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Age-Related Macular Degeneration

Online Health Chat with Dr. Justis Ehlers

March 23, 2011


Introduction

Cleveland_Clinic_Host: Age-related macular degeneration (AMD) is the most common cause of vision loss and blindness in Americans over the age of 50. Early diagnosis and treatment are the keys to preventing progression of the disease. Join Cole Eye Institute ophthalmologist Justis Ehlers, MD, in a free online chat where he will answer your questions concerning the diagnosis and treatment of AMD.

Cleveland Clinic Cole Eye Institute's vitreoretinal team is internationally recognized for its expertise in diagnosing and treating the full range of retinal disorders. Our patients benefit from access to the most advanced technology, as well as the latest clinical trials for AMD -- both for newly diagnosed patients and those who have been told there is no hope.

Dr. Ehlers joined Cole Eye Institute in September 2010. He specializes in the diagnosis and management of medical and surgical retina diseases -- including age-related macular degeneration, retinal vascular occlusive disease, and diabetic retinopathy -- as well as retinal detachment and ocular trauma. Dr. Ehlers graduated from Washington University School of Medicine in St. Louis. He completed his residency at the Wills Eye Institute in Philadelphia and his vitreoretinal surgery fellowship at Duke University in Durham, N.C.

Cleveland Clinic’s Cole Eye Institute is ranked among the top 10 ophthalmology programs in the country by U.S. News & World Report, making us the top-ranked program in Ohio. We are among an elite group of dedicated, comprehensive eye institutes. Our fully integrated model helps us provide patients with quick and easy access to specialty and subspecialty care for a wide spectrum of eye conditions – from the routine to the complex. Cole Eye Institute has extended its quality ophthalmic care to several locations throughout Northeast Ohio, allowing patient access to ophthalmologists closer to their homes.

To make an appointment with Dr. Ehlers or any of the specialists at the Cole Eye Institute, please call 216.444.2020 or call toll-free at 800.223.2273, ext. 42020. You can also visit us online at www.clevelandclinic.org/eye.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Justis Ehlers. We are thrilled to have him here today for this chat. Let’s begin with the questions.


AMD (Age Related macular Degeneration) Defined

clang: Please define age-related macular degeneration. Are there symptoms that one should recognize? What can be done to prevent AMD?

Dr__Justis_Ehlers: Age-related macular degeneration is a disease that occurs in older adults (typically > 55) that results in mild to severe degeneration of the central retina (macula) due to age-related pathologic changes in the tissues. This can have a significant impact on central vision, including blindness, but the peripheral vision is usually maintained. There are two forms of the disease: dry and wet. The dry form is usually very slow in progression. The dry form can convert to the wet form, which is defined by the presence of abnormal blood vessels (e.g., choroidal neovascularization). The wet form can progress quite quickly.

Once the dry form has reached the moderate stage, vitamin supplementation can help reduce the progression of the disease. Regarding prevention, lifestyle modification -- such as smoking cessation and a diet rich in antioxidants and omega fatty acids -- may reduce the risk of developing AMD. Symptoms may include blurred central vision and distortion.

Kara: Is there a usual age when AMD starts?

Dr__Justis_Ehlers: Most of the time, AMD starts after the age of 55. It can occasionally be seen in younger patients, but by definition it is an age-related disease.

SusieTT: Is AMD hereditary? My mother has it and I am concerned I may develop it. Are there any early indicators or signs that I will develop it?

Dr__Justis_Ehlers: There definitely appears to be a genetic predisposition to AMD. However, it is not as straightforward as -- if a close relative has it you will get it. New genetic testing is on the horizon that may help to identify those people "at risk" (which does not necessarily mean you will actually get AMD). The early signs of AMD are often asymptomatic. Because of the asymptomatic nature, having a regular dilated fundus exam by an ophthalmologist or a retina specialist is also important to identify the early signs of the disease.

shellybelly57: Can dry macular degeneration be helped? Can it be prevented if you have a familial link to it?

