Ocular nutrition: What physicians should be discussing with patients

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The AREDS 1 and 2 studies provide important information about the role of ocular nutrition in AMD. However, to benefit patients, the findings must be condensed into clear and concise advice that will help them select appropriate vitamin supplements and follow a healthy lifestyle.

By Nancy Groves; Reviewed by Michael Cooney, MD, MBA

New York City-Nutrition is one of the modifiable risk factors for age-related macular degeneration (AMD), and with the prevalence of neovascular AMD expected to increase to nearly 3 million people by 2020, nutrition is a subject that ophthalmologists should be discussing with their older patients. But trying to translate the results of complex studies into everyday language and make recommendations for different groups of patients is challenging.

The most reliable information on ocular nutrition and AMD today has emerged from the Age-Related Eye Disease Study (AREDS 1 and 2), sponsored by the National Eye Institute. However, these studies were complicated, and what patients need is a simple answer, said Michael Cooney, MD, MBA, who was an AREDS investigator. In his view, the AREDS studies should be the basis for what to tell your patients.

Why AREDS?

The results of the original AREDS study, released in 2001, showed that high levels of antioxidants and zinc reduced the risk of progression to advanced AMD by 25% and the risk of associated vision loss by 19%.

“These were pretty astounding results and a pretty dramatic risk reduction from just taking a vitamin, and the public health impact is obviously significant,” said Dr. Cooney, who is in practice with Vitreous Retina Macula Consultants of New York, New York City.

The NEI estimated that if all category 3 and 4 AMD patients took an AREDS formula vitamin as directed, 500,000 incidents of AMD-associated vision loss could be prevented over 5 years.

With these findings, an antioxidant vitamin and mineral supplement became a standard recommendation for patients with intermediate and advanced AMD-but not for those with early AMD or no clinical signs.           

Other ocular nutrition studies evaluated the role of additional nutrients-such as lutein, zeaxanthin, and omega-3 long-chain polyunsaturated fatty acids-and seemed to suggest that these were beneficial for eye health. AREDS investigators launched a second study to see if the addition of any of these nutrients would improve the original AREDS formula and achieve an additional significant reduction in risk of AMD progression.

Further investigation

While there were no statistically significant findings in the primary analysis, there were strong trends indicating that lutein and zeaxanthin had a protective effect, particularly if beta-carotene was removed from the original AREDS formula, while omega-3 fatty acids did not appear to be beneficial. It was also clear that lutein and zeaxanthin were safer than beta-carotene when it came to the development of lung cancer in current and former smokers.

A new formulation of the AREDS 2 supplement was then developed, containing vitamins C and E, lutein, zeaxanthin, zinc, and copper.

The idea that a vitamin supplement may help preserve vision has trickled down to the public, but with many of the details of the complex study design missing or misunderstood. Add to that the jumble of products on store shelves, and it’s enough to confuse even an ophthalmologist, to say nothing of an 85-year-old AMD patient with no medical training, said Dr. Cooney.

“It’s important, I believe, that we have a really simple message for patients so that when they go to the vitamin aisle, they know exactly what they’re looking for and can cut out the rest,” Dr. Cooney said.

Discussion tips

Dr. Cooney said he tells his category 3 and 4 AMD patients to take an AREDS 2 formula vitamin and mineral supplement containing lutein and zeaxanthin. He said he recommends Bausch+Lomb PreserVision AREDS 2 because it contains the exact amount of the six nutrients supported by the AREDS 2 study, but he also encourages patients to eat well-such as eating more green, leafy vegetables, and to take the same steps recommended for a healthy heart. These include exercising, losing weight, controlling high blood pressure, and not smoking.

While Dr. Cooney doesn’t advise patients to take a fish oil supplement, based on the AREDS 2 findings on omega-3 fatty acids, he doesn’t discourage patients who are using it for other health reasons. However, he also urges patients to eat more oily fish, since the triglyceride form of omega-3s in fish may be helpful.

But what about the “worried well,” or patients with just the slightest changes in their macula, or those with a family history of AMD?

“There’s no right answer and much debate,” Dr. Cooney said.

Dr. Cooney said his personal approach is to borrow from the available information. Given the strong findings about the benefits of the AREDS 2 formula for patients with full-blown disease, he said, it seems reasonable that a lower dose of these nutrients might be helpful for patients with early AMD or a healthy macula if they have a family history of AMD.

“If you’re empowered and motivated to do something, I think it makes sense, given the totality of information we have, that these things may be protective and helpful for your macula, but we don’t have a clinical trial that will ever demonstrate that for such an early level of disease,” Dr. Cooney said.

Michael Cooney, MD, MBA

E: mcooney@vrmny.net

Dr. Cooney is a consultant for Bausch + Lomb, Genentech, and Regeneron. He is also a speaker for Bausch + Lomb, Genentech, and Regeneron and a NEI AREDS 1 and 2 investigator

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