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THE VISION CARE INSTITUTE® is a trademark of Johnson & Johnson Medical Limited. © Johnson & Johnson Medical Limited. 2015
KEY PAPERS
KEY PAPERS ON EYE HEALTH
THE VISION CARE INSTITUTE® is a trademark of Johnson & Johnson Medical Limited. © Johnson & Johnson Medical Limited. 2015
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THE VISION CARE INSTITUTE® is a trademark of Johnson & Johnson Medical Limited. © Johnson & Johnson Medical Limited. 2015
Introduction Lifestyle factors have been linked to many general health conditions and people are generally aware of the benefits of a healthy diet, regular exercise, and avoiding smoking and excessive alcohol. But until recently little attention has been paid to the influence of lifestyle on eye health.
There is growing evidence for relationships between various exposures and common eye diseases. For some potential risk factors, such as smoking, the evidence is compelling, while associations with other behaviours are less well supported in the literature or findings are contradictory.
Eye care professionals need to keep abreast of the latest thinking on lifestyle and eye health to provide accurate advice to patients. This literature review introduces this complex and fascinating subject. It presents an overview of each exposure, summarises current research findings and suggests resources for further information.
Prepared by Alison Ewbank and Jane Veys Last updated October 2015
Alison Ewbank is a freelance writer and Jane Veys is Director – Global Professional Education for Johnson & Johnson Vison Care. Both are optometrists with a passion for preventative eye health and advocates for
evidence-based healthcare. The authors would like to acknowledge nutritionist Kiran Goraya for her expert review and input to the Diet section.
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Table of Contents INTRODUCTION .......................................................................................................................................................................... 2
WHAT’S INCLUDED ..................................................................................................................................................................... 4
HOW TO ACCESS AND EVALUATE RESOURCES ............................................................................................................................................ 5 KEY TO ABBREVIATIONS ........................................................................................................................................................................ 6
GENERAL OVERVIEW .................................................................................................................................................................. 7
PATIENT RESOURCES ............................................................................................................................................................................ 8 PRACTITIONER RESOURCE ..................................................................................................................................................................... 8
LANDMARK STUDIES .................................................................................................................................................................. 9
SMOKING OVERVIEW ............................................................................................................................................................... 11
PATIENT RESOURCES .......................................................................................................................................................................... 12 PRACTITIONER RESOURCE ................................................................................................................................................................... 12 SMOKING REFERENCES ....................................................................................................................................................................... 13
DIET OVERVIEW ........................................................................................................................................................................ 26
DIET OVERVIEW (CONTINUED) ................................................................................................................................................. 27
PATIENT RESOURCES .......................................................................................................................................................................... 28 PRACTITIONER RESOURCES .................................................................................................................................................................. 29 DIET REFERENCES .............................................................................................................................................................................. 30
ALCOHOL OVERVIEW ................................................................................................................................................................ 46
PATIENT RESOURCES .......................................................................................................................................................................... 47 ALCOHOL REFERENCES ........................................................................................................................................................................ 48
RECREATIONAL DRUGS OVERVIEW ........................................................................................................................................... 54
PATIENT RESOURCES .......................................................................................................................................................................... 55 RECREATIONAL DRUGS REFERENCES ...................................................................................................................................................... 56
EXERCISE OVERVIEW ................................................................................................................................................................ 59
PATIENT RESOURCES .......................................................................................................................................................................... 60 EXERCISE REFERENCES ........................................................................................................................................................................ 61
OBESITY OVERVIEW.................................................................................................................................................................. 65
PATIENT RESOURCES .......................................................................................................................................................................... 66 OBESITY REFERENCES ......................................................................................................................................................................... 67
LIGHT EXPOSURE OVERVIEW .................................................................................................................................................... 71
PATIENT RESOURCES .......................................................................................................................................................................... 72 LIGHT EXPOSURE REFERENCES .............................................................................................................................................................. 73
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What’s included • Papers published in peer-reviewed publications • Latest findings relevant to eye care professionals • Review articles, meta-analyses, landmark and key studies • Abstracts available online (and, where possible, full text or pdf) • Supporting patient resources
Various models have been proposed for a ‘Hierarchy of Evidence’, such as:
Hierarchy of Evidence Pyramid
More detailed levels of evidence from Oxford Centre for Evidence-Based Medicine.
Systematic
Review Randomised
Controlled Trial
Case-Controlled Study
Case Studies, Case Reports
Expert Opinion/Clinical
Cohort Study
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How to Access and Evaluate Resources
THE VISION CARE INSTITUTE® guide, How to Access Eye Care Resources
Click here To find out more about hierarchies of evidence in healthcare interventions: Evans D. Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. J Clin Nurse 2003;12:1 77-84.
Click here For more information on systematic reviews and meta-analyses: Rudnicka AR and Owen CG. An introduction to systematic reviews and meta-analyses in health care. Ophthalmic Physiol Opt 2012;32:174-183.
Click here And for more on evaluating clinical research: Veys J and Schnider C. Evaluating clinical research for your practice. Optician 2009;234:6118 22-25.
Click here THE VISION CARE INSTITUTE® flashcard, Evaluating Clinical Research
Click here
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Key to Abbreviations
AMD Age-related Macular Degeneration
ARM Age-related Maculopathy
AREDS Age Related Eye Disease Study
ETS Environmental Tobacco Smoke
POAG Primary Open Angle Glaucoma
PSC Posterior Sub Capsular
DES Dry Eye Syndrome
EFA Essential Fatty Acids
EPO Evening Primrose Oil
NHS National Health Service
UVR Ultra Violet Radiation
HEI Health Eating Index
MP Macula Pigment
RCT Randomised Controlled Trial
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General Overview Veys J and Desai P. Well-being and optometric practice. Optometry in Practice 2014;15:4 141-150.
• Optometrists have important role to play in health promotion and public health • Raise awareness of link between eye health and lifestyle to encourage changes in
behaviours such as smoking, exercise, diet and UV protection • Identify modifiable risk factors and provide advice based on individual needs • Record smoking status in patient’s history and provide ‘very brief advice’ • Be proactive with sport-based advice, recommend appropriate eye protection • Provide leaflets and recommend websites to supplement your advice.
Click here for full text
Klein BE and Klein R. Lifestyle exposures and eye diseases in adults. Am J Ophthalmol 2007;144:6 961-969.
• Extensive review of associations between lifestyle exposures/behaviours and eye disease • Reviews cataract, AMD, diabetic retinopathy, POAG, trauma, dry eye, refractive error by
risk factor • Some exposures, such as smoking, are significantly associated with risk of several different
diseases • Although data are imperfect, lifestyle alterations may reduce risk of eye disease at little or
no risk to the individual.
Click here for full text Fletcher AE (2009). Healthy Ageing: The Eye. In: Stanner et al (eds). Healthy ageing: the role of nutrition and lifestyle. Wiley-Blackwell, Oxford, 2009.143-158.
• Comprehensive review of research into relationship between lifestyle exposures and risk/development of age-related eye diseases
• Reviews association between UV exposure, smoking and nutrients, and AMD and cataract • Considers research findings in the context of public health advice • Conclusions:
- Smoking is major risk factor for cataract and AMD - There is moderate evidence high exposures to sunlight are associated with
increased risk of cataract and AMD - High dietary intakes of antioxidants can protect against AMD and cataract.
Although evidence is inconsistent, data suggest vitamin C and carotenoids lutein and zeaxanthin play critical role in eye health. Overall evidence supports general healthy eating guidelines for consumption of fruit and vegetables and oily fish.
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General Overview
Patient Resources
Feeling great, looking good. A guide to how a healthy lifestyle can help prevent sight loss. RNIB, 2006. RNIB, Looking after your eyes College of Optometrists, Look After Your Eyes website The Healthy Sight Institute Royal College of Ophthalmologists, Information for Patients NHS Choices, Look after your eyes All About Vision, Eight Ways to Protect Your Eyesight THE VISION CARE INSTITUTE® Top Ten Tips for Healthy Eyes
Practitioner Resource
OECD, Health at a Glance: Europe 2014 (Chapter 2, Determinants of Health)
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Landmark Studies The Age-Related Eye Disease Study (AREDS)
• Sponsored by the US National Eye Institute • Investigated natural history and risk factors of AMD and cataract • Randomised, placebo-controlled, clinical trial evaluating effect of high-dose antioxidants
and zinc supplementation on progression of AMD and cataract AREDS followed 4,700 subjects in US with varying stages of AMD from January 1998.
Key findings: High levels of antioxidants and zinc significantly reduce the risk of advanced AMD and associated vision loss but have no significant effect on the development or progression of cataract.
Click here for dedicated website
AREDS2
• Randomised, placebo-controlled, clinical trial evaluating effect of dietary lutein/zeaxanthin and/or omega-3 fatty acids (DHA and EPA) on progression to advanced AMD
• AREDS2 followed c4,000 participants aged 50 to 85 years with either bilateral large drusen or large drusen in one eye and advanced AMD in fellow eye.
Enrolment ended in June 2008 and participants were followed between 5-6 years.
Key findings: Adding omega-3 fatty acids did not improve the original AREDS formulation commonly recommended for treating AMD. Lutein and zeaxanthin also had no overall effect on AMD when added to the combination although they were safer than the related antioxidant beta-carotene.
Click here for dedicated website Beaver Dam Eye Study
• Funded by National Eye Institute to investigate prevalence and incidence of age-related cataract, AMD and diabetic retinopathy and their causes
• Now examining relationship of long-term exposures (eg, blood pressure, lipid levels, exposure to UV-light, and medications) to these eye conditions
Began in 1989 in Beaver Dam, Wisconsin and involved c5,000 subjects aged 43-84 years at baseline, followed at 5, 10, 15 and 20 years. Key findings: Association of cigarette smoking with cataract and AMD. Also looked at dry eye – smoking, caffeine use and multivitamins among factors investigated. Smoking, drinking alcohol, and physical activity associated with changes in vision over 20-year period.
