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Age-Related Macular Degeneration: What You Need to Know to Protect Your Vision

Online Health Chat with Dr. Rishi Singh

February 29, 2012

Introduction

Age-related macular degeneration (AMD) is the most common cause of vision loss and blindness in Americans over the age of 50. This eye disease affects the macula, the central part of the light-sensing nerve tissue in the eye known as the retina. The macula provides the sharp, straight-ahead vision that allows you to see small detail, read fine print, recognize faces, and see street signs. Early diagnosis and treatment are keys to preventing progression of the disease.

At Cleveland Clinic Cole Eye Institute, our retina specialists are renowned for their clinical acumen, innovation, and research. Our ophthalmology program has been highly ranked in the U.S. News & World Report “Best Hospitals” survey for 12 years in a row. Our retina team has some of the best clinical outcomes in the field and is nationally recognized for their expertise in diagnosing and treating a full range of retinal disorders, including age-related macular degeneration, diabetic retinopathy, retinal vascular disease, and other vitreoretinal conditions.

Dr. Rishi Singh is an Associate Staff Member in the Department of Ophthalmology at Cleveland Clinic’s main campus. His specialty interests include medical and surgical retina and diabetic retinopathy. He earned his medical degree from Boston University School of Medicine in Boston, Mass. He completed an internship at Lemuel Sattuck Hospital in Boston and a residency at the Massachusetts Eye and Ear Infirmary, also in Boston. He also completed a vitreoretinal fellowship at Cleveland Clinic Cole Eye Institute. Dr. Singh has published a number of articles in peer-reviewed journals. He has also lead clinical trials looking at the treatment of diabetic macular edema, central retinal vein occlusions, and age-related macular degeneration.

Cleveland Clinic Cole Eye Institute is ranked among the top 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. Singh 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 Cleveland Clinic ophthalmologist Rishi Singh, MD. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Causes and Risk Factors

Roadrnr821: Does macular degeneration increase with age? Is it hereditary?

Dr__Singh: The rates of macular degeneration do increase by age. We do think that there are inheritable components to the condition, but there are modifiable factors, like diet and smoking, that also play a critical role.

SkeletonKey: Do any eye conditions (map dot dysplasia) or diseases (like glaucoma) seem to make a patient more likely to get macular degeneration?

Dr__Singh: No. These diseases aren't associated with AMD directly.

cher: My mom died at age 86 and had both forms of macular degeneration. She had proton therapy. My aunt, age 76, had a macular hole unsuccessfully treated. I’m 63, a non-smoker, is there a strong chance for me of getting macular degeneration?

Dr__Singh: Genetics do play a significant role in the risk of developing macular. While I cannot quote exact percentages, I would recommend that you have a dilated eye examination with a retina specialist to determine your risk. At Cleveland Clinic we have physicians not only in our main office in downtown Cleveland, but also in our regional practices such as Hillcrest and Twinsburg.

WWW098: What happens to the eye when exposed to secondhand smoke such that it is considered a risk factor for macular degeneration?

Dr__Singh: We know that with primary smokers there is almost a four-fold increase in risk of developing macular degeneration. While I cannot quantify the risk of secondhand smoke, it most certainly increases the overall risk for developing it.

highlo: What is the likelihood that someone will develop AMD?

Dr__Singh: The risk of developing AMD increases as you age. By the age of 80, your risk is almost 30 percent.

lo_and_behold: Can age-related macular degeneration occur at any age?

Dr__Singh: It typically doesn't occur till later in life (after 60), but there are patients that experience it even as early as their mid-50s.

opus: Exercise and AMD?

Dr__Singh: There isn't a direct relationship between exercise and AMD.


Symptoms

joed: I apologize if you already answered this, but I signed on late. Are there any signs or symptoms of macular degeneration?

Dr__Singh: The signs of macular degeneration can be quite subtle. Initially, there may be no changes within the vision. Other signs include distortion, blurry vision, wavy vision, or problems with night vision.

GroKenHaMMer: Is an increase in floaters an indication of age-related macular degeneration?

Dr__Singh: No, typically not. Floaters are usually a sign of vitreous separations. That is when the vitreous jelly separates from the back of the eye. Typically, these are mobile spots in the vision. If this is a fixed floater that doesn't move, I would recommend you see an ophthalmologist for a dilated eye examination to determine the cause.

merrie: 50 years old. slightest blur in center vision when reading. Is this AMD symptom?

Dr__Singh: Not likely in a 50-year-old patient, but I would recommend you see an ophthalmologist for a dilated eye examination to determine the cause.


Prevention

robtoby: Is there anything a person can do prevent or delay AMD, such as diet, vitamins or anything else?

