Article

RECOMMEND SUPPLEMENTATION

NUTRITIONAL SUPPLEMENTS CAN BRING BENEFITS TO PATIENTS WHO HAVE AMD

AS THE AREDS1 and AREDS2 show that the addition of an oral, nutritional supplementation formula yields reductions in the risk of developing late-stage AMD, optometrists find it beneficial to prescribe vitamins and supplements to ward off worsening disease.1 Here, eye care professionals discuss the role of supplementation in their treatment of AMD.

PART OF THE TREATMENT PROTOCOL

“AMD patients with early or intermediate disease should be taking supplementation,” says Sherrol Reynolds O.D., F.A.A.O., an associate professor at Nova Southeastern University and columnist of Optometric Management’s “Retina.” “I also recommend supplements [for] patients with advanced disease.”

“Patients with early disease benefit from supplementation as studies, including AREDS1 and 2, showed a lower risk of progressing to late stage macular degeneration,” says Dr. Reynolds.

A back-to-basics approach that features healthy diet and exercise in an attempt to prevent a condition, like AMD, is what is first needed, with supplementation playing an adjunctive function, stresses Joseph J. Pizzimenti, O.D., F.A.A.O., faculty member at the Rosenberg School of Optometry at the University of the Incarnate Word, in San Antonio.

“The conversation [with the patient] starts in the optometrist’s office and focuses on food,” says Dr. Pizzimenti. “The discussion should center on diet, lifestyle and filling in any gaps with supplements. Optometrists should be recommending specific products to patients rather than sending them to a pharmacy to pick out [supplements] on their own.”

Whether it be for AMD, dry eye disease or wellness, there are so many ocular supplements out there, with varying ingredients and dosages, so rather than leave it up to the patient to decide which one to take, Dr. Pizzimenti says he prescribes a specific supplement for each patient.

“All ocular nutraceuticals are not created equal, in terms of ingredients and purity,” says Dr. Pizzimenti. “Therefore, the doctor should specify the appropriate supplement for each patient on an individual basis. We prescribe specific treatments for glaucoma and dry eye disease, and we should be doing the same for AMD.”

To increase the likelihood of patients taking the supplements that optometrists prescribe, Dr. Pizzimenti suggests optometrists may make the supplements available within or through their practices. (For more on offering supplements, see http://bit.ly/2uOPBQq .)

Like Dr. Reynolds and Dr. Pizzimenti, Brad Sutton O.D., F.A.A.O., clinical professor at the Indiana University School of Optometry and service chief of the Indianapolis Eye Care Center is on board with his intermediate AMD patients taking supplements.

But, Dr. Sutton says the role of supplementation could be broadened to a prophylactic one in which patients who are at an earlier stage of disease or “at risk” for AMD may obtain value from supplementation.

“No study or science says that taking these [supplements] prophylactically is something that we can prove will be beneficial,” says Dr. Sutton. “But it almost certainly will not hurt [to take supplements], and there is reason to believe [the action] will be positive. [Specifically,] common sense says that it would be helpful to build up levels of carotenoids in the macula.”

COST-EFFECTIVE

There is no doubt that the addition of supplementation to triple therapy (reduced-fluence photodynamic therapy with verteporfin [Visudyne, Bausch + Lomb,] intravitreal bevacizumab [Avastin, Genentech] and intravitreal dexamethasone [Ozurdex, Allergan]) has proven cost-effective in the treatment of AMD, according to Melissa Brown M.D., M.N., M.B.A., C.E.O., of the Center for Value Based Medicine in Hilton Head, S.C., a healthcare economic research organization.

A 24-month triple-blind, randomized clinical trial with 144 participants shows daily supplementation with 20 mg of the carotenoid zeaxanthin added to triple therapy led to 27% of eyes gaining three or more lines of vision vs. 9% of eyes undergoing triple therapy without supplementation (p=0.003).2

“Using zeaxanthin decreases the cost [overall] because you [the patient] end up receiving fewer [anti-VEGF] injections,” says Dr. Brown, an author of the study. “The wet AMD was treated; however, the therapy was also found to delay the conversion of the other eye from dry to wet AMD, which was exciting to see.”

“The results of the study did not indicate that triple therapy should replace VEGF-inhibitor monotherapy as first-line therapy,” explains Dr. Brown. “Nonetheless, the cost of triple therapy with zeaxanthin is similar to that of bevacizumab [Avastin, Genentech] therapy. For the patient, the management of multiple visits and injections cost less with triple therapy and zeaxanthin, because this therapy is given a mean 2.4 times per year, vs. at least five to six injections annually, with theoretically as many as 12 annually, with VEGF-inhibitor monotherapy. Thus, the clinician and patient have another very reasonable choice referent to monotherapy.”

In terms of cost, adding zeaxanthin daily in the trial was extremely cost-effective, estimated at $30 per quality-adjusted life year.