Click here for dedicated website
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Blue Mountains Eye Study
• First large population-based assessment of visual impairment and common eye diseases of representative older (49-97) Australian community sample
• Assessed visual impairment, cataract, AMD, glaucoma, other vascular retinopathy, other general health measures
• Also questioned on types of food consumed. The Blue Mountains Eye Study followed 3,654 subjects in Australia from 1992-1994 and followed surviving participants at 5, 10 and 15 years. A further 1,206 took part in an extension study in 1999-2000. Key findings: Increased risk of nuclear cataract with smoking and heavy alcohol use, while higher dietary intakes of protein and vitamins protective. For cortical cataract, moderate alcohol intake and higher dietary polyunsaturates protective. Sunlight exposure, smoking and higher dietary salt all associated with higher risk of posterior subcapsular cataract. Four-fold increased risk of late-stage AMD among smokers than past or non-smokers, and 10-year earlier onset than non-smokers. Higher fish consumption protective against AMD. Increased risk with higher consumption of dietary fat. Diabetes associated with higher rates of obesity.
Click here for overview Los Angeles Latino Eye Study
• Funded by National Eye Institute and largest, most comprehensive epidemiological analysis of visual impairment in Latinos conducted in US
• Assessed risk factors for eye disease and measuring health-related and vision-related quality of life
• Investigated prevalence of visual impairment, blindness, cataract, glaucoma, diabetic retinopathy, and AMD.
LALES followed 6,300 Latinos, primarily Mexican-Americans, aged 40 and older from the Los Angeles area. Results first reported in 2003. Key findings: Differences in eye disease prevalence between ethnic groups. Risk factors for visual impairment included low education and unemployment. Unmarried status associated with increased risk of glaucoma but no association found for smoking or alcohol use. Smoking and heavy alcohol consumption, particularly beer, associated with greater risk of advanced AMD.
Click here for key findings See also Rotterdam Eye Study and others listed by Eye Disease Prevalence Group.
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Smoking Overview
• The proportion of adults who smoke varies widely between countries from 32% in Greece to 14% in Sweden. Smoking has declined in most EU member states in recent years (OECD, 2014). Check the data for your country HERE
• Smoking is an important factor in eye health.
• Smokers double their risk of developing AMD, and tend to develop it earlier than non-
smokers.
• Smoking is associated with nuclear cataract but there is limited evidence of links with other types of cataract. Data on smoking and glaucoma, diabetic retinopathy and dry eye are inconclusive. Many other links investigated.
• Contact lens wearers who smoke have an increased risk of MK compared to non-smokers.
• Awareness of the link between smoking and eye disease is low and there is an untapped opportunity to educate patients on this issue.
• ‘Blindness’ deserves to be mentioned in the context of public health messages because of an unexpectedly high deterrent effect.
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Smoking
Patient Resources
Smoking and sight loss. RNIB, 2008. Factsheet
Go Smoke Free. Website and local stop smoking services Quitline. Website, helpline and QUIT pack. NHS Stop Smoking website Department of Health, Smoking policies Action on Smoking and Health (ASH) factsheet, Smoking and Eye Disease European Network of Quitlines, helping smokers in 30 countries quit
Practitioner Resource
Very Brief Advice on Smoking, National Centre for Smoking Cessation and Training Clinical Tip Record smoking status in every patient’s history, inform smokers of evidence for the link between smoking and eye health, and provide brief advice to help trigger an attempt to stop smoking.
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Smoking References
Smoking and Eye Health – General
Klein R, Lee KE, Gangnon RE et al. Relation of smoking, drinking, and physical activity to changes in vision over a 20-year period: the Beaver Dam Eye Study. Ophthalmology 2014;121:6 1220-8.
• Describes relationships of lifestyle to changes in vision and incidence of visual impairment (VI) in 4,926 persons aged 43-86 years at baseline
• Adjusting for age, income, and AMD severity, being current or past smoker was related to greater change in numbers of letters lost
• Those who had not consumed alcoholic beverages over past year and sedentary persons had higher odds of incident VI than persons who drank occasionally or who were physically active.
• Click here for full text Galor A and Lee DJ. Effects of smoking on ocular health. Curr Opin Ophthalmol 2011;22:6 477-82.
• Smoking is associated with eye health problems such as AMD and cataract • Smokers are more likely to develop ocular inflammation and to have more severe disease
than non-smokers • Eye care professionals should discuss and offer options for smoking cessation, especially
in those with ocular inflammation, AMD, lens opacities/cataract, and thyroid-associated orbitopathy.
Click here for abstract
Zhang, X, Kahende J, Fan AZ et al. Smoking and visual impairment among older adults with age-related eye diseases. Prev Chron Dis 2011;8:4 A84.
• Assesses association between smoking and visual impairment among adults aged over 50 years with age-related eye diseases
• Visual impairment defined as self-reported difficulty in recognising a friend across the street or difficulty in reading print or numbers
• Prevalence of visual impairment is higher among current smokers (48%) than among former smokers (41%) and those who have never smoked (42%).
Click here for pdf
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Lois N, Abdelkader E, Reglitz K et al. Environmental tobacco smoke exposure and eye disease. Br J Ophthalmol 2008;92:10 1304-10.
• Literature review on environmental tobacco smoke (ETS) and eye disease • Active smoking proposed as risk factor in AMD, Graves ophthalmology, glaucoma, uveitis,
refractive errors, strabismus, tobacco-alcohol amblyopia, non-arteritic ischaemic optic neuropathy, Leber optic neuropathy and diabetic retinopathy but literature on some conditions scarce
• Data on ETS and eye disease insufficient to draw conclusions but should be addressed in future studies
• Smoking is direct cause of tobacco-alcohol amblyopia • Increased risk of blindness should be added to arguments against smoking.
Click here for abstract
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Smoking and AMD
Myers CE, Klein BE, Gangnon R et al. Cigarette smoking and the natural history of age-related macular degeneration: the Beaver Dam Eye Study. Ophthalmology 2014;121:10 1949-55.
• Examines association of current cigarette smoking and pack-years smoked with incidence and progression of AMD
• Current smoking associated with increased risk of transitioning from minimal to moderate early AMD
• Greater number of pack-years smoked associated with increased risk of transitioning from no to minimal early AMD and from severe early to late AMD
• Current smoking and greater number of pack-years increased risk of death.
Click here for abstract Choudhury F, Varma R, McKeen-Cowdin R et al. Risk factors for four-year incidence and progression of age-related macular degeneration: the Los Angeles Latino Eye Study. Am J Ophthalmol 2011; 152:3 385-95.
• Identifies risk factors for 4-year AMD incidence and progression in Latinos • Current smoking independently associated with progression of AMD • Promoting smoking cessation may reduce incidence and progression of AMD.
• • Click here for abstract
Chakravarthy U, Wong TY, Fletcher A et al. Clinical risk factors for age-related macular degeneration: a systematic review and meta-analysis. BMC Ophthalmol 2010;10:31.
• Review of 18 prospective and cross-sectional and 6 case control studies • Current smoking shows strong and consistent association with late AMD • Risk factors with moderate and consistent associations included higher BMI.
• • Click here for full text
Nolan JM, O’Regan S, O’Regan G et al. Update on modifiable risk factors for age-related macular degeneration. Optometry in Practice 2010;11:4 143-150.
• Average construction worker is at 2X risk of AMD than normal population • Smoking cessation, reduced light exposure, dietary modification and, in some cases,
dietary supplementation should be advised for these and other individuals with similar environmental and lifestyle traits.
Click here for full text
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Thornton J, Edwards R, Mitchell P et al. Smoking and age-related macular degeneration: a review of association. Eye 2005;19:935-44.
• UK-based review of epidemiological evidence associating smoking with AMD • Of 17 studies reviewed, 13 found a statistically significant association • 2-3X increased AMD risk in current smokers compared with never-smokers • Evidence of dose-response, temporal relationship and reversibility of effect • Cigarette smoking likely to have toxic effects on the retina • Highlights lack of awareness about the risks of developing eye disease from smoking
among both healthcare professionals and the general public. •
• Click here for full text AREDS Research Group. Risk factors associated with age-related macular degeneration. A case-control study in the age-related eye disease study: Age-Related Eye Disease Study Report Number 3. Ophthalmology 2000;107:12 2224-32.
• AREDS participants aged 60-80 ranging from no to advanced AMD in one eye • Those with drusen, neovascular AMD or geographic atrophy were more likely to be
smokers • Avoidance of smoking may reduce the risk of developing AMD • Prevention of vision impairment may be used as a motivating factor to help them modify this
risk factor. • Click here for full text
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Smoking, Drinking and AMD
Klein R, Lee KE, Gangnon RE et al. Relation of smoking, drinking, and physical activity to changes in vision over a 20-year period: the Beaver Dam Eye Study. Ophthalmology 2014;121:6 1220-8.
• Describes relationships of lifestyle characteristics to changes in vision and incidence of visual impairment (VI) over 20-year period
• Adjusting for age, income, and AMD severity, being a current or past smoker was related to a greater change in the numbers of letters lost
• Persons who had not consumed alcoholic beverages over the past year and sedentary persons had higher odds of incident VI than persons who drank occasionally or who were physically active.
• Click here for abstract
Venza I, Visalli M, Oteri R et al. Combined effects of cigarette smoking and alcohol consumption on antioxidant/oxidant balance in age-related macular degeneration. Aging Clin Exp Res 2012;24:5 530-6.
• Investigates single and joint effects of chronic cigarette smoking and alcohol consumption on oxidative stress in AMD
• Compared with healthy controls, early- and late- AMD patients showed significant decreases in antioxidant activity
• Combination of cigarette smoking and alcohol consumption aggravating factor contributing to oxidative imbalance and DNA damage in AMD.
