Vision Loss: Macular Degeneration
Guest: Dr. Esther Bowie - Ophthalmology/Storm Eye Institute
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Esther Bowie, who is Assistant Professor of Ophthalmology here at MUSC, and specialist in diseases of the eye that pertain to the vitreous; the gel part of the eye, as well as the retina; the back part of the eye. Dr. Bowie, one of your areas of great interest, and work, is in macular degeneration. I know that’s a very common problem, just how common is that?
Dr. Esther Bowie: It’s the leading cause of blindness in patients over 50 years old in the United States.
Dr. Linda Austin: Tell us what, actually, is occurring in the eye. First of all, what is the macula? And what happens when it starts to degenerate?
Dr. Esther Bowie: The macula is that portion of the eye that’s part of the retina. It’s important in you central vision, or your more detailed vision. As you get older, deposits can form; when you get macular degeneration, and these are called drusen. You may also have pigment changes that form in this area. When we see these changes, as ophthalmologists, we know that you have macular degeneration.
Dr. Linda Austin: So, in other words, when a doctor is using an ophthalmoscope, a hand-held device, to shine a light and look at the back surface of the eye; the retina, one of the things they’re looking at is that macula, because it’s critically important for fine vision, right?
Dr. Esther Bowie: Right, it’s very important for good vision.
Dr. Linda Austin: At what age should a person start to get regular eye exams to make sure that everything is okay, and that they don’t have that condition?
Dr. Esther Bowie: We usually say over 50 years old.
Dr. Linda Austin: That used to sound old. It doesn’t sound old anymore. And then, you, among other things, are looking to see if there’s that, what is it, speckled look that the macular gets?
Dr. Esther Bowie: Right. We’re looking for changes such as yellowing; because of the drusen, or pigment changes; darker areas, or atrophic areas; meaning, loss of tissue in the area of the retina. And if we see these changes, it alerts us that dry macular degeneration is present.
Dr. Linda Austin: Now, what causes this? Does it run in families, or is it related to other health problems?
Dr. Esther Bowie: It is related to age; it’s part of the aging process, but there’s also an association with a family history; not directly. For example, if your mom has it, or your dad has it, it doesn’t necessarily mean that you’ll get it, but it does put you at an increased risk. And then there are other associated environmental factors that we know make this worse, such as smoking. If you have a strong family history and you smoke, that definitely increases your risk significantly for having this disorder, and having it in a more advanced manner. Other diseases or conditions that make it worse include hypertension; if it’s uncontrolled, high cholesterol, and obesity.
Dr. Linda Austin: Hmm. It’s always the same cast of suspects, isn’t it, that seem to cause everything? Smoking is always at the top of the list; obesity and cholesterol, and all that sort of thing.
Dr. Esther Bowie: Right. That’s correct.
Dr. Linda Austin: So, let’s imagine, now, you’re examining someone and you’re seeing early changes. What do you do, as an ophthalmologist?
Dr. Esther Bowie: The main thing, now, is prevention; preventing the progression of the disorder. We usually advise a patient to stop smoking; if they’re a smoker, control their hypertension and cholesterol. Depending on the stage of the disease, we’ll recommend multivitamins. This is based on an age-related eye disease study. We recommend antioxidant vitamins, which the study showed to be beneficial in these patients.
Dr. Linda Austin: Which one, vitamin E?
Dr. Esther Bowie: Vitamin E, zinc, beta carotene, and C.
Dr. Linda Austin: Do you recommend multivitamins for everybody then, based on that, to prevent this?
Dr. Esther Bowie: No. It was not shown in the study that everyone with macular degeneration, or with a family history of macular degeneration, should use these multivitamins. It was actually just found to be beneficial in the more advanced or moderately advanced stages of the disease. So, not everyone should use them. And I should point out that study also found that if you’re a smoker, you probably shouldn’t use these vitamins, as beta carotene did increase the risk of lung cancer.
There are formulations that are out there, without beta carotene, but it’s not exactly what was studied. But, subsequent to the results of the study, they’ve made all the formulations that a smoker can take, but the smoker probably should avoid the ones with beta carotene, or vitamin A.
Dr. Linda Austin: But I think it’s important to just insert that there are, now, some medications out; Chantix is one, that can help people stop smoking. I bet somebody listening this will have this problem, and be smoker, and wonder how they can stop smoking.
Dr. Esther Bowie: Right. I’ve had patients with macular degeneration who have taken Chantix, or other agents, and they’ve stopped smoking; it’s worked for them.