Dr__Singh: We recommend the following things to prevent the occurrence of macular degeneration:

  1. Multivitamin daily - Centrum® Silver® or equivalent is OK.
  2. Green leafy vegetables, which have beta carotene
  3. Fish for omega 3 fatty acids
  4. Anti-oxidants in the form of oral medications or through natural sources such as red wine
  5. Smoking cessation

carlespo: I am a 54-year-old well-controlled diabetic. I see an ophthalmologist twice a year. What can I do to avoid MD?

Dr__Singh: Annual or semi-annual visits like you are making to your ophthalmologist are sufficient to evaluate for this condition. For supplements or vitamins, please refer to the answer for robtoby.

readinggirl: What foods should be avoided via diet modification?

Dr__Singh: Please see the answer I gave to Robtoby. There aren't particular foods to avoid but rather ones you should be taking.

nance: Do you recommend statins to prevent AMD progression when cholesterol is up?

Dr__Singh: A multitude of studies have evaluated the role of statins in preventing AMD. Unfortunately, no study has conclusively shown that statin therapy reduces the progression of disease. Cholesterol independently has not been shown to be a risk factor of AMD.

some_way: How important is eye protection from the sun? Can this cause macular degeneration?

Dr__Singh: Sun is thought to cause oxidative damage to the eye, which is a key mediator of the progression of cataracts and macular degeneration. We do recommend sunglasses to patients as a way to reduce the risk of developing these two conditions.

Supplements

walterweloveyou: My husband is 73 years old and has had macular degeneration for at least 15 years. He had been on two PreserVision® daily along with B 12, B 6, folic acid, and lutein for many years, and recently his ophthalmologist switched him to ScienceBased Health® MacularProtect Complete®, four capsules per day. Is this supplement better or just as good as the PreserVision® combination? Also, is there anything new that can be done for dry AMD? Thank you for your time and consideration.

Dr__Singh: I don't know about this supplement. I don't think that it is better than the AREDS formula, which is the formulation you first mentioned. Because of the lack of evidence-based studies other than for the I-caps with the AREDS formulation, I cannot recommend this other vitamin.

readinggirl: What eye vitamins/supplements do you recommend?

Dr__Singh: Thanks for the question. Please refer to the answer given to Robtoby.

kinakerst: What type of ocular vitamins do you recommend for a 50-year-old female with a family history of MD. I have no health issues.

Dr__Singh: If this is truly diagnosed MD, I would recommend the AREDS vitamin formula along with a Centrum® Silver® or equivalent vitamin. That has been shown to be the best for this condition. If you are not thought to have MD, but have a family history, diet modification and multivitamins are sufficient in the early stage to prevent the progression.

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

Dr__Singh: Fish oil is available in pill form so you don't have to eat fish to get this. It is strictly the omega-3 fatty acid. Flax seed oil has similar properties, but is not a substitute.


Treatment

Pines: Best/newest treatment for existing DRY condition?

Dr__Singh: The dry treatments that currently exist are vitamins for slowing the progression. We do have a clinical trial at Cleveland Clinic for an oral pill that is thought to slow progression of the most advanced form of dry disease, called geographic atrophy. You can learn more about it by scheduling an appointment at 216.444.2020 and asking for our retina specialists. Not everyone qualifies for these special trials because it is based on medical and ocular history.

ethel2: I am under the care of ophthalmologist Dr. Lisa Faia at St. Joe's Hospital in Ann Arbor, Michigan, where I have so far received four Lucentis® (ranibizumab) shots in my right eye. The left is too far gone with the macular degeneration. What are the qualifying criteria for LASEK for MD? What is the expected outcome of LASEK for MD?

Dr__Singh: I know Dr. Faia very well. She is a good doctor. LASEK is not an option for macular degeneration. Unfortunately, other than the eye injections, there isn't another treatment available for this.

davidchang9941: After taking injection for four times, every month or so, my sight on the right eye stopped to improve. Should I continue the treatment?

Dr__Singh: No. The goal of therapy is to preserve vision, which it does in almost 85 percent of patients. It only improves vision in 45 percent of cases by three lines or more. Additionally, people may experience visual gains only after repeated treatment, so I wouldn't give up hope just yet.


Physician Appointments

nance: I recently was diagnosed with dry ARMD. What is your recommendation for frequency of follow-up appointments? Other than seeing the ophthalmologist immediately for any change in vision, would every 6 months be better than an annual visit? Also, would it be better to see a retinologist or stay with the ophthalmologist?

Dr__Singh: I would recommend that you see a retina specialist every 6 months for a dilated eye evaluation. In addition, you want to monitor your vision with an Amsler grid weekly to determine if there is a worsening in your vision or new blurring. This could be the first sign of progression of the disease.

nance: How would you interpret an ophthalmologist's remark as follows: "Your macular degeneration is nothing to write home about." I was stunned but he left before I could ask any questions.