• • Click here for abstract
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Smoking and Cataract
Chang JR, Koo E, Agrón E et al. Risk factors associated with incident cataracts and cataract surgery in the Age-related Eye Disease Study (AREDS): AREDS report number 32. Ophthalmology 2011;118:11 2113-9.
• Investigates potential risk factors associated with nuclear, cortical, and PSC cataracts and cataract surgery in AREDS participants
• Smoking associated with raised risk of cortical cataract and cataract surgery. •
• Click here for abstract Kelly SP, Thornton J, Edwards R et al. Smoking and cataract: review of causal association. J Cataract Refract Surg 2005 31:12 2395-404.
• UK-based review of 27 epidemiological studies on smoking and cataract • Found strong association, particularly for nuclear cataract • Smoking associated with 3-fold increase on risk for incident nuclear cataract • Limited evidence of an association between smoking and posterior subcapsular cataract,
and little or no association with cortical cataract.
• Click here for abstract
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Smoking and Glaucoma
Ramdas WD, Wolfs RCW, Hofman A et al. Lifestyle and risk of developing open-angle glaucoma. Arch Ophthalmol 2011;129:6 767-772.
• Looks at whether lifestyle-related risk factors, such as socioeconomic status, smoking, alcohol consumption, and obesity, are associated with POAG
• Obesity appears to be associated with a higher IOP and lower risk of developing POAG. These associations are only present in women
• Other lifestyle factors, including smoking, are not associated with POAG. •
• Click here for full text Edwards R, Thornton J, Ajit R et al. Cigarette smoking and primary open angle glaucoma: a systematic review. J Glaucoma 2008;17:7 558-66.
• Review of 11 epidemiological studies on smoking and POAG • Found mostly poor methodology and little evidence for causal association • Further, high-quality studies needed • Highlights importance of warning ophthalmic patients of dangers of smoking and providing
cessation support since clear evidence of links between smoking and other ocular and systemic diseases.
• Click here for abstract
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Smoking and Diabetic Retinopathy
Moss SE, Klein R, Klein BE. The 14-year incidence of vision loss in a diabetic population. Ophthalmol 1998;105:6 998-1003.
• Examines potential risk factors for vision loss among younger onset insulin-dependent
diabetics • Loss of vision associated with more pack years smoked.
• Click here for abstract
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Smoking and Dry Eye
Lee S-Y, Petznick A and Tong L. Associations of systemic diseases, smoking and contact lens wear with severity of dry eye. Ophthalmic Physiol Opt 2012;32:518-526.
• Prospective study of effect of systemic and ocular conditions on severity of dry eye (categorised by symptoms and clinical assessment) in patients attending dry eye clinic
• No association between dry eye severity and smoking (or contact lens wear).
Click here for abstract Ward SK, Dogru M, Wakamatsu T et al. Passive cigarette smoke exposure and soft contact lens wear. Optom Vis Sci 2010;87:5 367-372.
• Effects of passive smoking on ocular surface and tear film in soft lens wearers • Mean tear evaporation rates, tear breakup times (TBUTs), and staining scores worse in CL
wearers compared with non-wearers • TBUTs worse after passive smoke exposure in both groups • Mean tear evaporation rate and staining scores increased with brief passive smoke
exposure in non-wearers but not in CL wearers. •
• Click here for abstract
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Smoking and Microbial Keratitis
Stapleton F, Keay L, Edwards K et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology 2008;115:10 1655-62.
• Establishes risk factors for contact lens-related microbial keratitis • Odds ratio for daily wear users was 2.96X in current smokers compared to non-smokers
• • Click here for abstract
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Smoking and Uveitis
Yuen BG, Tham VM, Browne EN et al. Association between smoking and uveitis: results from the Pacific Ocular Inflammation Study. Ophthalmology 2015;122:6 1257-61.
• Assesses whether cigarette smoking is associated with the development of uveitis in a population-based setting
• Current smokers had a 1.63X and 2.33X times greater odds of developing uveitis compared with those who never smoked using the general and ophthalmology control groups, respectively.
• The association was even stronger with non-infectious uveitis.
• Click here for full text Lin P, Loh AR, Margolis TP et al. Cigarette smoking as a risk factor for uveitis. Ophthalmology 2010;117:3 585-90.
• Retrospective, case-control study of patients seen in uveitis clinic • History of smoking associated with all types of uveitis and infectious uveitis • Association greater in those with intermediate uveitis and panuveitis with cystoid macular
oedema (CME) compared with those without CME. •
• Click here for full text
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Smoking Cessation – Attitudes of Eye Care Professionals and Public Lawrenson JG, Roberts CA and Offord L. A pilot study of the feasibility of delivering a brief smoking cessation intervention in community optometric practice. Public Health 2015;129:2 149-51.
• Pilot study of smoking cessation intervention by community optometrists • 77% of optometrists were aware of link between smoking and AMD • 4% regularly took smoking history; 12% provided regular advice on cessation • 88% unaware of mechanism for referring patients to local specialist services • Following intervention, knowledge of link between AMD and smoking 95%, more likely to
take a smoking history 55% and provide advice to their patients on stopping smoking 45%.
Click here for full text Ratneswaran C, Chisnall B, Drakatos P et al. A cross-sectional survey investigating the desensitisation of graphic health warning labels and their impact on smokers, non-smokers and patients with COPD in a London cohort. BMJ Open 2014;4:7 e004782.
• Probes effectiveness of graphic health warning labels (GHWL) • Smokers, in particular those with chronic obstructive pulmonary disease (COPD), less
susceptible to GHWL than non-smokers • Lung (95%) and oral (90.2%) cancer, heart disease (84.7%) and stroke (71.2%) were
correctly associated with smoking, blindness least associated (23.9%) • Blindness was prioritised over oral cancer, stroke and in patients with COPD also over
heart disease, when asked about hypothetical treatment/prevention • Mention of ‘blindness’ in context of public health messages has high-deterring impact.
• Click here for full text
Kennedy RD, Spafford MM, Douglas O et al. Patient tobacco use in optometric practice: a Canada-wide study. Optom Vis Sci 2014;91:7 769-77.
• 98% of optometrists believed smoking was a risk factor for developing AMD but only 55% assessed thesmoking status of patients during initial visit
• 7% discussed the benefits of tobacco use prevention with patients <19 years • 33% always or regularly assess patients' interest in quitting smoking.
• Click here for abstract
Lawrenson JG and Evans JR. Advice about diet and smoking for people with or at risk of age-related macular degeneration: a cross-sectional survey of eye care professionals in the UK. BMC Public Health 2013;13:564.
• Survey of current practice of UK eye care professionals • 32% regularly took smoking history in new patients; 21.2% in review patients • 49% frequently informed smokers of link between smoking and eye disease • Only a third regularly advised smokers to quit
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• 70% considered smoking history when recommending nutritional supplements for AMD • Ophthalmologists more likely to take smoking history; 70-80% frequently explain smoking
and eye disease and advise quitting. Click here for full text
Willeford KT and Rapp J. Smoking and age-related macular degeneration: biochemical mechanisms and patient support. Optom Vis Sci 2012;89:11 1662-1666.
• Reviews pathogenesis of AMD and smoking, and suggests eye care professionals: • Note tobacco use in patient’s record as a reminder to discuss • Hand out leaflets on smoking cessation sites or services • Use the five Rs to motivate: relevance, risks, rewards, roadblocks, repetition • Need <30seconds of discussion to prompt a successful quit attempt.
• • Click here for abstract
Sheck LHN, Field AP, McRobbie H et al. Helping patients to quit smoking in the busy optometric practice. Clin Exp Optom 2009;92:2 75-77.
• ‘ABC’ framework to apply when addressing smoking cessation: Asking about smoking; Brief advice to quit; and offering Cessation treatment
• Suggests useful wording for delivering advice which can be provided in <30seconds.
• Click here for full text
Moradi P, Thornton J, Edwards R et al. Teenagers' perceptions of blindness related to smoking: a novel message to a vulnerable group. Br J Ophthalmol 2007;91:5 605-7.
• Survey of teenagers attending four organised social events • Only 5% believed smoking caused blindness, whereas 15%, 27% and 81% believed that
smoking caused stroke, heart disease and lung cancer • Subjects were significantly more fearful of blindness than other conditions • More teenagers said they would stop smoking on developing early signs of blindness
compared with early signs of lung or heart disease. Teenagers should be made more aware of the ocular risks of cigarette smoking as a novel public health measure.
• • Click here for abstract
Thompson C, Harrison RA, Wilkinson SC et al. Attitudes of community optometrists to smoking cessation: an untapped opportunity overlooked? Ophthalmic Physiol Opt 2007;27:4 :389-93.
• Few community optometrists routinely asked about smoking habits: 6.2% at new patient consultations, and 2.2% at follow-up visits. Reasons: not role, lack of time, forget to ask
• Overall 67.6% community optometrists wanted to improve their knowledge of smoking and visual impairment with 56.2% requesting further training
• Untapped opportunities for brief interventions to promote smoking cessation services. •
• Click here for abstract
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Diet Overview
• Nutrition is an important determinant of health. Daily consumption of fruit and vegetables varies from country to country (OECD, 2014). Check the data for your country HERE
• Eating a wholesome, balanced diet will provide all of the nutrients required to keep the body healthy and may help maintain eye health.
• Many studies on diet and eye health have focused on a potential role for the antioxidant vitamins C and E and the carotenoids beta carotene, lutein and zeaxanthin, especially in AMD and cataract.
• Research has investigated the effect of these nutrients within the diet and/or when taken as dietary supplements.
• This research is derived both from observational and intervention studies; it is important to take study design into account when interpreting research outcomes, especially when causal links cannot be established.
• Epidemiological data provide evidence for a protective effect of high antioxidant intakes against AMD and cataract. Observational data suggest higher dietary intakes of carotenoids may protect against cataract and AMD.