Dr__Justis_Ehlers: The AREDS study has shown that individuals with moderate dry macular degeneration can benefit from taking a specific set of vitamins (called the AREDS formulation). Taking these vitamins has been shown to reduce the risk of significant vision loss by around 25 percent. The early studies have not specifically looked at prevention in those with or without a family history. Further genetic studies are ongoing to look at susceptibility and possible treatments. As of now, using the AREDS formulation if you have moderate dry macular degeneration is important. Otherwise, reducing risk factors (e.g., smoking cessation) and possibly increasing intake of antioxidant foods and foods high in omega-3 fatty-acids may be useful.

Gingersnap: Do eye doctors look for and test for signs of macular degeneration at annual eye exams? Is there any special testing done?

Dr__Justis_Ehlers: The best way to screen for macular degeneration is through a dilated fundus exam by an ophthalmologist. No specific additional testing needs to be completed unless there are possible signs of the disease, and then more testing may be warranted.


Wet and Dry AMD

summersun: With regard to dry and wet AMD, is one easier to treat than the other?

Dr__Justis_Ehlers: The two are very different diseases. As of now, the only treatment for dry AMD is modification of risk factors (e.g., smoking cessation) and the use of specific vitamin supplementation (e.g., AREDS vitamins). There are currently many new treatments under study for the treatment of dry AMD. Dry AMD tends to be a very slow in terms of progression.

Wet AMD, in contrast, can be rapidly progressive. In wet AMD, our treatments target the abnormal blood vessels that cause rapid vision loss and bleeding. The most frequently used treatments are medications that are injected into the eye. These are a fairly recent addition to our treatment options (last five years). These treatments appear to stabilize wet AMD in about 90 percent of patients and show possible improvement in around 30 percent of patients.

Kathysue1: I will be at work but wanted to ask. I have been told I have the onset of AMD and was told it was the DRY stage. What is the difference between dry and wet? How can I take care of it so that is does not progress? Can AMD be stopped once it is started?

Dr__Justis_Ehlers: The main difference between the dry and the wet is the presence of abnormal blood vessels in the wet form (e.g., choroidal neovascularization). The dry form is typically very slow in progression, and the wet form can be much more aggressive. Depending on the severity of your dry AMD, AREDS vitamins may be useful in reducing your risk of vision loss. Additionally, lifestyle factors, such as smoking cessation and a healthy diet, can help to reduce the risk of progression.

jmichael_1: How often does dry change to wet?

Dr__Justis_Ehlers: It is fairly rare overall (1-5%) that the dry form changes to the wet. There are certain features of the dry form that can predict increased risk of transformation into the wet form of the disease. Your retina specialist or ophthalmologist would be able to give you more information regarding your risk based on the examination of your eyes.

skoestler: Can anything be done for leaky blood vessels with the wet kind of AMD?

Dr__Justis_Ehlers: Yes. Most frequently, we use injections of medicines to address the leaky blood vessels. The most common medications that we use are called ranibizumab (Lucentis) and bevacizumab (Avastin). Laser and photodynamic therapy can also be used to address the leaky blood vessels, but these are not as commonly used because of the visual acuity results. Occasionally, surgery may also be used, although this is rare.

Kara: How is dry AMD diagnosed? Do you have a wavy grid?

Dr__Justis_Ehlers: Usually dry AMD is diagnosed with a dilated fundus exam by an ophthalmologist or retina specialist. Other testing may also be helpful. A wavy grid may or may not be present. Often, dry AMD may be initially asymptomatic. Wet AMD often will present with sudden new onset of distortion or blurring.


Progression

Lillybell: I was diagnosed in the very early stages of AMD. How quickly does this typically progress to partial or complete vision loss? Is there an estimated time frame?

Dr__Justis_Ehlers: Unfortunately, predicting rate of progression is extremely difficult. If you were diagnosed with the dry form of the disease, the rate can be extremely slow with potential for no vision loss at all. The wet form tends to be more aggressive and can change vision dramatically over days to weeks.

jmichael: From first diagnosis, what is the typical progression timeline until vision changes are noticed?