Dr. Linda Austin: Now, if somebody, let’s say, with early changes, and let’s say they’re a smoker, does stop smoking, what are their odds of being able to arrest the disease at that point, or does it just slow it down?
Dr. Esther Bowie: Well, it slows it down, but we don’t know at exactly what rate, because these are more demographic, long-term studies. But it’s definitely been shown that if you’re a smoker, it definitely increases your risk. When they compared smokers and nonsmokers, with the same level of disease, it was found that smoking definitely makes it worse.
Dr. Linda Austin: In more advanced cases, is there treatment for macular degeneration?
Dr. Esther Bowie: There are really two types of macular degeneration, or two subsets. There’s the dry type, which causes a mild decrease in vision; usually sensual acuity, and you see the changes, as discussed, the drusen and pigment deposits. And you may see some atrophic changes; meaning, loss of tissue in that area of the macula. This can progress in about ten percent of patients affected with macular degeneration. They can go on to get the wet type.
Patients with wet macular degeneration, or exudative macular degeneration, usually get a sudden loss of their central vision. When we look in, we see blood beneath the retina, or fluid beneath the retina, and it tells us that they have the wet type of macular degeneration.
Treatment options for these include anti vascular endothelial growth factor agents: Lucentis, or an off-label agent; not FDA approved, called Avastin. There are other agents that were used previously that were anti-VEGF agents, including Macugen. And there’s laser treatment; photodynamic therapy, that was available even before the anti vascular endothelial growth factor agents or anti-VEGF agents, became available. The anti-VEGF agents seem to be the most promising so far.
Dr. Linda Austin: Do they just halt the progression, or can they reverse the condition?
Dr. Esther Bowie: The good thing about the anti-VEGF agents is that they halt, and in some patients it actually improves vision. So, in the study, maybe about 35 percent of patients would actually see an improvement of their vision with this treatment. And this is new compared to what we had before; the photodynamic therapy, or the cold laser, which would improve vision in probably only about six to seven percent of patients. It’s still not a whole lot, but it’s a lot better than what we had two or three years ago.
Dr. Linda Austin: If there’s macular degeneration in one eye, is it certain that it will occur in the other eye as well?
Dr. Esther Bowie: Usually, macular degeneration affects both eyes simultaneously. But the stages, usually, are not necessarily the same. So, you may have the mild, dry, type in both eyes, or you can have a more advanced stage; the wet, or exudative, type in one eye, and then the dry type in the other eye. So, it’s variable. And it doesn’t mean that if you have the exudative, or wet, type in one eye that you’re likely to get it in the other eye.
Dr. Linda Austin: Can you give some feeling, or range, for how rapidly progressive this disorder is? Let’s say, from the first symptoms to total blindness in an eye, what is the range of how long that takes?
Dr. Esther Bowie: It’s usually a slow process, from the time you’re first diagnosed. It’s hard to give a rate. Some patients will go on to form the wet, or exudative, type; which doesn’t necessarily mean they will go blind. Previously, our thoughts were that patients would lose their central vision. But with these new treatments, now, we’ve been able to halt the progression of the disease in a significant portion of patients. So, it really doesn’t mean doom-and-gloom, or you’re going to go blind.
And the earlier it’s detected; where you have the more advanced stage, the better the prognosis is.
Dr. Linda Austin: So yet another reason to get regular checkups, it sounds like.
Dr. Esther Bowie: Correct.
Dr. Linda Austin: Well, I know what I’m going to do today; call and make that appointment. Is it relatively uncommon, then, that somebody, if they’re being actively treated, will lose all their vision in both eyes? Can you offer pretty good hope to someone to at least keep some vision?
Dr. Esther Bowie: Yes. Generally, patients don’t lose all their vision with macular degeneration. It usually only affects their central vision. They’ll always have peripheral vision. But, because the central vision, or macula, is important in allowing you good vision, it’s devastating. But, generally, most patients do not go blind. Only ten percent of patients that have macular degeneration will get the exudative, or the advanced type. So, it’s not a whole lot. And then of that ten percent, with our new treatment options, now, not all of these patients are going to be severely affected. A significant portion will stabilize and maintain good reading and driving vision, which are things that people consider to be factors for independent living.
Dr. Linda Austin: So, yes, it’s a serious diagnosis, but there’s good reason to be hopeful.
Dr. Esther Bowie: There’s a lot of hope.
Dr. Linda Austin: Dr. Bowie, thank you so much for talking with us today.
Dr. Esther Bowie: Thank you.
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