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In this captivating episode, join Dr. Jennifer Lyerly and her esteemed guests, Dr. Jessica Haynes and Dr. Rudrani Banik, in discussing the importance of advocating for your geographic atrophy (GA) patients. This comprehensive discussion offers insights from both optometrist and ophthalmologist perspectives and highlights the importance of a holistic approach to eye care. Discover the latest in ocular nutrition, the impact of lifestyle choices, and the emerging field of the gut-eye connection, all essential for anyone interested in the advanced stages of macular degeneration and patient advocacy.
Whether you’re a healthcare professional or someone keen on eye health, this conversation on geographic atrophy is an indispensable resource that combines scientific understanding and practical advice. Don’t miss out on this enlightening conversation that promises to enhance your knowledge and approach to geographic atrophy in eye care.
Editorially Independently Sponsored by Iveric Bio, An Astellas Company. Iveric Bio had no control over the content of this piece.
Key Objectives
Geographic Atrophy (GA) Experts
Dr. Jennifer Lyerly:
Hello, everyone. Welcome to a new episode. I’m Dr. Jennifer Lyerly, and today, and we were discussing our patients, their experience with geographic atrophy (GA), and how we, as their eye care doctors, can best advocate for them. The best way to have this conversation is with the true eye care team, so we’re bringing both the optometrist and the ophthalmologist perspective to this show.
Let’s start the show by introducing our amazing geographic atrophy (GA) expert, Dr. Jessica Haynes. Can you share a bit about yourself and your practice?
Jessica Haynes:
Yes, I’m Jessica Haynes. I practice in a retina specialty clinic. My work is specialized as an optometrist in a clinic focused on retina care. I don’t engage in primary care or refractions but focus on patients with retina diseases, predominantly macular degeneration. We see patients with age-related macular degeneration at all stages, but many are in more advanced stages of the disease.
Dr. Rani Banik:
I’m Dr. Rudrani Banik, but you can call me Dr. Rani. I’m a board-certified ophthalmologist with fellowship training in neuro-ophthalmology and certification in integrative and functional medicine. I incorporate various aspects of health to support and improve vision, such as nutrition, lifestyle, supplements, botanicals, and stress modulation. My approach to vision care is holistic, aiming to provide patients with a comprehensive experience.
What is Macular Degeneration?
Dr. Jennifer Lyerly:
Wet macular degeneration is a severe form of the disease, but dry macular degeneration can be devastating for our patients. How do we consider the difference in mindsets between mild and severe forms when our patients may not experience it that way?
Dr. Rani Banik:
I prefer to think about age-related macular degeneration in terms of its categories, which can be a bit scientific. Age-related macular degeneration can be categorized into four types based on the fundus appearance and drusen size. Category one has small drusen, less than 63 microns. Category two includes slightly larger drusen between 63 and 125 microns. Category three is greater than 125 microns. Category four combines geographic atrophy (GA) and neovascular age-related macular degeneration, distinct forms of the disease.
It’s not just a simple division of dry and wet, or early and advanced. There are multiple stages in between.
Assessing Visual Function Loss in Geographic Atrophy (GA) Patients
Jessica Haynes:
These patients often experience significant visual function loss that isn’t always evident from their visual acuity. They commonly have dark adaptation issues, making low-light tasks, like driving at night, very difficult. There are also contrast sensitivity problems. And this happens even before they develop geographic atrophy (GA). With geographic atrophy (GA), patients experience scotomatous lesions, which can reduce reading speeds.
Even those in early or intermediate stages start to experience a decline in visual function. Patients can have 20/20 vision with intermediate-stage age-related macular degeneration but still struggle with certain visual tasks. They might not always communicate these difficulties, and the standard acuity chart may not reveal them. However, if you inquire specifically, for example, about night driving difficulties, they might confirm these challenges. These issues often affect them more than we realize.
Dr. Jennifer Lyerly:
What tests do you conduct in your office to assess geographic atrophy (GA) patients?
Dr. Rani Banik:
Previously, for geographic atrophy (GA) patients, I used contrast sensitivity tests using a device called Vector Vision. It was quite time-consuming and required some patient learning, making it impractical for office settings. In research and clinical trials, we use the Peli-Robson chart or the Sloan chart. Considering the patient volume in a regular office setting, conducting these tests for geographic atrophy (GA) is challenging. Instead, I focus on understanding the patient’s symptoms and document them as a substitute for contrast sensitivity and reading speed tests.
Challenges in Early and Advanced Macular Degeneration
Dr. Jennifer Lyerly:
What are common complaints from patients with early geographic atrophy (GA) or advanced dry macular degeneration?
Dr. Rani Banik:
The most common issue with early geographic atrophy (GA) or advanced dry macular degeneration is difficulty reading due to central or paracentral scotomas. Many patients also struggle with adapting to changing lighting conditions, such as moving from bright sunlight to indoor lighting. It takes them a considerable amount of time to adjust. These symptoms are hard to measure clinically, so I ask specific questions about their experiences, like reading on digital devices. I inquire about the font size they use, giving me an insight into the impact of their condition on daily activities and vision needs.
Jessica Haynes:
Light and dark adaptation issues are significant for our patients, and they often specifically mention them. While we may not be able to completely fix these issues, acknowledging that their eyes don’t adapt as quickly as normal due to macular degeneration is important. This acknowledgment validates their experience, especially when they have 20/20 vision but still face difficulties. It’s important to recognize and confirm that their problems are legitimate and common in those with this disease. Near vision is another area where these patients tend to have more difficulties compared to distance vision tasks.