• Research in this area is inconsistent; the US Food and Drug Administration concluded there is insufficient evidence to support a protective role of lutein and zeaxanthin for risk of AMD and cataract.
• A diet high in omega-3 fat and low in total fat may decrease the risk of developing AMD and slow its progression, although evidence for a preventative effect is inconsistent.
• Intervention studies have shown a specific high dosage of antioxidants could help reduce the risk of advanced AMD for people who already have moderate AMD. High doses are contraindicated in some groups (e.g. smokers).
• Intervention studies have generally found no benefit to vitamin supplements for cataract.
• Adding omega-3 fatty acids does not improve a combination of nutritional supplements commonly recommended for treating AMD. Lutein and zeaxanthin also have no overall effect on AMD when added to the combination although they are safer than beta carotene.
• Lutein/zeaxanthin supplements had no overall effect on rates of cataract surgery or vision loss.
• Controlled intervention trials have shown foods high in omega-6 fatty acids may improve dry eye symptoms in women and some dietary supplements are also effective in managing dry eye.
• Omega-3 supplementation may also have a role in treating meibomian gland dysfunction (MGD).
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Diet Overview (continued)
• Evidence supports general guidelines for a diet rich in fruit and vegetables, especially fruit high in vitamin C and vegetables high in lutein and zeaxanthin.
• Vitamin/mineral supplements are not a substitute for a healthy, balanced diet and are of no proven benefit in the prevention of age-related disease.
• Those diagnosed with AMD and considering supplements are advised to consult their doctor.
• A healthy, balanced diet will also help to protect against other conditions associated with poor eye health, such as obesity, diabetes and hypertension.
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Diet
Patient Resources
NHS Choices. Health Eating All About Vision. Nutrition and Vitamins for Your Eyes British Nutrition Foundation. Healthy Eating Food Standards Agency RNIB, Nutrition and the Eye American Optometric Association, Diet & Nutrition recommendations
Dietary Source of Various Nutrients Linked to Eye Health
Nutrient Dietary sources Vitamin A Cheese, eggs, oily fish (such as salmon, fresh tuna and
mackerel), milk, margarine, yoghurt. Carrots, dark green leafy vegetables and orange-coloured fruits (eg mangoes and apricots) contain carotenoids, which are converted to vitamin A in the body
Vitamin C Found in a wide variety of fruit and vegetables. Good sources include peppers, broccoli, Brussels sprouts, sweet potatoes, oranges and kiwi fruit
Vitamin E Plant oils such as soya, corn and olive oil. Nuts and seeds, and wheatgerm (found in cereals and cereal products)
Zinc Meat, shellfish, milk and dairy foods such as cheese, bread, and cereal products such as wheatgerm
Lutein, zeaxanthin Spinach, kale, broccoli, red, orange and yellow peppers, mangoes, bilberries and corn
Omega-3 fats Best sources are oily fish such as salmon, fresh tuna, trout and mackerel); vegetarian sources include vegetable oils, such as linseed, flaxseed, and rapeseed, and walnuts
Note: Patients should be advised to follow a healthy, balanced diet, in line with government recommendations (eg 5-a-day fruit and vegetable message), to obtain these nutrients; vitamin supplements are not a substitute for a healthy diet.
Click here for full details
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Practitioner Resources
Stevens R and Bartlett H. Nutrition and age-related macular degeneration. Optometry Today 2015;55:18 42-46.
Click here for full text Click here for Aston University flowchart on nutrition advice
Clinical Tip Introduce a brief discussion about the importance of eating a healthy, balanced diet to eye health. Inform patients on what they can do to prevent, or at least delay, onset of disease, particularly those patients with a family history of AMD, glaucoma or diabetes. Advise any patient who would benefit from more in-depth advice on diet or dietary supplements to consult their doctor.
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Diet References
Diet and Age-related Macular Degeneration – Observational studies
Dietary Supplements and AMD Downie LE and Keller PR. Nutrition and age-related macular degeneration: research evidence in practice. Optom Vis Sci 2014; 91:8 821-31.
• This review critically evaluates currently available evidence relating to nutrition and AMD, with particular reference to key findings of two large NEI-sponsored clinical studies, AREDS and AREDS2
• Discusses topical controversies relating to nutrition and AMD • Provides foundation for clinicians to provide informed advice to AMD patients based on
available research evidence • Argues it is reasonable for guidelines to recommend changes to encourage a healthy diet
that includes consumption of potentially beneficial whole foods.
Click here for full text
Age-Related Eye Disease Study 2 Research Group (2013). Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 randomized clinical trial. JAMA 2013;309:19 2005-15.
• Landmark study to determine whether adding lutein + zeaxanthin, DHA + EPA, or both to AREDS formulation decreases risk of developing advanced AMD and evaluate the effect of eliminating beta carotene, lowering zinc doses, or both in AREDS formulation
• Addition of lutein + zeaxanthin, DHA + EPA, or both to AREDS formulation in primary analyses did not further reduce risk of progression to advanced AMD
• Because of potential increased incidence of lung cancer in former smokers, lutein +zeaxanthin could be an appropriate carotenoid substitute in AREDS formulation.
Click here for full text Schleicher M, Weikel K, Garber C et al. Diminishing risk for age-related macular degeneration with nutrition: a current view. Nutrients 2013;5:7 2405-56.
• Reviews value of various nutrients, particularly omega-3 fatty acids, lower glycemic index diets and carotenoids, in reducing AMD onset/progression risk
• Diet regularly rich in fruits and vegetables, with sufficient fish, supports good retina health • Consider supplements in absence of sufficient regular dietary supplies of omega-3 fatty
acids, lower glycemic index diets and several micronutrients • Overall healthy lifestyles, including diet, appear to also be beneficial for AMD.
Click here for full text
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Sin HP, Liu DT and Lam DS. Lifestyle modification, nutritional and vitamins supplements for age-related macular degeneration. Acta Ophthalmol 2013;91:1 6-11.
• Systematic review of published studies on lifestyle modification, dietary, nutritional and vitamin supplements for preventing or halting AMD
• Smoking and obesity risk factors for AMD. High dietary intakes of omega-3 FAs, lutein and zeaxanthin associated with lower prevalence/incidence AMD
• Vitamin B and extracts from wolfberry, Gingko biloba and berry anthocyanins also researched but no concluding scientific evidence
• Patients with documented intermediate risk of AMD or advanced AMD in one eye are recommended to take AREDS-type vitamin supplements.
• Click here for abstract Schleicher M, Weikel K, Garber C et al. Diminishing risk for age-related macular degeneration with nutrition: a current view. Nutrients 2013;5:7 2405-56.
• Reviews value of various nutrients, particularly omega-3 fatty acids, lower glycemic index diets and carotenoids, in reducing AMD onset/progression risk
• Diet regularly rich in fruits and vegetables, with sufficient fish, supports good retinal health • Consider supplements in absence of sufficient regular dietary supplies of omega-3 fatty acids, lower
glycemic index diets and several micronutrients • Overall healthy lifestyles, including diet, appear to also be beneficial for AMD.
Click here for full text
Ma L, Dou HL, Wu YQ et al. Lutein and zeaxanthin intake and the risk of age-related macular degeneration: a systematic review and meta-analysis. Br J Nutr 2012;107:3 350-9.
• Evaluates relationship between dietary intake of lutein and zeaxanthin and AMD risk from six longitudinal cohort studies
• Dietary lutein and zeaxanthin is not significantly associated with a reduced risk of early AMD
• However, an increase in the intake of these carotenoids may be protective against late AMD.
• Click here for pdf Krishnadev N, Meleth AD, Chew EY et al. Nutritional supplements for age-related macular degeneration. Curr Opin Ophthalmol 2010;21:3 184-9.
• Reviews current literature on role of nutritional supplements in primary and secondary AMD prevention
• Insufficient evidence to recommend routine nutritional supplements in healthy adults for primary AMD prevention
• Patients with intermediate risk of AMD or advanced AMD in one eye should consider taking AREDS-type supplements containing vitamins C and E, beta carotene, zinc and copper (after discussing with health professional/doctor)
• Observational studies suggest benefit from increased dietary intake of carotenoids (lutein and zeaxanthin) and omega-3 fatty acids (derived from fish oils).
Click here for full text
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Sabour-Pickett S, Nolan JM, Loughman J et al. A review of the evidence germane to the putative protective role of the macular carotenoids for age-related macular degeneration. Mol Nutr Food Res 2012;56:2 270-86.
• Dietary carotenoids (lutein, zeaxanthin, and meso-zeaxanthin) accumulate at macula, where they are collectively known as macular pigment (MP)
• MP rises in response to supplementation with macular carotenoids, although evidence that such supplementation results in risk reduction of AMD and/or its progression is still lacking
• Supplementation with macular carotenoids is probably best means of fortifying anti-oxidant defences of macula, thus putatively reducing risk of AMD and/or its progression.
• • Click here for abstract
Diet and AMD Gopinath B, Flood VM, Louie JC et al. Consumption of dairy products and the 15-year incidence of age-related macular degeneration. Br J Nutr 2014;111:9 1673-9.
• Assesses relationship between change in dairy product consumption (regular fat and low/reduced fat) and 15-year incidence of AMD in Blue Mountains Eye Study
• Lower consumption of dairy products and dietary calcium was independently associated with a higher risk of developing incident late AMD in the long term
• • Click here for abstract
Wang JJ, Buitendijk GH, Rochtchina E et al. Genetic susceptibility, dietary antioxidants, and long-term incidence of age-related macular degeneration in two populations. Ophthalmology 2014;121:3 667-75.
• Examines effect modification between genetic susceptibility to AMD and dietary antioxidant or fish consumption on AMD risk in participants from the Blue Mountains Eye Study and Rotterdam Study
• Protection against AMD from greater lutein/zeaxanthin and fish consumption in persons with high genetic risk based on two major AMD genes raises the possibility of personalised preventive interventions
• Click here for abstract Hong T, Flood V, Rochtchina E et al. Adherence to dietary guidelines and the 10-year cumulative incidence of visual impairment: the Blue Mountains Eye Study. Am J Ophthalmol 2014;158:2 302-8.
