Age

Report
The Aging Eye:
How to Keep Your Sight For Life
Nicholas J. Volpe, MD
Tarry Professor and Chairman
Department of Ophthalmology
Feinberg School of Medicine
Northwestern University
Volpe Healthy Transitions ‘13
Strategies to Preserve Your Vision
• Prevention is our most potent tool in the quest to
reduce disease (and healthcare costs)
• Choose your parents well and stop aging!!! OR
• Don’t Smoke
• Wear Glasses that are UV protective
– Safety glasses for high risk activities
• Pay Attention to Nutrition and Vitamins
• Don’t Ignore Symptoms
• Get Regular Eye Examinations
Volpe Healthy Transitions ‘13
Major Causes of Chronic Visual Loss
Preventable and Treatable
•
•
•
•
Cataracts
Glaucoma
Macular degeneration
Diabetic retinopathy
• Other Issues
– Dry eye
– Presbyopia near vision blurring
Volpe Healthy Transitions ‘13
Protective Eye Ware
• Avoid fireworks!
• Always if you have poor vision in one eye
• High risk activities
– Racquet sports
– Sawing
– Drilling
– Sawing
– Working overhead
– Any high speed tool
– firearms
Volpe Healthy Transitions ‘13
Stop Smoking
• Clearly a risk factor for cataracts
– 3X the risk
• Clearly a risk factor for macular degeneration and its
response to treatment
Volpe Healthy Transitions ‘13
Nutrition
• Healthy tear film
• Macular degeneration
• Fruits and Green Leafy Vegetables
– Carotenoid pigments (lutein) accumulate in macula and
prevent light damage
• Omega fatty acids
• Lutein and Zeaxanthin
– Studied in AREDS 2
• Vitamins A,C, E
Volpe Healthy Transitions ‘13
Regular Check Ups
•
•
•
•
Many diseases can be detected
Every 2-3 years from age 40-65
Every 1-2 years after age 65
More frequently with diabetes or family history of
glaucoma or macula degeneration
• Young adults, in the absence of symptoms, do not
require routine examinations
Volpe Healthy Transitions ‘13
Cataracts
• Expected if ≥ 60 years old
50% - 65 - 75 years old
70% > 75 years old
• Most common cause of
decreased vision
• Symptoms
–
–
–
–
Loss of acuity
Difficulty with colors
Glare at night
Trouble reading small print
Volpe Healthy Transitions ‘13
Age
Steroids (PSC)
Trauma
Inflammation
Diabetes
Other drugs
Subcapsular cataract
Anterior
Volpe Healthy Transitions ‘13
Posterior
Nuclear cataract
Progression
•
Exaggeration of normal nuclear
ageing change
•
Increasing nuclear opacification
•
Causes increasing myopia
•
Initially yellow then brown
Volpe Healthy Transitions ‘13
Classification according to maturity
Immature
Hypermature
Volpe Healthy Transitions ‘13
Mature
Morgagnian
Drugs
Systemic or topical steroids
- initially posterior subcapsular
Chlorpromazine
- central, anterior capsular
granules
Other drugs
Long-acting miotics
• Amiodarone
• Busulphan
•
Volpe Healthy Transitions ‘13
Cataract Surgery
•
•
•
•
•
•
•
•
•
•
Outpatient
Very successful > 95%
Almost all with intraocular lenses
Most common surgical procedure
in U.S.