Ocular Nutrition Beyond Green Leafy Vegetables for Age-Related Macular Degeneration
Dr. Jennifer Lyerly:
Let’s start by discussing ocular nutrition, which plays a significant role in macular degeneration. We have Dr. Banik, an expert in this field and a published author of ‘Beyond Carrots: The Best Foods for Eye Health A-Z’. Dr. Banik, could you provide an in-depth discussion on nutrition for eye health, going beyond the usual advice of eating green leafy vegetables? This is typically where most eye care providers conclude their dietary recommendations.
Dr. Rani Banik:
This is my passion, and I’m excited to share about it. We know from multiple studies that high levels of lutein and zeaxanthin in diets can reduce the progression of age-related macular degeneration from earlier to advanced stages. However, the question is about the required amount. Eye care providers may not be aware that studies suggest most people need about 6.5 milligrams of lutein daily, with some studies recommending at least ten or even 20 milligrams. Yet, most people on a Western diet get only about one or two milligrams, indicating a significant gap.
Promoting natural food intake that supports these needs is crucial to address this. While leafy greens like spinach, kale, collard greens, dandelion greens, and swiss chard are excellent sources, there are other options people might not be aware of. Yellow and orange fruits and vegetables, such as corn, and yellow and orange peppers, provide lutein and zeaxanthin. Some spices also offer these macular carotenoids, which is a lesser-known fact.
Dr. Rani Banik:
The standard regarding supplements comes from the AREDS studies – AREDS1 and AREDS2. These studies included specific formulations of vitamins C and E. AREDS1 included beta-carotene, while AREDS2 replaced it with lutein, zeaxanthin, and copper and zinc. The studies showed some benefit, particularly for patients with intermediate-stage age-related macular degeneration, in preventing the progression to advanced stages of the disease.
Most of the eye care community advises patients to take AREDS supplements only if they have intermediate-stage age-related macular degeneration, as there’s no perceived role for supplementation in the early stages. However, my approach is different. Even if a patient doesn’t need the AREDS2 formulation, I recommend ensuring they get these nutrients from their diet and consider a supplement with lutein and zeaxanthin to bridge any dietary gaps.
Moreover, research indicates that omega-3 fatty acids are beneficial. Although the AREDS2 study didn’t show significant benefits, studies focusing on dietary intakes reveal that high levels of omega-3s are associated with lower rates of age-related macular degeneration progression. I advise patients to ensure adequate omega-3 intake and, if their diet is lacking, to consider a high-dose omega-3 supplement. My philosophy is proactive; don’t wait for the disease to progress, but take steps to prevent it.
Jessica Haynes:
Indeed, many professionals adhere to the standard of recommending supplementation only for those with intermediate age-related macular degeneration. This is partly because, as far as I’m aware, there’s no evidence showing the benefits of supplementing at an earlier stage of age-related macular degeneration. However, there are suggestions of potential benefits, including improvements in visual function, from lutein and zeaxanthin. Like Dr. Banik, I tend to reserve full AREDS2 supplementation for patients in the intermediate stages, but I also acknowledge a shift in the eye care community towards supplementing with lutein, zeaxanthin, and possibly mesozeaxanthin, even in earlier stages.
Lifestyle Modifications for Age-Related Macular Degeneration Prevention
Dr. Jennifer Lyerly:
Besides nutrition, what other lifestyle modifications are important to discuss with your patients?
Dr. Rani Banik:
A major risk factor is smoking. We should always inquire about our patients’ smoking habits, exposure to secondhand smoke, and other airborne toxins. Air pollution is also a known risk factor for macular degeneration. I advise my patients to quit smoking and consider using an air filter at home, especially if they live in urban areas with high air pollution. This helps decrease the toxin load from volatile compounds in the air, reducing the risk for macular degeneration.
Dr. Jennifer Lyerly:
Do you discuss cardiovascular health and exercise with your patients?
Dr. Rani Banik:
Absolutely. Studies, including one conducted on women, show that regular exercise, like moderate activity at least three times a week, is associated with lower rates of macular degeneration. The risk is even lower for those who exercise more frequently. I encourage patients to stay active but avoid using the term ‘exercise’ as it can be intimidating. Simple activities like walking, using stairs, or taking a stroll with family or pets are beneficial. It’s also important to avoid obesity, as increased waist circumference is a risk factor for macular degeneration.
Dr. Jennifer Lyerly:
Besides diet, cardiovascular health, exercise, and avoiding smoking, are there other modifiable risk factors you discuss with your patients, Dr. Haynes?
Jessica Haynes:
I also talk about sunlight exposure, as it’s linked to the acceleration or development of macular degeneration over time. I advise wearing sunglasses for protection. But as Dr. Banik mentioned, what’s good for the body, heart, and brain tends to ward off macular degeneration. So, when considering whether something is good for the eyes, it’s helpful to ask if it’s beneficial for overall health, as the answer is likely yes.
Dr. Rani Banik:
I’d like to add one more aspect: the gut-eye connection. This concept, which explores the impact of the gut microbiome on various aspects of health, including the brain, heart, skin, and immune system, is now being linked to visual and eye health. There are early and intriguing studies showing a connection between gut dysbiosis, an imbalance of unhealthy and healthy bacteria in the gut, and macular degeneration. This emerging field suggests that maintaining a healthy gut microbiome could be important for eye health as well.