• Assesses whether adherence to dietary guidelines at baseline is associated with incidence of visual impairment among older persons after 10 years
• Compliance with dietary guidelines (diet quality, dietary habits, energy balance) associated with decreased long-term risk of visual impairment in sample of Australians aged 65+ years
• • Click here for abstract
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Ersoy L, Ristau T, Lechanteur YT et al. Nutritional risk factors for age-related macular degeneration. Biomed Res Int 2014;2014:413150
• Evaluates role of nutritional factors, serum lipids, and lipoproteins in late AMD • Besides age and smoking, obesity and red meat intake identified as risk factors for
developing late AMD. Fruit intake showed a protective effect • Serum lipid and lipoprotein levels no significant association with late AMD
• • Click here for full text
Merle B, Delyfer MN, Korobelnik JF et al. Dietary omega-3 fatty acids and the risk for age-related maculopathy: the Alienor Study. Invest Ophthalmol Vis Sci 2011;52:8 6004-11.
• Population-based study in France on nutrition and age-related eye diseases • Reports associations of ARM with past dietary intakes in elderly subjects • Decreased risk for ARM in subjects with high dietary intake of long-chain omega-3 fatty
acids (found in oily fish) • Click here for full text
Mares JA, Voland RP, Sondel SA et al. Healthy lifestyles related to subsequent prevalence of age-related macular degeneration. Arch Ophthalmol 2011;129:4 470-80.
• Investigates relationships between lifestyle behaviours of diet, smoking, and physical activity and the subsequent prevalence of AMD
• Women whose diets scored in the highest quintile compared with the lowest quintile on a Healthy Eating Index had 46% lower odds for early AMD
• Having a combination of three healthy behaviours (healthy diet, physical activity, and not smoking) was associated with 71% lower odds for AMD
• Modifying lifestyles might reduce risk for early AMD as much as 3-fold.
Click here for full text Chiu C-J, Klein R, Milton RC et al. Does eating particular diets alter risk of age-related macular degeneration in users of the age-related eye disease study supplements? Br J Ophthalmol 2009;93:1241-1246.
• Part of AREDS • Progression to both dry and wet AMD was 25% less likely among those eating diet rich in
omega-3 fatty acids (DHA or EPA). • High omega-3 diet combined with low glycaemic index (GI) carbohydrate intake reduced
risk of progression to advanced AMD further, cutting it by 50% • Eating two to three servings of oily fish, such as salmon, tuna, mackerel and herring every
week, would achieve recommended daily intake of omega 3, cutting risk of both early and late stage AMD.
• Click here for abstract
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Chong EW, Simpson JA, Robman LD et al. Red meat and chicken consumption and its association with age-related macular degeneration. Am J Epidemiol 2009;169:7 867-76.
• Higher red meat intake positively associated with early AMD • Odds ratio for consumption of red meat > or =10 times/week versus <5 times/week was
1.47 • Similar trends seen with higher intakes of fresh and processed red meat. • Consumption of chicken > or =3.5 times/week versus <1.5 times/week was inversely
associated with late AMD • Different meats may differently affect AMD risk and may be a target for lifestyle
modification. • Click here for abstract
Chong EW, Robman LD, Simpson JA et al. Fat consumption and its association with age-related macular degeneration. Arch Ophthalmol 2009;127:5 674-80.
• Evaluates associations between past dietary fat intake and AMD prevalence • Higher trans-unsaturated fat intake associated with increased prevalence of late AMD • Higher omega-3 fatty acid intake inversely associated with early AMD • Olive oil intake associated with decreased prevalence of late AMD • No significant associations for intakes of fish, total fat, butter, or margarine • Diet low in trans-unsaturated fat and rich in omega-3 fatty acids and olive oil may reduce
risk of AMD. • Click here for full text
Tan JS, Wang JJ, Flood V et al. Dietary fatty acids and the 10-year incidence of age-related macular degeneration. Arch Ophthalmol 2009;127:5 656-665.
• Part of Blue Mountains Eye Study • Assesses relationship between baseline dietary fatty acids and 10-year incident AMD • One serving of fish per week associated with reduced risk of incident early AMD, primarily
among those with less than median linoleic acid consumption • Similar findings for intake of long-chain omega-3 polyunsaturated fatty acids • 1-2 servings of nuts/week associated with reduced risk of incident early AMD • Supports protection against early AMD from regularly eating fish, greater consumption of
omega-3 polyunsaturated fatty acids, and low intakes of foods rich in linoleic acid. Regular consumption of nuts may also reduce AMD risk.
• Click here for full text Chong EW, Kreis AJ, Wong TY et al. Dietary omega-3 fatty acid and fish intake in the primary prevention of age-related macular degeneration: a systematic review and meta-analysis. Arch Ophthalmol 2008;126:6 826-33.
• Reviews evidence on dietary omega-3 fatty acid and fish intake in AMD • High dietary intake of omega-3 fatty acids associated with 38% reduction in risk of late AMD • Fish intake ≥2X/week associated with reduced risk of early and late AMD • Insufficient evidence from current literature (few prospective studies and no randomised
clinical trials) to support routine consumption for AMD prevention. • However, general healthy eating guidelines in the UK recommend consumption of two
portions of fish per week, including one portion of oily fish. • Click here for full text
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Diet and Age-related Macular Degeneration – Intervention Studies Overview of AREDS2 study Click here for dedicated website Summary of results and recommendations from the AREDS research group
Click here for full text
Lawrenson JG and Evans JR. Omega 3 fatty acids for preventing or slowing the progression of age-related macular degeneration. Cochrane Database Syst Rev 2015 Apr 9;4:CD010015. [Epub ahead of print]
• Reviews evidence that increasing the levels of omega 3 long-chain polyunsaturated fatty acids (LCPUFA) in diet (either eating more foods rich in omega 3 or taking supplements) prevents AMD or slows its progression
• Found 2 RCTs with 2,343 participants with AMD • Omega 3 LCPUFA supplementation in people with AMD for up to five years does not
reduce risk of progression to advanced AMD or development of moderate to severe visual loss
• No published randomised trials identified on dietary omega 3 FAs for primary prevention of AMD
• Current evidence does not support increasing dietary intake of omega 3 LCPUFA for the explicit purpose of preventing/slowing AMD progression.
• Click here for full text AREDS2 Research Group. Lutein/zeaxanthin and Omega-3 fatty acids for age-related macular degeneration. The Age-Related Eye Disease Study 2 (AREDS2) controlled randomized clinical trial. JAMA 2013;309:19 2005-15.
• Investigates whether adding lutein + zeaxanthin, DHA + EPA, or both to AREDS formulation decreases risk of developing advanced AMD
• Also evaluates effect of eliminating beta carotene, lowering zinc dose or both • Addition of lutein + zeaxanthin, DHA + EPA, or both to AREDS formulation did not further
reduce risk of progression to advanced AMD. • However, because of potential increased incidence of lung cancer in former smokers, lutein
+ zeaxanthin could be an appropriate carotenoid substitute.
• Click here for full text
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Chew EY, Clemons TE, Agron E et al. Long-term effects of vitamins C and E, β-Carotene, and Zinc on age-related macular degeneration: AREDS Report No. 35. Ophthalmology 2013;120:8 1604-11.
• Describes long-term effects (10 years) of AREDS formulation of high-dose antioxidants and zinc supplement on progression of AMD
• 4,757 participants with varying severity of AMD randomly assigned to antioxidants C, E, and β-carotene and/or zinc versus placebo
• Five years after trial, beneficial effects of AREDS formulation persisted for development of neovascular AMD but not for central geographic atrophy
• Persons with intermediate or advanced AMD in one eye should consider taking the AREDS formulation.
Click here for full text Evans JR and Lawrenson JG. Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration.Cochrane Database Syst Rev 2012 Nov 14;11:CD000254. doi: 10.1002/14651858.CD000254.pub3.
• Assesses effects of antioxidant vitamin or mineral supplementation on progression of AMD in people with AMD
• 13 trials (6150 participants) reviewed (3640 from one trial, AREDS) • AREDS found beneficial effect of antioxidant (beta-carotene, vitamin C and vitamin E) and
zinc supplementation on progression to advanced AMD over average of 6.3 years • Systematic review of evidence on harms of vitamin supplements needed.
• Click here for full text
Evans JR and Lawrenson JG. Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration. Cochrane Database Syst Rev Jun 13;6:CD000253. doi: 10.1002/14651858.CD000253.pub3.
• Reviews four randomised controlled trials (62,520 participants) investigating vitamin E and beta-carotene supplements
• No decreased (or increased) risk of developing AMD with these supplements • No evidence for other antioxidant supplements, such as vitamin C, lutein and zeaxanthin, or
any of commonly marketed multivitamin combinations • Although generally regarded as safe, vitamin supplements may have harmful effects. Clear
evidence of benefit needed before they can be recommended.
• Click here for full text Dasari B, Prasanthi JRP, Marwarha G et al. Cholesterol-enriched diet causes age-related macular degeneration-like pathology in rabbit retina. BMC Ophthalmol 2011;11:22.
• Cholesterol-enriched diets in rabbits cause retinal degeneration that the authors suggest is relevant to AMD
• Results in this animal model suggest high cholesterol levels and subsequent increase in the cholesterol metabolites are potential culprits in AMD.
• Click here for full text
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Evans J. Antioxidant supplements to prevent or slow down the progression of AMD: a systematic review and meta-analysis. Eye 2008;22:6 751-60.