>1.4 million/year
Most successful surgical
intervention
Complications
uncommon
sight threatening
IOL technology continues to evolve
for astigmatic correction and
presbyopia
• Newest modality is femtosecond
laser
Volpe Healthy Transitions ‘13
Cataract Prevention
• Smoking cessation
– Reduces Vitamin C in the eye
– Vitamin C levels are high in the eye and this helps
remove prooxidants
• Fruits and vegetables
– 5 fold decrease at 3-4 servings per day
• Regular alcohol consumption increases risk of cataract
• Steroids and inflammatory conditions are risks for
cataracts
• Obesity and radiation
Volpe Healthy Transitions ‘13
Ultraviolet Light
• Cataracts and Macular Degeneration
– Cataracts much more prevalent in equatorial climate
– AMD more common in light eyes
• Same rules as sun tan lotions
– if you might tan or burn you should be wearing
sunglasses
• 10-30% transmission of light
• Wide brimmed hat
• Also water, sand and snow
• Polarized not necessary but will cut glare
• Don’t assume expensive is UVA and B protective
• Test lens quality and fit to ensure successful use
Volpe Healthy Transitions ‘13
Age- Related Macular Degeneration
• Age-related macular degeneration (AMD) is the most
common cause of severe, irreversible vision loss in older
Americans and Europeans. (AMD Alliance International 2008;
Ferris et al. 1984; National Society to Prevent Blindness 1980).
• Worldwide, AMD disease affects 25-30 million people.
• Etiology is complex and poorly understood
– Free-radical mediated damage to the photoreceptors
and the RPE may disrupt the transport of metabolites
from photoreceptors to choroidal capilaries
– Angiogenesis is a feature of neovascular AMD
– AMD may be associated with a systemic vascular
disorder
– Genetic and environmental factors
– Variation in the complement factor H gene
Volpe Healthy Transitions ‘13
Free radicals and antioxidants in
CNV
light
damage
blocked by
antioxidants
free radical
production
photoreceptors and RPE damage
Volpe Healthy Transitions ‘13
AMD Risk Factors
•
•
•
•
•
•
Gender ♀ > ♂
Race/Ethnicity
Smoking
Family History
Atherosclerosis
Hypertension
Volpe Healthy Transitions ‘13
• Symptoms
• early = None, mild distortion
• late = acute loss of vision
Atrophic AMD
Progression
Initially drusen and non-specific RPE
changes
Late RPE (geographic) atrophy
Volpe Healthy Transitions ‘13
Atrophic AMD
Fluorescein angiogram
Management
Hyperfluorescence from RPE window defect Low-vision aids if appropriate
Volpe Healthy Transitions ‘13
Pathophysiology: Penetration of
Bruch’s Membrane
schematic
fundus photograph
New blood vessels penetrate
Bruch’s membrane
Volpe Healthy Transitions ‘13
Choroidal Neovascularization (CNV)
•
•
•
Less common than atrophic AMD but more serious
Metamorphopsia is initial symptom
Many lesions are not visible clinically
Suspicious clinical signs
Gray-yellow subretinal lesion
with fluid
Volpe Healthy Transitions ‘13
Subretinal blood or lipid
Current Status of Therapies
for CNV
• Antiangiogenic therapy
• Lucentis, Avastin, Macugen
– CATT trial (Avastin vs
Lucentis)
• Photodynamic therapy with
verteporfin
• Steroids
• Thermal Laser
Volpe Healthy Transitions ‘13
Treatment w/Anti VEGF
Volpe Healthy Transitions ‘13
Volpe Healthy Transitions ‘13
Treatment for Dry AMD
-Age-related Eye Disease Study
(AREDS) –role of antioxidants
•
•
•
•
•
vitamin E, 400 IU
vitamin C, 500 mg
beta carotene, 15 mg (approximately 25,000 IU Vitamin A)
zinc 80 mg as zinc oxide
copper, 2 mg, as cupric oxide
– Copper should be taken with zinc, because high-dose zinc is
associated with copper deficiency.
Volpe Healthy Transitions ‘13
Established Age Related Macular
Degeneration
• Use Amsler Grid to monitor central vision
•
•
•
•
•
•
AREDS-Occuvite Preservision
B carotene vs. Lutein and Zeaxanthin (AREDS 2)
Vitamin C
Vitamin E
Zinc Oxide (?necessary and ? Stomach upset)
Copper
• NB: No beta carotene for smokers and others at risk
for lung cancer
• Others??? Lutein Eyes, PhoVision, Perspective, Ocuforce
Volpe Healthy Transitions ‘13
AREDS Results
Recommendations
• Evaluation:
• Persons over 55 years old receive a dilated eye exam to
assess risk of advanced AMD.