Dr__Justis_Ehlers: The early changes of dry AMD are typically asymptomatic. Many patients will remain asymptomatic indefinitely. If the disease stays in the dry form and is mild at presentation, it will often be years before any significant changes may be noticed.

dottie: I have glaucoma and macular degeneration. Does the glaucoma cause the macular degeneration to progress faster, or affect it at all?

Dr__Justis_Ehlers: Glaucoma and macular degeneration are independent diseases. Glaucoma does not appear to have an impact on the rate of progression of macular degeneration.


Treatments

skoestler: What new treatments are becoming available that are approved and covered by Medicare?

Dr__Justis_Ehlers: The most recent treatments approved for wet AMD include a medication called ranibizumab (Lucentis®). We also often use bevacizumab (Avastin®), which is used off-label for wet AMD. Both of these medications are covered by Medicare. A new study will soon be released showing which of these drugs is better or if they are equivalent in the treatment of AMD. These medications are injections that help to bind the protein, VEGF, which appears to be a key player in many of the causes of vision loss in wet AMD (retinal edema, bleeding). There are many drugs that are currently being considered, including other medications that may have longer-lasting effects than the current medicines. Additionally, many treatments for dry AMD are currently being studied as well.

vkirbykat: I am 80 years old and getting Lucentis® injections, which are helping me tremendously. How long do I have to get them? Will I need them for the rest of my life?

Dr__Justis_Ehlers: The decision of when to stop injections is very difficult. Many factors may play a role in that decision (e.g., vision in the other eye, functional needs). The injections do not "cure" the blood vessels, and they may reactivate when the injections are stopped. The large initial phase III studies of ranibizumab (Lucentis) examined monthly injections for two years. Most retina specialists do not feel this is necessary, but most studies looking at fewer injections did not show the same good results as the monthly injection trial. It is really an individualized patient-doctor decision at this point. A new trial coming out soon will help to clarify the best management strategy. Some physicians will try drug holidays, some will try to extend the time between injections, and others will continue monthly injections.

skoestler: Is there any chance that lost vision from this disease can be reversed?

Dr__Justis_Ehlers: The recent studies in wet AMD have shown that treatment with Lucentis® results in about 30 percent of patients with wet AMD gaining vision. Avastin® appears to have similar results, but the new trial results will give us a better idea of how each drug compares. Other treatments may -- in some patients -- result in visual improvement, but the anti-VEGF drugs, as mentioned, are the most consistent treatments to show possible improvement.

Stonewall: I had a zoster attack 3/15/10 on right side of face with 2+ crusting of upper eyelid. Emergency treatment led to the diagnosis of NVMD, which was treated with Avastin®. My ophthalmologist found mild dry AMD and prescribed a six month follow-up. Lost some vision (blurring) and have been taking AREDS vitamins with the addition of 20mg lutein. Is this efficacious?

Dr__Justis_Ehlers: Is the diagnosis of wet AMD in one eye and dry AMD in the other eye? Avastin® is a commonly used treatment for wet AMD. Wet AMD is typically followed on a regular basis (four to six weeks). Follow-up for dry AMD is often every 4 to 12 months, depending on the severity of the disease and the clinical situation. AREDS vitamins have been shown to be efficacious for moderate (not mild) AMD in a large study. Currently, the evidence suggests that lutein may be helpful, but we do not know this based on large trials. A study is now ongoing looking at omega fatty acids, lutein, and the AREDS formulation and their roles and effectiveness for AMD. The study results will help to clarify the role of lutein.


Supplements

Tommy77: I've heard that taking high levels of antioxidants reduces the risk of developing macular degeneration. Is this true?