• Examines evidence from 3 randomised, placebo-controlled trials investigating whether antioxidant vitamin or mineral supplements prevent development of AMD or slow progression
• No evidence that antioxidant (vitamin E or beta-carotene) supplementation prevented AMD • Antioxidant (beta-carotene, vitamin C, and vitamin E) and zinc supplementation slowed
progression to advanced AMD and VA loss • People with AMD, or early signs, may experience some benefit from taking supplements as
used in AREDS trial • Potential harms of high-dose antioxidant supplementation must be considered. These may
include increased risk of lung cancer in smokers (beta-carotene), heart failure in people with vascular disease or diabetes (vitamin E) and hospitalisation for genitourinary conditions (zinc).
• Click here for pdf Connolly EE, Beatty S, Thurnham DI et al. Augmentation of macular pigment following supplementation with all three macular carotenoids: an exploratory study. Curr Eye Res 2010;35:4 335-51.
• Measures serum and macular responses to a supplement formulation containing meso-zeaxanthin (MZ), lutein (L), and zeaxanthin (Z)
• Ten subjects (five normal and five with early AMD consumed a formulation containing 7.3 mg of MZ, 3.7 mg of L, and 0.8 mg of Z everyday for 8 weeks
• Significant increases in serum concentrations of MZ and L and a significant increase in MP optical density after 2 weeks.
• Click here for abstract Trieschmann M, Beatty S, Nolan JM et al. Changes in macular pigment optical density and serum concentrations of its constituent carotenoids following supplemental lutein and zeaxanthin: the Luna Study. Exp Eye Res 2007;84:4 718-728.
• Intervention group, most of whom exhibited features of AMD, received a daily supplement of lutein and zeaxanthin for 6 months Increase in macular pigment optical density (MPOD) for the intervention group and no increase in control group
• Those with low baseline MPOD were more likely to exhibit a dramatic rise in MPOD, or no rise in MPOD, than those with medium to high baseline values.
• Click here for abstract
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AREDS Study 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. Arch Ophthalmol 2001;119:10 1417-36.
• Investigates effects of antioxidant and zinc supplementation on progression of AMD in subjects (median age 69 years) with intermediate ARM or late AMD at baseline
• Significant odds reduction for development of advanced AMD with antioxidants plus zinc supplementation.
• Persons older than 55 years in high-risk group, and without contraindications such as smoking, should consider taking a supplement of antioxidants plus zinc such as that used in this study.
• Click here for full text plus comments and corrections
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Diet and Cataract – Observational Studies
Appleby PN, Allen NE and Key TJ. Diet, vegetarianism, and cataract risk. Am J Clin Nutr 2011;93:5 1128-35.
• Investigates association between diet and cataract risk in over 27,000 UK participants aged 40 years and over
• Finds strong relation between cataract risk and diet group, with a progressive decrease in risk of cataract in high meat eaters to low meat eaters, fish eaters (participants who ate fish but not meat), vegetarians, and vegans.
• Click here for abstract Tan AG, Mitchell P, Flood VM et al. Antoxidant nutrient intake and the long-term incidence of age-related cataract: the Blue Mountains Eye Study. Am J Clin Nutr 2008;87:6 1899-905.
• Investigates relationship between antioxidant nutrient intakes measured at baseline and 10-
year incidence of age-related cataract • Dietary antioxidants, including beta-carotene, zinc, and vitamins A, C, and E, assessed. • Higher intakes of vitamin C or combined intake of antioxidants had long-term protective
associations against development of nuclear cataract in this older population. •
• Click here for full text
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Diet and Cataract – Intervention Studies
There have been very few controlled trials specifically investigating the effects of diet and supplementation on cataracts; other trials designed to investigate non-eye diseases have generally found no benefits of vitamin supplementation on cataract. Zhow LQ, Li LM and Zhu H. The effect of multivitamin/mineral supplements on age-related cataracts: a systematic review and meta-analysis. Nutrients 2014;6:3 931-49.
• Pooled results from 12 cohort studies indicate multivitamin/mineral supplements decrease risk of nuclear cataract (RR: 0.73), cortical cataract (RR: 0.81) and any cataract (RR: 0.66)
• No decreases in risk of posterior capsular cataract (RR: 0.96) or cataract surgery (RR: 1.00)
• Two RCTs showed supplements could decrease risk of nuclear cataract • Sufficient evidence to support role of dietary multivitamin/mineral supplements for
decreasing risk of age-related cataract. • Click here for full text
The Age-Related Eye Disease Study 2 (AREDS2) Research Group. Lutein/zeaxanthin for the treatment of age-related cataract AREDS2 Randomized Trial Report No. 4. JAMA Ophthalmol 2013;131:7 843-50.
• Investigates whether daily oral supplementation with lutein/zeaxanthin affects risk for cataract surgery
• 4,203 participants aged 50 to 85 years, at risk for progression to advanced AMD randomly assigned to daily placebo; lutein/zeaxanthin 10mg/2mg, omega-3 long-chain polyunsaturated fatty acids 1g, or a combination
• Daily supplementation with lutein/zeaxanthin had no statistically significant overall effect on rates of cataract surgery or vision loss.
• Click here for full text Mathew MC, Ervin AM, Tao J et al. Antioxidant vitamin supplementation for preventing and slowing the progression of age-related cataract. Cochrane Database Syst Rev 2012 Jun 13;6:CD004567. doi: 10.1002/14651858.CD004567.pub2.
• Reviews 9 trials (117,272 individuals) aged ≥35 years or older with 2-12 years’ follow-up • No evidence supplementation with antioxidant vitamins (beta carotene, vitamin C or vitamin
E) prevents or slows progression of age-related cataract • Costs and adverse effects should be weighed carefully with unproven benefits before
recommending their intake above recommended daily allowances.
• Click here for full text
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Diet and Diabetic Retinopathy – Observational studies
Mayer-Davis EJ, Bell RA, Reboussin BA et al. Antioxidant nutrient intake and diabetic retinopathy: the San Luis Valley Diabetes Study. Ophthalmology 1998;105:12 2264-70.
• Examines the relationship between dietary and supplement intakes of vitamins C, E, and beta-carotene and risk of diabetic retinopathy.
• 387 participants with type 2 diabetes in San Luis Valley Diabetes Study • No protective effect was observed with antioxidant nutrients • Depending on insulin use, appeared to be potential for deleterious effects of nutrient
antioxidants. Further research needed. •
• Click here for abstract
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Diet and Glaucoma – Observational Studies
Pasquale LR, Wiggs JL, Willett WC et al. The relationship between caffeine and coffee consumption and exfoliation glaucoma or glaucoma suspect: a prospective study in two cohorts. IOVS 2012;53:10 6427-6433.
• Part of Nurses Health Study (78,977 women) and Health Professionals Follow-up Study (41,202 men)
• Compared to abstainers, those who drank ≥3 cups of caffeinated coffee daily had 1.66X higher risk of exfoliation glaucoma or exfoliation glaucoma suspect
• No associations with other caffeinated products (caffeinated soda, caffeinated tea, decaffeinated coffee or chocolate).
• Click here for full text Pasquale LR and Kang JH. Lifestyle, nutrition and glaucoma. J Glaucoma 2009;18:6 423-8.
• Reviews modifiable lifestyle factors, such as exercise, diet, and smoking, that may influence
intraocular pressure • Epidemiologic studies on lifestyle factors are few, and current evidence suggests no
environmental factors clearly associated with POAG.
• Click here for abstract
•
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Diet and Dry Eye – Observational Studies
Diet / Dietary Supplements and Dry Eye Hom MM, Asbell P and Barry B. Omegas and dry eye: more knowledge, more questions. Optom Vis Sci 2015;92:9 948-956.
• Identifies 12 clinical trials of omega-3 and omega-6 supplementation and dry eye disease published in literature 2010-2015
• Increasing scientific evidence supports potential use but RCTs limited • No consensus on dose, composition, length of treatment • Increased quality evidence on the usefulness of supplements needed to confidently outline
specific treatment recommendations. Click here for abstract
Rand AL and Asbell PA. Nutritional supplements for dry eye syndrome. Curr Opin Ophthalmol 2011;22:4 279-82.
• Unclear how omega-6 EFAs which are thought to be otherwise pro-inflammatory seem to
have a benefit in dry eye disease • Limited studies to date suggest a well designed masked multicenter randomised controlled
trial of EFA would be welcome and may supply needed evidence for use of EFA, specifically omega 3, for use as supplement to current therapies for dry eye disease.
• • Click here for full text
Roncone M, Bartlett H and Eperjesi F. Essential fatty acids for dry eye: A review. Cont Lens Anterior Eye 2010;33:2 49-54.
• Reviews literature relating to treatment of dry eye with omega-3 EFAs • Omega-3 and -6 EFAs need to be consumed together to be effective (ideally ratio 1:4).
Typical diets in developed countries lack omega-3 EFA • Supplementation clears meibomitis, allowing a thinner, more elastic lipid layer to protect
tear film and cornea. • Click here for abstract
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Diet and Dry Eye – Intervention studies
Liu A and Ji J. Omega-3 essential fatty acids therapy for dry eye syndrome: a meta-analysis of randomized controlled studies. Med Sci Monit 2014;6;20:1583-9.
• Compares omega-3 FA and placebo FA in management of dry eye syndrome • Reviews RCTs with 790 participants in 7 independent studies • Omega-3 fatty FA associated with better TBUT (by 1.58s) and Schirmer test • No significant differences in OSDI test results • Findings suggest omega-3 FA offers effective therapy for dry eye syndrome.
• • Click here for full text
Wojtowicz JC, Butovich I, Uchiyama J et al. Pilot, prospective, randomized, double-masked, placebo-controlled clinical trial of an omega-3 supplement for dry eye. Cornea 2011;30:3 308-314.