Dr__Singh: I think I would interpret this as it is probably in a very early stage and that there is nothing acutely that has to be done at this point about it. I'm sorry that your doctor was short with you. Maybe it would be beneficial to discuss your feelings with the doctor and schedule another appointment to get your questions answered.


Other Eye Disorders

LJE: I have been diagnosed with macular puckers in both eyes. My left eye has been worse up until lately. Now, I notice that my right eye is getting worse. In the left eye there is a 'dip' in the center of my vision when I look at horizontal lines. When I look with only the right eye, in the center, a horizontal line looks raised up. Is my right eye trying to compensate for the left eye? How risky is surgery for macular puckers and is it recommended to get surgery one eye at a time? Thank you so much.

Dr__Singh: Macular puckers or epiretinal membranes are commonly seen. When you use both eyes to see, you have stereo vision that allows you to determine depth perception. Without this, you can start to see some of the abnormalities that you are describing. Surgery is quite safe and effective for this condition, even at relatively good vision levels. The biggest risks of surgery are infection, bleeding, and recurrence of the lesions, which is very low.

shopgirl_1: My mother is 82 years old and has wet macular. She is now seeing things that are not there, like people and animals. I was told that she might have Charles Bonnet syndrome.

Dr__Singh: Charles Bonnet has been described to occur in those with advanced forms of AMD. Unfortunately, there is no treatment for Charles Bonnet other than to try to fix the underlying ophthalmic condition.


Research

opus: Is there any research on why some people's dry macular degeneration doesn't progress or progresses slowly and why others lose their sight rapidly?

Dr__Singh: There are lots of factors as they relate to genetics, race, and smoking that help predict a patient’s progression with the disease. In many of the upcoming clinical trials, we will be evaluating these alongside the response to determine which treatments work the best for patients of different backgrounds.

kinakerst: My mother is 78 and has the dry form of MD. She is interested in stem cell therapy for the MD and wanted to know if CCF is holding any clinical trials.

Dr__Singh: We are currently not holding trials on stem cell therapies for AMD. Unfortunately, more work needs to be done to validate these studies before a larger trial is undertaken.

nance: Any word on when to expect the results of the AREDS 2 study?

Dr__Singh: No. The results from the AREDS 2 trial are set to be released later this year.

glenda: Can you tell us what the CATT trial is and what is Cole Eye Institute involvement?

Dr__Singh: The CATT trial evaluated the use of Avastin® (bevacizumab) versus Lucentis® for the treatment of age-related macular degeneration. Dr. Martin is our chair of the Cole Eye Institute and there is a video available online that summarizes the findings of the trial. It is available at www.clevelandclinic.org/CATT


Geographic Atrophy

opus: If you have dry AMD and have geographic atrophy, can anything be done to prevent vision loss?

Dr__Singh: Geographic atrophy is the worst stage of dry AMD. Vitamin therapy with the AREDS formula has been shown to slow the conversion to the wet form of the disease, even in this category. We are studying an oral medication that has been shown to slow the progression of this disease in a clinical trial at the Cleveland Clinic. As with many trials, not all patients are eligible and they do require an ophthalmic and medical exam to determine your eligibility. You can call 216.444.2020 to make an appointment to be evaluated for this trial.

opus: Does geographic atrophy always progress to blindness?

Dr__Singh: No. Geographic atrophy doesn't always progress to legal blindness. Many times it can be outside the fixation area or your focus area of your eyes, and therefore while it is a nuisance, it doesn't lead to blindness.


General Questions

nance: Is there an average to the progression of most AMD or is it simply sometimes very slow and other times very rapid?

Dr__Singh: It varies per the patient. Some patients progress rapidly while other do not. This may be due to a variety of factors, including age and race.

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

Dr__Singh: Absolutely. Having macular degeneration is not a contraindication to having a successful cataract surgery outcome.

nownow: Can you reverse macular derision? Does this lead to macular degeneration?

Dr__Singh: You unfortunately cannot reverse macular degeneration.

book_worm: Does constant reading harm the eyes?

Dr__Singh: No, reading does not cause harm to the eyes, even over extended periods.

i_know: With AMD, how can someone be told they have 20/20 vision, yet still have problems seeing? That does not seem right to me.

Dr__Singh: Visual acuity measurements can be misleading. It’s only a number and not telling of the quality of your overall vision state. It doesn't tell us about the problems you might have with color or contrast sensitivity.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic ophthalmologist Rishi Singh, MD, is now over. Thank you, Dr. Singh, for taking the time to answer our questions today about Age-Related Macular Degeneration.

Dr__Singh: Thank you for joining me for this web chat. I hope it was an informative event for those of you with this visually debilitating disease. As a physician who takes care of these patients, I realize the great impact that this disease has on patient's lives.


More Information

To make an appointment with Dr. Singh 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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