J.L. WEBB

Age-related macular degeneration is already the most common cause of legal blindness in Americans older than 50. But as the baby-boom generation hastens the graying of the nation, that statistic will increase proportionately and dramatically. The trend begs the question: will medical science and technology keep pace with the diagnosis and treatment of this incurable disease?

Dr. Saad Shaikh, a vitreoretinal disease and surgery consultant at Central Florida Retina in Orlando, says yes. That opinion is based mainly on the advancements that have been made in the drugs that are used to treat AMD, and also because of clinical evidence that simple approaches to diet, vitamins and lifestyle can delay the progression of dry AMD and the occurrence of the less common, but much more debilitating, wet AMD.

Shaikh, 34, who is associated with Orlando Regional Medical Center and also serves as assistant professor of ophthalmology at the University of South Florida College of Medicine in Tampa, said the treatments for wet AMD not only have become less expensive, but using them in combinations of “eye cocktails’’ increases the chances for an effective outcome for patients.

By far, the most groundbreaking drug for the treatment of wet AMD has been Lucentis, which was approved for use by the FDA (Food and Drug Administration) in 2006. The same company that cultivated Lucentis, Genentech, also manufactures Avastin, which was developed to stop the growth of blood vessels in colon cancer patients. Because of its success for that use, eye surgeons are using it as an off-label medicine to retard wet AMD.

A third drug is Visudyne, marketed by Novartis Corp. It is injected into the arm and activated by laser light in photodynamic therapy.

Shaikh said, “We’re beginning to use a lot of these options in combination. By doing that, we can decrease the number of total injections and make the treatment more effective. So … our understanding of what the right treatment is and how to administer it is all evolving.’’

Another reason ophthalmologists have turned to Avastin is because of the cost. A single injection of Lucentis costs about $2,200; one injection of Avastin is less than $50, Shaikh said. “A number of insurance companies are not covering Lucentis because of the costs, but they will pay for Avastin,’’ he said.

Dr. Elliot Cooperman echoed that concern. “The results with Avastin have been terrific,’’ said the 57-year-old vitreoretinal surgeon, who has a solo practice in Orlando and is affiliated with Florida Hospital. “A lot of us were hesitant, but Avastin is a good drug (for treating wet AMD) and a lot cheaper,’’ Cooperman said.

But Shaikh and Cooperman both acknowledge the ultimate goal is to find ways to prevent patients from developing wet AMD. So far, the best hope to delay the onset and progression of dry AMD, which accounts for about 80 percent of the cases, is to advise patients to make changes in their diets and lifestyles, and to take some combination of the vitamins that were recommended in the 1999
Age-Related Eye Disease Study (AREDS) by the National Institute of Health.
Cooperman tells his patients about the AREDS supplements, a formula that includes zinc, vitamins A, C and E, and antioxidants. But he says he also cautions some patients about the dosages recommended in the AREDS. For example, “If they have been a smoker, they need a formula without beta-carotene,’’ Cooperman explained.

Shaikh concurred. “You just can’t give vitamins to everyone. … Zinc could be a problem for guys who have prostate problems. You want to let their general physicians know,’’ he said, noting “we’re subspecialists. If I put a patient on AREDS vitamins, I send a letter to their primary care doctor so they are aware of any potential conflict.’’

But Shaikh said he does not typically recommend the AREDS vitamins to patients who are in the early stages of dry AMD. “I recommend diet and lifestyle changes,’’ he said. “A lot of the green, leafy vegetables and foods high in vitamins C and E. There is a consensus that a healthy dietary intake’’ delays the progression of dry AMD, he said.

But patients can do more than eat all their vegetables. “In the past couple of years, there is evidence of genes that predispose individuals to macular degeneration. If you have the gene and a higher risk for developing (AMD), there are certain environmental and social modifiers that could push you over. Some of these are smoking, poor dietary intake and not wearing sunglasses.’’

In his book, Eyes on Ice and No Blind Mice: Visions of Science from the Science of Vision, Shaikh devotes a full chapter to macular degeneration and covers the positive benefits of supplements and diet. The book is a collection of short stories, some told in narrative, which should be entertaining and informative to both physicians and patients.

Shaikh and Cooperman both tell their AMD patients to eat plenty of spinach, broccoli and collard greens. Based on the results of a European study, Shaikh also recommends they eat fish at least twice a week.

Meredith H. Luce, a registered dietician at Florida Hospital in Orlando, said the daily dosage of antioxidants recommended in the AREDS is as follows: Vitamin C, 500mg; Vitamin E, 400IU; beta-carotene, 15mg or 25,000IU; zinc, 80mg; and copper, 2mg. Luce also recommends that in addition to eating green vegetables and fish, patients should “choose to snack on vegetables, fruit and nuts, versus processed chips and sweets.’’

In addition, Shaikh notes in his book that since the AREDS results were published, the natural nutrients and minerals of omega-3 fatty acids, lutein and zeaxanthin have been linked to appreciably benefit AMD patients.

Still, Cooperman advises the best way to combat AMD is to “see your eye doctor once a year and take the (Amsler) grid test.’’


July 2007