With great excitement, I entered the world of private practice ophthalmology in 1987, hoping to enhance vision and save eyesight, one patient at a time. Frequently, I had a euphoric feeling upon improving someone’s eyesight dramatically with cataract and/or corneal transplant surgery. However, unfortunately, I came to the painful realization that I would also experience a dreaded feeling upon making a diagnosis of macular degeneration on a patient, acutely aware that it was the beginning of the end for their occupational and vocational activities. Telling patients that they had macular degeneration was greeted with tears pouring down their faces when the reality hit that driving was now over and, depending upon the extent of the macular degeneration, many other activities were also eliminated. Worse yet, was the looming knowledge that the level of vision would only steadily decline from there.
Our clinical exam during that era was supplemented with an Amsler grid test, whereby a patient would cover one eye, look at a black piece of cardboard with horizontal and vertical white lines printed in a grid pattern, and note where the lines appeared to be wavy, distorted, or missing. Alternatively, the Amsler grid was white paper with black lines. The defects in the grid were circled and this test was repeated with the other eye. In the late 80’s most eye physicians felt that the Amslergrid was the most useful diagnostic test for detection of macular degeneration.
Additionally, whenever a patient experienced vision loss, a Goldmann Peripheral Visual Test was performed to rule out or monitor glaucoma, macular degeneration, and other ocular maladies. The Goldmann test provided somewhat valuable information, especially for glaucoma, but testing results varied with each examiner performing the test and the methodology that they employed. Therefore, there was limited value in following the progression of the field test for macular degeneration. The Goldmann test took about 30 minutes per eye, with fatigue setting in, making the examination on the second eye less reliable.
The third test that was performed for suspected or known macular degeneration was a medical procedure known as fluorescein angiogram (FA), whereby a fluorescent dye was injected into the blood stream while photos were simultaneously taken of the back of the eye. This dye accentuates the retinal vasculature so that problems such as an incipient subretinal neovascular membrane (SRNVM) can be detected. Additionally, this procedure was utilized to ascertain the origin of retinal bleeding, swelling of the back of the eye, and other maladies. This procedure has always been disliked by patients due to the approximately 10% incidence of nausea, vomiting, itchiness, and irritation. Tragically, about 4 patients per one million died due to an anaphylactic response to the fluorescein dye.
If the macular degeneration were atrophic, or dry, there was little that we could do for our patients, except to show empathy, provide comfort, and work with them on low-vision aids. This prognosis was gut wrenching for the physician, the patient, and family members. When the FA demonstrated a SRNVM, or a bleed, we were now in the extremely difficult position of deciding whether we should perform a laser procedure, known as macular grid pattern, or not. Ruefully, this was the proverbial “catch-22.” By not pursuing treatment, it was inevitable that the macula would take a significant permanent hit, with marked loss of vision. However, depending on the precise location of the SRNVM, or bleed, the laser procedure could potentially worsen the patient’s vision. Centrally located bleeds, when treated with the laser, would stop the bleeding, but would result in a large blind spot in the visual field, referred to as a scotoma. Perhaps 30% of patients with a macular bleed who had laser treatment subsequently deeply regretted it, because they were left with worse vision and a huge blind spot. Without a crystal ball, both the ophthalmologist and the patient were unsure about the optimal path to take.
Complicating matters in the late 80’s and early 90’s was the fact that cataract surgery was far more invasive and replete with more frequent complications. Therefore, we would wait to proceed with cataract surgery until the patient was severely limited in the performance of activities of daily living. Just as light rays have a difficult time penetrating through a dense cataract, the eye physician’s view of the back of the eye is suboptimal with a dense cataract. In that era, getting a good look at the back of the eye was problematic for several reasons: First of all, a subtle SRNVM would not be detected by the patient nor the examining physician until a later date, when damage was already irreversible. Second of all, the actual performance of a macular laser procedure was impeded by the presence of the visually obstructing cataract. Third of all, the cataract surgeon was tasked with making a professional guess of the degree to which the cataract was causing a decrease in vision versus the degree to which the macular degeneration was causing a decrease in vision. With moderate or severe macular degeneration, it would be very unlikely to proceed with cataract surgery. But at times, a surgeon could incorrectly guess, for example, that the cataract was 75% of the cause of diminished vision, while the macular degeneration was 25% cause of the limited vision. If these percentages, in actuality, were the opposite, then the patient would be very disappointed with the post-operative visual results.