SELECTED AMD OCULAR NUTRITIONAL SUPPLEMENTS
COMPANY WEBSITE PRODUCT NAME ACTIVE INGREDIENT(S)
ALCON systane.com/products/eye-care Systane ICAPS Eye Vitamin AREDS 2 Chewable Formula
Systane ICAPS Eye Vitamin AREDS 2 Softgel Formula
Systane ICAPS Eye Vitamin AREDS 2 Tablet Formula
Systane ICAPS Eye Vitamin AREDS Tablet Formula
Systane ICAPS Eye Vitamin AREDS Softgel Formula
Lutein, zeaxanthin, vitamins C and E, zinc and copper
Lutein, zeaxanthin, vitamins C and E, zinc and copper
Lutein, zeaxanthin, vitamins C and E, zinc, copper, iron and calcium
Lutein, zeaxanthin, vitamins A (as beta carotene) C and E, zinc, copper and calcium
Vitamins A (as beta carotene) C and E, zinc and copper.
SCIENTIFIC STUDIES
Age-Related Eye Disease Study (AREDS1), sponsored by the NEI: https://nei.nih.gov/amd
Age-Related Eye Disease Study 2 (AREDS2), sponsored by the NEI: https://nei.nih.gov/areds2
BAUSCH + LOMB preservision.com PreserVision Eye Vitamin AREDS 2 Formula; AREDS 2
Formula + Multivitamin;* AREDS 2 Formula Chewables
Lutein, zeaxanthin, vitamins C and E, zinc and copper
*Includes multivitamin
SCIENTIFIC STUDY
AREDS2
BIOSYNTRX biosyntrrx.com Eye & Body Complete Lutein, zeaxanthin, meso-zeaxanthin, vitamins A, C, E, B complex, and a number of phytochemical and mitotrophic compounds for a full-spectrum vitamin / mineral multivitamin
SCIENTIFIC STUDIES
Kang JH, Choung SY. Protective effects of resveratrol and its analogs on age-related macular degeneration in vitro. Archives of Pharmacal Research. 2016 Dec; 39: 1703-1715. doi: 10.1007/s12272-016-0839-0.
Feher J, Kovacs B, Kovacs I, Schveoller M, Papale A, Balacco Gabrieli C. Improvement of visual functions and fundus alterations in early age-related macular degeneration treated with a combination of acetyl-L-carnitine, n-3 fatty acids, and coenzyme Q10. Ophthalmologica. 2005; 219: 154-66.
Merle BM, Silver RE, Rosner B, Seddon JM. Dietary folate, B vitamins, genetic susceptibility and progression to advanced nonexudative age-related macular degeneration with geographic atrophy: a prospective cohort study. The American Journal of Clinical Nutrition. 2016; 103: 1135-44.
COVALENT MEDICAL focusvitamins.com Focus Select, Focus Select Citrus Chewable, Focus Select Zinc Free and Focus MaculaPro Lutein, zeaxanthin, vitamins C and E, zinc and copper (with the exception of Focus Select Zinc Free)
SCIENTIFIC STUDIES
AREDS1 and AREDS2 studies