• Investigates effect of dietary supplementation with omega-3 FA on lipid composition of meibum, aqueous tear evaporation, and tear volume in dry eye
• Patients received daily dose of fish oil and flaxseed oil for 90 days • No significant effect in meibum lipid composition or aqueous tear evaporation rate but
average tear production and tear volume increased. • Click here for abstract
Drouault-Holowacz S, Bieuvelet S, Burckel A et al. Antioxidants intake and dry eye syndrome: a crossover, placebo-controlled, randomized trial. Eur J Ophthalmol 2009;19:3 337-42.
• Assesses whether 12-weeks of antioxidant dietary supplement (Oxybiane) improves signs and symptoms of DES
• Breakup time and Schirmer scores significantly increased on placebo, and symptoms of burning, itching, foreign body sensation and redness improved
• Oral antioxidants improve tear stability and quantity. Click here for abstract
Macsai MS. The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction (an AOS thesis). Trans Am Ophthalmol Soc 2008;106: 336–356.
• Evaluates effect on omega-3 dietary supplementation (two 1000-mg capsules 3X daily in
patients with blepharitis and MGD • At 12 months, omega-3 group had improved TBUT, OSDI score, and meibum score.
Click here for full text
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Kokke KH, Morris JA and Lawrenson JG. Oral omega-6 essential fatty acid treatment in contact lens associated dry eye. Cont Lens Anterior Eye 2008;31:3 141-6
• Evaluates effects of evening primrose oil (EPO) on symptoms, signs and tear film
characteristics in contact lens associated dry eye • Treated for 6 months with either EPO or placebo (olive oil) • EPO group showed significant improvement in symptom of 'dryness' at 3 and 6 months,
and in overall lens comfort and tear meniscus height at 6 months.
• Click here for abstract
Pinna A, Piccinini P and Carta F. Effect of oral linoleic and [gamma]-linolenic acid on meibomian gland dysfunction. Cornea 2007;26: 3 260-264.
• Assesses effect of oral linoleic and γ-linolenic acid, 2 omega-6 essential fatty acids, on MGD
• Initially and after 60 and 180 days of therapy, patients assessed by self-evaluation questionnaire on ocular surface disorders and biomicroscopy
• Therapy with linoleic and γ-linolenic acid tablets along with eyelid hygiene improves symptoms and reduces eyelid margin inflammation in MGD more than either omega-6 fatty acids or eyelid hygiene alone.
Click here for abstract
Diet and Dietary Supplements – Attitudes of Eye Care Professionals Lawrenson JG and Evans JR. Advice about diet and smoking for people with or at risk of age-related macular degeneration: a cross-sectional survey of eye care professionals in the UK. BMC Public Health 2013;13:564.
• Survey of current practice of UK eye care professionals • 68% frequently provide dietary advice to patients with AMD; 54% to those at risk of AMD • Typical advice was to eat plenty of leafy green vegetables and more oily fish • 93% advised supplements if advanced AMD in one eye • AREDS formula supplement one of least likely to be recommended • Ophthalmologists less likely to recommend supplements for primary prevention but, when
recommended, more likely to advise AREDS formula.
Click here for full text
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Alcohol Overview
• The EU region has the highest alcohol consumption in the world. Annual adult consumption per capita varies between countries, and is lowest in Italy and highest in Lithuania (OECD, 2014). Check the data for your country HERE
• Alcohol consumption has decreased in some areas of Europe over the past decades but overall levels of alcohol-attributable deaths are still high, and consumption in some countries is increasing (OECD, 2014).
• Although some studies have found an association between alcohol intake and common eye diseases, the literature in this area is not as compelling as it is for smoking.
• Moderate consumption of alcohol does not appear to have a negative impact on eye health and some studies suggest possible protective effects from moderate drinking.
• Avoidance of heavy drinking is recommended for eye and general health reasons, especially when combined with smoking or poor diet.
• Excessive alcohol intake should also be avoided in pregnancy since it can lead to foetal alcohol syndrome which includes ocular anomalies.
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Alcohol
Patient Resources
Royal College of Ophthalmologists, Alcohol and the Eye NHS Choices. Drinking and Alcohol Drinkaware, Facts about Alcohol Status Report on Alcohol and Health in 35 European Countries, WHO 2013 UK Government guidelines for alcohol consumption Men should not regularly drink more than 3-4 units a day Women should not regularly drink more than 2-3 units a day ‘Regularly’ means drinking every day or most days of the week. You should also take a break for 48 hours after a heavy drinking session to let your body recover.
• One unit equals 10ml or 8g of pure alcohol, which is around the amount of alcohol the average adult can process in an hour.
• The number of units in a drink is based on the size of the drink as well as its alcohol strength. For example, a pint of strong lager contains 3 units of alcohol, whereas the same volume of standard lager has just over 2 units.
• You can work out how many units there are in any drink by multiplying the total volume of a drink (in ml) by its alcohol by volume (ABV).
• A 750ml bottle of red, white or rose wine (ABV 13.5%) contains 10 units. • Heavy or binge drinking should be avoided; there is no strict medical definition for heavy
drinking, although The Office of National Statistics defines a heavy drinker as a man drinking eight or more units in one sitting at least once a week and a woman drinking six units.
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Alcohol References
Alcohol and Eye Disease – General
Fan AZ, Li Y, Zhang X et al. Alcohol consumption, drinking pattern, and self-reported visual impairment. Ophthalmic Epidemiol 2012;19:1 8-15.
• Health survey among 42,713 adults aged 50 years and older • Drinking patterns included drinking quantity (drinks per drinking day), frequency (drinking
days in past month), and binge drinking • Drinking more than one drink per drinking day (OR 1.21) and binge drinking (OR 1.32)
associated with self-reported visual impairment (difficulty recognising a friend across the street or reading print) among current drinkers, although there were no objective measurements of visual acuity or visual fields.
Click here for full text Xu L, You QS and Jonas JB. Prevalence of alcohol consumption and risk of ocular diseases in a general population: The Beijing Eye Study. Ophthalmol 2009;116:10 1872-1879.
• Examines associations between alcohol consumption and ocular diseases in 4,141 adults in China of whom 549 were moderate beer or wine drinkers
• Alcohol consumption not a significant risk factor for AMD, glaucoma, diabetic retinopathy, retinal vein occlusion, pterygium, trachoma, optic nerve atrophy, dry eye, cortical cataract, subcapsular posterior cataract or nuclear cataract.
• Click here for abstract
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Alcohol and AMD
Adams MKM, Chong EW, Williamson E et al. 20/20: Alcohol and age-related macular degeneration. The Melbourne Collaborative Cohort Study. Am J Epidemiol 2012;176:4 289-298.
• Examines associations between AMD prevalence and alcohol intake in 20,963 participants aged 40-69 years at baseline
• Drinking more than 20g of alcohol per day associated modest increase in odds of early AMD (OR 1.21) compared with reported no alcohol intake
• Positive association for wine, beer, spirits. Estimates similar for both sexes. • OR 1.44 for those drinking more than 20g of alcohol per day for late AMD.
• Click here for abstract
Chong EW, Kreis AJ, Wong TY et al. Alcohol consumption and the risk of age-related macular degeneration: a systematic review and meta-analysis. Am J Ophthalmol 2008;145:4 707-715.
• Review of evidence on alcohol consumption and risk of AMD • Of 441 studies identified, five cohort studies reviewed • Heavy alcohol consumption (more than three standard drinks per day) associated with
increased risk of early AMD. • Association between heavy alcohol consumption and risk of late AMD inconclusive • Although this association seems to be independent of smoking, residual confounding
effects from smoking cannot be excluded completely.
• Click here for abstract Boekhoorn SS, Vingerling JR, Hofman A et al. Alcohol consumption and risk of aging macula disorder in a general population: the Rotterdam Study. Arch Ophthalmol 2008;126:6 834-9.
• Looked at alcohol consumption among 4,229 subjects at risk of AMD • Did not find association between overall or specific alcohol consumption and development
of early AMD or dry or wet late AMD.
• Click here for abstract
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Alcohol, Smoking and AMD
Venza I, Visalli M, Oteri R et al. Combined effects of cigarette smoking and alcohol consumption on antioxidant/oxidant balance in age-related macular degeneration. Aging Clin Exp Res 2012;24:5 530-6.
• Investigates single and joint effects of chronic alcohol consumption and cigarette smoking
on oxidative stress in AMD • Compared with healthy controls, early- and late- AMD patients showed significant
decreases in antioxidant activity • Combination of alcohol consumption and cigarette smoking an aggravating factor
contributing to oxidative imbalance and DNA damage in AMD.
• Click here for abstract
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Alcohol and Cataract
Gong Y, Feng K, Yan N et al. Different amounts of alcohol consumption and cataract: a meta-analysis. Optom Vis Sci 2014;92:4 471-9.
• Meta-analysis of 10 studies to evaluate association between different amounts of alcohol consumption and risk of age-related cataract
• Heavy alcohol consumption (>2 standard drinks per day) significantly increased risk of cataract, whereas moderate consumption (<2 standard drinks a day but more than never any) may be protective
• Patient's drinking history should be collected on routine basis in eye clinics.
• Click here for abstract
Cumming RG and Mitchell P. Alcohol, smoking and cataracts: the Blue Mountains Study. Arch Ophthalmol 1997;115:10 1296-303.
• Investigates associations between alcohol consumption, tobacco smoking, and cataract • Only adverse effect of alcohol was among smokers: people who smoked and drank heavily
had increased prevalence of nuclear cataract.
Click here for abstract
•
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Alcohol and Glaucoma
Wide LA, Rosenberg L, Radin RG et al. A prospective study of diabetes, lifestyle factors, and glaucoma among African-American women. Ann Epidemiol 2011; 21:6 430-9.
• Evaluates association of lifestyle factors including alcohol consumption and cigarette smoking with risk of POAG in African-American women.
• Alcohol consumption is an independent risk factor for POAG in this group • Obesity and smoking may also be associated early-onset POAG
Click here for abstract
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Alcohol and Dry Eye
Moss SE, Klein R and Klein BE. Long-term incidence of dry eye in an older population. Optom Vis Sci 2008;85:8 668-74.