• Contraindications to Treatment:
• Smokers and ex-smokers should not use beta carotene,
because previous studies have suggested an association
with lung cancer and beta carotene in smokers.
• There were no benefits from treatment shown in the
AREDS for patients with no AMD (Category 1) and early
AMD (Category 2).
Volpe Healthy Transitions ‘13
AREDS 2
• Adding omega 3’s did not help
• Taking away B Carotene did not hurt and lutein and
zexanthine may have been a bit more protective
• Reducing zinc dose did not hurt and less side effects
• No prevention of cataracts
Volpe Healthy Transitions ‘13
Diabetic Retinopathy
•most common cause of
• new blindness among adults 20-64 yo
• Blindness in working adults
•affects over 5.3 million Americans age >18 (2.5%
of this population)
•Prevention- worse in HTN, obesity, renal failure,
hyperlipidema, smoking, anemia, pregnancy and
POOR glycemic control
Volpe Healthy Transitions ‘13
Clinical Findings in NPDR
• Microaneurysms
• Earliest clinical sign of diabetic
retinopathy
• Appear as small red dots in the
superficial retinal layers
• Rupture produces blot/flame
hemorrhages
Volpe Healthy Transitions ‘13
Macular Edema (CSME)
•
Leading cause of
visual impairment in
patients with diabetes
Volpe Healthy Transitions ‘13
Volpe Healthy Transitions ‘13
Macular Edema Treatments
• ETDRS
– focal laser surgery for CSME reduces the incidence of moderate
visual loss (doubling of visual angle or roughly a 2-line visual loss)
from 30% to 15% over a 3-year period
• Steroids
-peri-ocular
-intraocular
Anti-VEGF agents
Volpe Healthy Transitions ‘13
Ischemic diabetic maculopathy
•
•
Macula appears relatively normal
Poor visual acuity
Volpe Healthy Transitions ‘13
•
•
Capillary non-perfusion on FA
Treatment not appropriate
PDR
• Proliferation of new
blood vessels due to
ischemia
• NVD Disc
• NVE Elsewhere
• NVI Iris
• NVA Angle
Volpe Healthy Transitions ‘13
PDR - cont.
•
•
•
•
•
Treatment Options
Pan-retinal photocoagulation
Peripheral Retinal Cryotherapy
Vitrectomy
Anti-VEGF
Volpe Healthy Transitions ‘13
Retinopathy Screening
• Type 1 diabetes - screen within 3-5
years of diagnosis after age 101
• Type 2 diabetes - screen at time of
diagnosis1
• Pregnancy - women with preexisting
diabetes should be screened prior to
conception and during first trimester1
• Follow-up depends on severity of
disease
Volpe Healthy Transitions ‘13
Diabetic Eye Care
• Like glaucoma, you will NOT HAVE SYMPTOMS UNTIL
IT IS TOO LATE!
• 95-100% treatable with early detection
• Regular eye exams at 6 or 12 month interval depending
on what MD sees
• Bleeding, swelling and growth of blood vessels
• Diabetes control (Hemoglobin A1c) is the most important
way to reduce your risk
• High blood pressure is a risk
• Diet and exercise
Volpe Healthy Transitions ‘13
Glaucoma
• Optic nerve
• 1.2 million nerve fibers
• Ganglion cells in retina
exit to brain as optic nerve
Volpe Healthy Transitions ‘13
Definition of Glaucoma
• A group of optic neuropathies in which retinal ganglion
cells die by apoptosis with resultant optic disc cupping and
characteristic visual field deficits
– Optic neuropathy
– Retinal ganglion cell apoptosis
– Optic disc cupping or excavation
– Loss of visual function
-IOP is too high for the nerve???