Dr__Justis_Ehlers: A major clinical trial showed that high levels of anti-oxidants can reduce the progression of AMD in patients with moderate AMD. In patients with mild disease, these antioxidants were not shown to be helpful. There is some evidence that a well-rounded diet rich with antioxidants and omega fatty acid intake may reduce the development of the disease, but this still has not been definitively shown. For this reason, the high dose vitamins specifically for AMD (AREDS) are only being recommended for those patients with moderate AMD or worse. Additionally, smoking cessation, which reduces some of the oxidative stress on the body, is very important in reducing risk.

jmichael_1: Is it better to take supplements based on AREDS or AREDS 2?

Dr__Justis_Ehlers: The AREDS 2 trial data has not been released; however, some AREDS formulations now include lutein (part of the AREDS 2 trial). There is a suggestion that lutein and omega fatty acids may be beneficial, so many patients may choose to take these. However, we are still waiting on the definitive data to draw a final conclusion.

michaelf: The mother’s eye doctor has recommended rather expensive vitamin supplements to help her vision and stabilize the degeneration. Are these supplements valuable? If so, which are best? (My mother is 72.)

Dr__Justis_Ehlers: The AREDS vitamin formulation has been shown to reduce the risk of progression by 25 percent in patients with moderate or worse dry macular degeneration. Any formulation that has the actual AREDS formulation is fine. Beta-carotene should be avoided in smokers.

harper: Instead of fish, what can a vegan eat that would provide the same benefit? Would flax seed oil offer a suitable substitute?

Dr__Justis_Ehlers: The data on omega fatty acids is still being sorted out in large clinical trials. There is a suggestion that they may be beneficial. Any substitute that provides the omega fatty acids may provide a similar benefit.


General Questions

Queenbee: Do all ophthalmologists treat AMD or are there specialists?

Dr__Justis_Ehlers: All ophthalmologists can screen for AMD. Additionally, many general ophthalmologists are comfortable following dry AMD, particularly in the early stages.

Retina specialists are ophthalmologists who have completed an additional two years of training in retinal diseases, including AMD. In general, wet AMD is usually treated by a retina specialist, particularly because of the need for interventions (e.g., injections of medicines, lasers). Additionally, retina specialists are often the physicians who have access to the latest studies and research trials if that is something that a patient is interested in.

jasper: What happens to the eye when exposed to second-hand smoke, such that it is considered a risk factor for macular degeneration? What is the exact relationship between smoking and AMD?

Dr__Justis_Ehlers: Macular degeneration (AMD) is known to have an inflammatory component. Exposure to smoke has been linked with oxidative stress. This may, in turn, increase the risk of AMD and AMD progression.

koph: Can you have cataract surgery if you have macular degeneration?

Dr__Justis_Ehlers: Yes. Depending on the extent of macular degeneration, cataract surgery may or may not result in any improvement in vision. A complete retinal exam may help to optimize expectations for outcomes prior to cataract surgery, but often it is difficult to know the impact of each condition on the vision until after the cataract surgery.

klm908: When you, as a physician, can no longer medically help a patient, do you provide resources to assist them with their vision loss? In other words, what follow- up or guidance is given as a patient approaches blindness?

Dr__Justis_Ehlers: Low vision specialists are professionals who specialize in helping patients who have functional disability from their vision loss. This multidisciplinary approach can be critical to maintaining quality of life. I also think that maintaining the relationship with the patient is really important, even if there is no current medical therapy. New therapies are often on the horizon and the field is changing rapidly.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Justis Ehlers is now over. Thank you again, for taking the time to answer our questions about age-related macular degeneration (AMD).

Dr__Justis_Ehlers: Thank you for joining us today and for all the questions. It was a pleasure being here.. Please feel free to contact us here at the Cole Eye Institute with any additional questions or for scheduling a future appointment.


More Information

  • To make an appointment with Dr. Ehlers or any of the specialists at the Cole Eye Institute, please call 216.444.2020 or call toll-free at 800.223.2273, ext. 42020. You can also visit us online at www.clevelandclinic.org/eye.
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