Awh CC, Lane A, Hawken S, Zanke B, Kim IK. CFH and ARMS2 genetic polymorphisms predict response to antioxidants and zinc in patients with age-related macular degeneration. Ophthalmology. 2013. 120: 2317-23.
DOCTOR’S ADVANTAGE PRODUCTS doctorsadvantage.net Macular Shield, Macular Shield plus Complete Multivitamin*, Macular Shield Zinc Free, 2-in-1 AREDS 2 formula and Daily Shield  Lutein, zeaxanthin, vitamins C and E, zinc and copper (with the exception of Macular Shield Zinc Free)
*Includes multivitamin
SCIENTIFIC STUDY
AREDS2
EYEPROMISE/ZEAVISION eyepromise.com EyePromise Restore
EyePromise AREDS 2 Plus Multi-Vitamin
EyePromise AREDS 2 Plus Zinc-Free
Lutein, zeaxanthin, vitamins B6, B12, C, D3 and E, zinc, mixed tocopherols, alpha lipoic acid, folic acid and CoQ10
Zeaxanthin, vitamin D3 and omega-3s
Lutein, zeaxanthin, vitamins C, D3 and E, omega-3s, alpha lipoic acid and mixed tocopherols
SCIENTIFIC STUDIES
AREDS2
Herman JP, Kleiner-Goudey SJ, Davis RL. Case Report of Dietary Supplements Improving Macular Pigment and Visual Function. Advances in Ophthalmology & Visual System. 2017, 6: 00166. doi: 10.15406/avos.2017.00166.
FOCUS LABORATORIES focuslaboratories.com Tozal Lutein, zeaxanthin, taurine and omega-3 from fish oil
SCIENTIFIC STUDY
AREDS1 and AREDS2
GUARDION HEALTH SCIENCES guardionhealth.com Lumega-Z
Omega Boost DHA concentrate
Lutein, zeaxanthin, meso-zeaxanthin, vitamins C and E, zinc and copper
Fish oil concentrate (DHA & EPA
SCIENTIFIC STUDIES
Landrum JT, Bone RA. Dietary lutein & zeaxanthin: Reducing the risk for macular degeneration. Agro Food Industry Hi Tech. 2004; 15: 22-25.
Landrum JT, Bone RA, Joa H, Kilburn MD, Moore JL, Sprague KE. A one year study of macular pigment: The effect of 140 days of a lutein supplement. Experimental Eye Research. 1997; 65: 57-62.
Li B, Ahmed F, Bernstein PS. Studies on the singlet oxygen scavenging mechanism of human macular pigment. Archives of Biochemistry and Biophysics. 2010; 504: 56-60.
MACUHEALTH macuhealth.com Macuhealth with LMZ3
MacuHealth Plus with LMZ3
Lutein, zeaxanthin and meso-zeaxanthin
Lutein, zeaxanthin, meso-zeaxanthin and vitamins C and E, zinc, copper
SCIENTIFIC STUDIES
Nolan JM, Akkali MC, Loughman J, Howard AN, Beatty S. Macular carotenoid supplementation in subjects with atypical spatial profiles of macular pigment. Experimental Eye Research. 2012; 101: 9-15.
Nolan JM, Power R, Stringham J, et al. Enrichment of macular pigment enhances contrast sensitivity in subjects free of retinal disease: Central retinal enrichment supplementation trials - report 1. Investigative Ophthalmology & Visual Science. 2016; 57: 3429-39.
Nolan JM, Meagher K, Kashani S, Beatty S. What is meso-zeaxanthin, and where does it come from? Eye. 2013; 27: 899-905.
MAXIVISION maxivision.com Macula Formula Lutein, zeaxanthin, vitamins C and E, zinc, copper and taurine
SCIENTIFIC STUDY
Not available at press time
NORDIC NATRUALS nordicnaturalspro.com ProDHA Eye Lutein, zeaxanthin, omega-3, 845 mg DHA, 360 mg EPA
SCIENTIFIC STUDIES
Arnold C., Winter, L., Frohlich K., et al. Macular xanthophylls and w-3 long-chain polyunsaturated fatty acids in age-related macular degeneration: a randomized trial. Jama Ophthalmology 2013; 131::564-72.
Garcia-Layana A., Recalde S., Alaman AS, Robredo PF. Effects of lutein and docosahexaenoic acid supplementation on macular pigment optical density in a randomized controlled trial. Nutrients. 2013; 5: 543-51.
Georgiou T., Prokopiou E. The new era of omega-3 fatty acids supplementation: Therapeutic effects on dry age-related macular degeneration. Journal of Stem Cells. 2015; 10: 205-15.
PRN prnomegahealth.com Macular Vitamin Benefits
Eye Omega Advantage
Lutein, zeaxanthin, vitamins C, E, zinc and copper
Lutein, zeaxanthin, vitamin D, omega-3
SCIENTIFIC STUDIES
AREDS2
Christen WG, Glynn RJ, Chew EY, Albert CM, Manson JE. Folic acid, pyridoxine, and cyanocobalamin combination treatment and age-related macular degeneration in women. Archives of Internal Medicine. 2009;169: 335-341.
SCIENCEBASED HEALTH sciencebasedhealth.com MacularProtect Complete AREDS2* and MacularProtect AREDS2 Complete AREDS nutrients: vitamins C and E, zinc, copper, lutein and zeaxanthin; WAFACS nutrients: vitamins B6 and B12, folate.
*Includes multivitamin, additional antioxidants
SCIENTIFIC STUDIES
AREDS and AREDS2
Christen WG, Glynn RJ, Chew EY, Albert CM, Manson JE. “Folic acid, pyridoxine, and cyanocobalamin combination treatment and age-related macular degeneration in women: the women’s antioxidant and folic acid cardiovascular study.” Archives of Internal Medicine. 2009 ;169: 335-41.
The scientific studies listed are those provided by each manufacturer when queried to provide those that support their supplements. While there may be more studies that address this, due to space limitations, we asked the companies to limit their respective studies to three. Optometric Management suggests you conduct your own research regarding nutritional supplements. The online version of this table will be periodically updated.

TAKEAWAY

Eye care professionals, agree on the clear value in prescribing eye vitamins for specific types of AMD, and research supports the effectiveness of nutritional supplements. OM

Dr. Pizzimenti has received honoraria and consulting fees from EyePromise, Zeiss, Genentech, and ThromboGenics. Dr. Reynolds and Dr. Sutton had no financial disclosures.

REFERENCES

  1. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report No. 8. Archives of Ophthalomology. 2001; 119: 1417-36.
  2. Olk RJ, Peralta E, Gierhart DL, Brown MM, Brown GC. Combination Therapy with Dietary Zeaxanthin for Neovascular Age-Related Macular Degeneration. A Randomized Clinical Trial. Journal of Clinical & Experimental Ophthalmology. 2017; 8. DOI: 1000692.