• Most common cause blindness:
• African-Americans
COMPLETE/TOTAL BLINDNESS
Volpe Healthy Transitions ‘13
Volpe Healthy Transitions ‘13
Volpe Healthy Transitions ‘13
Glaucoma
• Loss of visual field
• Site of visual field loss
corresponds to area of
damage on optic disc,
e.g., “cupping”
Volpe Healthy Transitions ‘13
Classification of the Glaucomas
•
•
•
•
RISK FACTORS
Open-angle glaucomas (90%)
IOP  21 mm Hg
Angle-closure glaucomas (10%)
Family history
Risk is increased
Primary glaucomas
by x2 if parent has
Secondary glaucomas
POAG
Risk is increased
x4 if sibling has
POAG
African American
C:D ratio > 0.5
Asymmetric cupping
Myopia
Diabetes
Age > 75 years
Volpe Healthy Transitions ‘13
Angle Closure Glaucoma
• Acute pain, redness, tearing
• Associated with dilation of
pupil
• Natural (e.g., movie theater)
• Pharmacologic
• Nausea & vomiting
often in ER with “acute abdomen”
Risk factor of narrow angle can be
detected on screening exam
(esp hyperope) and
prophylactic iridotomy is
preventative of attack in 100%
Volpe Healthy Transitions ‘13
Acute angle-closure glaucoma
Signs
•
Severe corneal edema
•
Ciliary injection
•
Dilated, unreactive,
vertically oval pupil
•
Shallow anterior
chamber
•
Complete angle closure
Medical rx to lower IOP, followed by laser (Yag) iridotomy
Volpe Healthy Transitions ‘13
Primary Open-Angle Glaucoma
• The most prevalent type of glaucoma in the United States
• Elevated intraocular pressure is not part of the diagnostic
criteria
– 25% of patients with primary open-angle glaucoma in
the US have normal intraocular pressure
• Asymptomatic
– Some loss of visual field
– Most common type
– Familial, bilateral
– “Sneak thief of sight”
Volpe Healthy Transitions ‘13
Primary Open-Angle Glaucoma
•
•
•
•
Evidence that IOP reduction is beneficial
Collaborative Normal-Tension Glaucoma Study (CNTGS)
Advanced Glaucoma Intervention Study (AGIS)
Early Manifest Glaucoma Study (EMGT)
– 25% IOP reduction RoP 62% to 45% at a median of 6
years.
• Ocular Hypertension Treatment Study (OHTS)
Volpe Healthy Transitions ‘13
Treatment for POAG
• Lower the IOP
• Medical therapy
• Prostaglandin , Bblockers,Sypathomimetic
s, Carbonic-anyhrase
inhibitors
• Laser surgery (ALT, SLT)
• Incisional surgery (Trab,
shunt)
Volpe Healthy Transitions ‘13
Incisional Surgey
Most glaucoma specialists use
an anti-fibrosis agent for every
case in the year 2003
Limit episcleral fibrocellular
proliferation
Mitomycin C (MMC) antitumor antibiotic 0.2 to 0.5
mg/mL for 1 to 5 minutes
5-Fluorouracil (5-FU)
antimetabolite 50 mg/mL for 5
minutes
Volpe Healthy Transitions ‘13
Tube Shunts
Volpe Healthy Transitions ‘13
Eye Strain
•
•
•
•
•
•
•
•
Myth??
Often dry eye
Maybe the muscles around the eye
Worse with misalignment issues
Cant do any harm
Take breaks often and focus at distance
A few extra blinks
Lubricate before long drives, plane trips, windy or smoke
filled environments
• Careful not to dismiss Headaches as “eye strain”
• Seek care if not responsive to behavioral strategies
Volpe Healthy Transitions ‘13
Summary
• Diabetic Retinopathy
•Prevention, treatment
• Cataract
–Surgical treatment continues to improve
• Glaucoma
–Silent blindness, family history
–Medical and surgical rx
• ARMD
–New age of available prevention strategies and treatments exudative
variety
Volpe Healthy Transitions ‘13
Strategies to Preserve Your Vision
• Prevention is our most potent tool in the quest to
reduce disease (and healthcare costs)
• Choose your parents well and stop aging!!! OR
• Don’t Smoke
• Wear Glasses that are UV protective
– Safety glasses for high risk activities
• Pay Attention to Nutrition and Vitamins
• Don’t Ignore Symptoms
• Get Regular Eye Examinations
Volpe Healthy Transitions ‘13

similar documents