Preventive care for macular degeneration during the end of the 20th century consisted of recommending carrots, salads, and green vegetables to patients. The renown Age Related Eye Disease Study (AREDS) did not commence until after the turn of the century. Furthermore, there was speculation about the increased incidence of macular degeneration with smoking and concomitant diabetic retinopathy, but nothing was scientifically proven. Our innovations for almost all other ocular diseases moved forward at an amazing rate, but those for macular degeneration lagged considerably, leaving countless distraught patients and families.
The first few years of the 2000’s finally brought us out of the dark ages of macular degeneration into a new world of preventive research, wonderful new diagnostic testing, and exciting new treatment options. All three transpired concurrently and have changed the configuration of how we approach macular degeneration.
In the 21st century, OCT (Optical Coherence Tomography) testing has become an invaluable diagnostic aid for the very early detection of macular degeneration and its sequalae. This testing is extremely valuable in monitoring disease progress and treatment responses. Very helpfully, an OCT will frequently detect a macular problem even before the patient is symptomatic, thereby enabling expedient care to preserve eyesight, as opposed to waiting for damage to present itself on an Anslergrid test. With the current 3rd generation OCT machines, such as the Zeiss Cirrus OCT, the number of fluorescein angiograms has plummeted nationally. This is excellent for quality of care as well as patient safety as the OCT has zero health risks, while the FA is fraught with potential complications.
Macular laser treatments were the sole option in the latter portion of the 20th century for SRNVMs and macular bleeds. These laser treatments brought with them an inherent loss of vision with blind spots. This all changed with the advent of intravitreal injections in the early 2000’s, which are dramatically more effective. These injections contain a medication called anti-VEGF, which counteracts the vascular endothelial growth factor (VEGF), a dangerous substance that propels the bleeding in macular degeneration. Macular laser treatments, widespread in earlier decades, have now been largely supplanted by the more beneficial intravitralinjections.
Age Related Eye Disease Study (AREDS) has become a prominent fixture in the world of ophthalmology and outstanding preventive care. Currently, certain nutrients and vitamin supplements are highly recommended, especially carotenoids, to those afflicted with macular degeneration. These key nutrients contained within the supplemental vitamins are of paramount importance. It is commonplace for supplemental vitamins touted to promote macular health to contain two of the carotenoids, lutein and zeaxanthin. Several researchers believe that adding a third carotenoid, meso-zeaxanthin (a structural isomer of zeaxanthin), is even more beneficial because it works in tandem with the former two to provide an even higher degree of macular protection. This is the strategy behind MacuHealth. These caretonoids are pigments contained in the cell body of photoreceptors, hence the name macular pigments. The macular pigments protect the eye from oxidative damage, and concurrently, improve visual function.
Other research teams have identified additional very important steps one can take to significantly protect macular health:
1. Refrain from smoking
2. Wear sunglasses when outdoors during daylight hours with UV-400 blocker and
polarization on both lens surfaces.
3. Eating food, such as fish, or supplement with alpha-omega-3 fatty acid
4. When using digital devices, wear eyeglasses with lenses that have blue blocker embedded within the lens
During my 30 years of practice as an ophthalmologist, the bleak outlook for patients with macular degeneration has now transformed into a more optimistic picture. This rosier outlook is a result of the triumvirate of OCT testing, intravitreal injections, and possibly, most importantly of all, our expanded knowledge of nutrient and vitamin supplements, especially carotenoids, as effective preventative measures.
Dr Alan Mendelsohn works at Eye Surgeons and Consultants. He has worked as an ophthalmologist in the South Florida area for the past 30 years.