - Works synergistically with vitamins C and E - as an antioxidant - fighting free radicals that can cause vision loss.

B Vitamins

Feb. 24, 2009 - The risk of developing the leading cause of blindness in older people - age-related macular degeneration (AMD) - was reduced by 34 percent in women taking a combination of vitamins B6 and B12 and folic acid. The risk of visually significant AMD was 41 percent lower. There were no men in the study. 

Recent studies have drawn a connection between AMD and blood levels of homocysteine, an amino acid. High levels of homocysteine are associated with dysfunction of the blood vessel lining, whereas treatment with vitamin B6, vitamin B12 and folic acid appears to reduce homocysteine levels and may reverse this blood vessel dysfunction. 

William G. Christen, Sc.D., of Brigham and Women's Hospital and Harvard Medical School, Boston, and colleagues conducted a randomized, double-blind clinical trial involving 5,442 women age 40 and older who already had heart disease or at least three risk factors. 

Of these 5,205 did not have AMD at the beginning of the study. In April 1998 these women were randomly assigned to take a placebo or a combination of folic acid (2.5 milligrams per day), pyridoxine hydrochloride (vitamin B6, 50 milligrams per day) and cyanocobalamin (vitamin B12, 1 milligram per day). 

Participants continued the therapy through July 2005 and were tracked for the development of AMD through November 2005. Over an average of 7.3 years of treatment and follow-up, 137 new cases of AMD were documented, including 70 cases that were visually significant (resulting in a visual acuity of 20/30 or worse). 

Of these, 55 AMD cases, 26 visually significant, occurred in the 2,607 women in the active treatment group, whereas 82 of the 2,598 women in the placebo group developed AMD, 44 cases of which were visually significant. 

Women taking the supplements had a 34 percent lower risk of any AMD and a 41 percent lower risk of visually significant AMD. 

"The beneficial effect of treatment began to emerge at approximately two years of follow-up and persisted throughout the trial," the authors write. 

"The trial findings reported herein are the strongest evidence to date in support of a possible beneficial effect of folic acid and B vitamin supplements in AMD prevention," the authors write. 

Because they apply to the early stages of disease development, they appear to represent the first identified way-other than not smoking-to reduce the risk of AMD in individuals at an average risk. 

"From a public health perspective, this is particularly important because persons with early AMD are at increased risk of developing advanced AMD, the leading cause of severe, irreversible vision loss in older Americans," they add.

"Beyond lowering homocysteine levels, potential mechanisms for the effectiveness of B vitamins and folic acid in preventing AMD include antioxidant effects and improved function of blood vessels in the eye, they note."