• Part of Beaver Dam Eye Study • Estimates 10-year incidence and risk factors in older population aged 43-86 • Incidence of dry eye significantly lower in subjects consuming alcohol (although this finding
was not commented on in Discussion or Conclusions).
• Click here for abstract
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Recreational Drugs Overview
• Almost a quarter of adults in the EU, or over 73 million people, have used illicit drugs at
some points in their lives (OECD, 2014).
• Cannabis is the illicit drug most used among young adults in Europe, especially among young men (OECD, 2014)
• Use of illicit drugs in some EU countries is stable while in others it is on a downward trend but use remains prevalent among young people.
• Misuse of drugs can result in a range of ocular effects. Marijuana decreases IOP but its medical use in glaucoma has not yet been investigated to the extent that it can be recommended as a therapeutic drug.
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Recreational Drugs
Patient Resources
NHS Choices, Drugs UK Department of Health, Drug Misuse and Dependence American Academy of Ophthalmology, Marijuana in the Treatment of Glaucoma Drug Abuse and the Eye, Replay Learning, 2012. World Drug Report, United Nations 2014 The Global Drug Survey 2014
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Recreational Drugs References
Recreational Drugs and Eye Health – General
Firth AY. Class A drug abuse: an ophthalmologist's problem? Eye 2005;19 609-610.
• Ocular sequelae from illicit drug use are varied, affecting visual acuity, visual perception, ocular posture or motility, globe itself or adnexa
• Cocaine and crack cocaine probably have the highest number of ocular problems reported from their use
• Sight-threatening conditions can occur in heroin users • Among hallucinogenics fewer problems have been reported • Clinicians need to be aware of ocular problems that may be drug use related.
Click here for full text
Firth AY. Ocular sequelae from the illicit use of class A drugs. Br Ir Orthopt J 2004;1: 10-18.
• Highlights changes in visual system of the class A drug abuser • Literature review of ocular/visual sequelae of more common class A drugs • Include stimulants (cocaine and crack cocaine), narcotics (heroin, morphine, methadone)
and hallucinogenics (ecstasy, lysergic acid diethylamide, magic mushrooms, mescaline, phencyclidine)
• Ocular sequelae affecting visual acuity, the eye and adnexa, ocular posture and ocular motility can result from recreational use of these drug(s)
• Awareness of the consequences of illicit drug use should lead to more pertinent questioning during history-taking.
• Click here for abstract Sachs R, Zagelbaum BM and Hersh PS. Corneal complications associated with the use of crack cocaine. Ophthalmology 1993;100:2 187-91.
• Case series of patients with corneal complications with crack cocaine use • Crack cocaine users appear to represent a unique subset of young patients predisposed to
infectious keratitis and corneal epithelial defects • Ophthalmologists and public should be aware of these severe problems.
• No abstract available
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McLane NJ, Carroll DM. Ocular manifestations of drug abuse. Surv Ophthalmol 1986;30:5 298-313.
• Abuse of drugs, including some used clinically and others with no legal or clinical use, can cause ocular injury and disease
• Ocular manifestations of drug abuse may be due to substances themselves, to invasive methods of administration, or to injury suffered during states of altered consciousness
• Grouping drugs into five categories (opiates, marijuana, stimulants, depressants and hallucinogens), authors describe pharmacologic, congenital, toxic, infectious, embolic, and psychological ocular manifestations of abuse.
• Click here for abstract
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Recreational Drugs and Glaucoma
Whiting PF, Wolff RF, Deshpande S et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA 2015;313:24 2456-73.
• Systematic review of randomised clinical trials of cannabinoids for various indications, including glaucoma. 79 trials (6,462 participants) included
• Most trials showed improvement in symptoms associated with cannabinoids but these associations did not reach statistical significance in all trials
• Increased risk of short-term adverse events with cannabinoids, including dizziness, dry mouth, nausea, fatigue, somnolence, euphoria, vomiting, disorientation, drowsiness, confusion, loss of balance, and hallucination.
• Click here for abstract Ben Amar M. Cannabinoids in medicine: A review of their therapeutic potential. J Ethnopharmacol 2006;105(1-2) 1-25.
• Meta-analysis of 72 studies of therapeutic potential of cannabinoids • Cannabinoids (cannabis, marijuana, hashish) have therapeutic potential for range of
conditions, including glaucoma.
• Click here for abstract
Recreational Drugs and Ocular Surface
Mantelli F, Lambiase A, Sachetti M et al. Cocaine snorting may induce ocular surface damage through corneal sensitivity impairment. Graefes Arch Clin Exp Ophthalmol 2015;253:5 765-72.
• Investigates whether corneal sensitivity, ocular surface, and tear function are damaged by habitual cocaine snorting
• Tested 48 cocaine addicts, 22 heroin addicts and 30 drug-free controls • Decreased corneal sensitivity in 26 cocaine addicts, neurotrophic keratitis in 6 • No significant changes in ocular surface in heroin addicts.
• • Click here for abstract
•
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Exercise Overview
• Only one in five children in EU member states report that they undertake moderate-to-
vigorous exercise regularly (OECD, 2012).
• The benefits of regular exercise for general health and wellbeing are well recognised.
• The effects of physical activity and active lifestyle on eye health, on the other hand, are not well documented although these are important modifiable behaviours in maintaining general health.
• The evidence that exists in the literature favours regular exercise, particularly when combined with a healthy diet and avoiding smoking
• Exercise may reduce the risk of sight loss from arterio-sclerosis, hypertension and diabetes.
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Exercise
Patient Resources
Royal College of Ophthalmologists, Exercise and Eyesight NHS Choices, Health and Fitness British Heart Foundation, Staying Active Department of Health, Physical Activities Guidelines for Adults (aged 19-64) Clinical Tip Where appropriate, mention the benefits of regular exercise to general health, particularly when combined with a balanced diet and avoiding smoking. Provide advice on eye injury prevention for high-risk sports and activities.
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Exercise References
Exercise and Eye Health – General
Gale J, Wells AP and Wilson G. Effects of exercise on ocular physiology and disease. Surv Ophthalmol 2009;54:3 349-55.
• Review of effects of acute exertion and regular physical activity on ocular physiology and disease
• Intraocular pressure transiently reduced by dynamic exercise • For most patients exercise is beneficial to eyes by reducing risk of central retinal vein
occlusion and neovascular AMD, and by improving control of systemic hypertension and diabetes
• Ophthalmologists should be advocates of regular exercise with appropriate eye protection.
• Click here for abstract
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Exercise and AMD
Williams PT. Prospective study of incident age-related macular degeneration in relation to vigorous physical activity during a 7-year follow-up. Invest Ophthalmol Vis Sci 2009;50:1 101-6.
• Tests whether risk of AMD decreases with vigorous physical activity. • Survival analyses of incident AMD versus average running distance, cardiorespiratory
fitness, BMI, cigarette use and diet • Higher doses of vigorous exercise (running) associated with lower incident AMD risk
independent of weight, cardiorespiratory fitness, and cigarette use.
• Click here for full text Knudtson MD, Klein R and Klein BE. Physical activity and the 15-year cumulative incidence of age-related macular degeneration: the Beaver Dam Eye Study. Br J Ophthalmol 2006;90:12 1461-3.
• After controlling for other factors eg body mass index (BMI), people with active lifestyle (regular activity ≥3 times/week) at baseline less likely to develop exudative AMD compared with people without an active lifestyle.
• Physical activity not related to early AMD or pure geographic atrophy • Suggests possible modifiable behaviour that might be protective against developing AMD.
• Click here for abstract
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Exercise and Cataract
Selin JZ, Orsini N, Lindblad DE et al. Long-term physical activity and risk of age-related cataract. Ophthalmology 2015;122:2 274-280.
• Examines association of total and specific types of physical activity with age-related cataract
• 52,660 male and female participants aged 45 to 83 years in Sweden (participants with history of cardiovascular disease or diabetes excluded)
• Highest quartile of total physical activity associated with 13% decreased risk of cataract compared with lowest
• Walking or bicycling (>60 minutes/day vs hardly ever) and work or occupational activity (heavy manual labor vs mostly sitting) associated with decreased risk of cataract.
• Click here for abstract
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Exercise and Glaucoma
Roddy G, Curnier D and Ellemberg D. Reductions in intraocular pressure after acute aerobic exercise: a meta-analysis. Clin J Sport Med 2014;24:5 364-72.
• Analysis of 10 studies on effect of acute aerobic exercise on IOP • Post-exercise change in IOP produced a significant effect of exercise, almost 2-fold greater
for sedentary populations than for normally active populations • Intensity and duration do not contribute to the overall effect nor explain difference between
sedentary and normally active populations.
• Click here for abstract Yip JLY, Broadway DC, Luben R et al. Physical activity and ocular perfusion pressure: The EPIC-Norfolk Eye Study. Invest Ophthalmol Vis Sci 2011;52:11 8186-8192.
• Examines relationship between physical activity and ocular perfusion pressure (OPP), a consistent risk factor for glaucoma, in adults aged 48-90
• Lower levels of physical activity were associated with lower OPP • Further research is needed to investigate the potential benefit of increased physical activity
as a safe and simple method of modifying glaucoma risk. •
• Click here for abstract Risner D, Ehrlich R, Kheradiya NS et al. Effects of exercise on intraocular pressure and ocular blood flow: a review. J Glaucoma 2009;18:6 429-36.
• Reviews studies on glaucoma, IOP, ocular blood flow (OBF), and exercise • Physical fitness is associated with lower baseline IOP but diminished acute IOP-lowering
response to exercise • IOP-lowering effects are greater in glaucoma patients than in healthy subjects • Effects of exercise on prevention of glaucoma and progression unknown.
• Click here for abstract
•
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Obesity Overview
• More than half (53%) of the adult population in the EU are overweight or obese. The prevalence of overweight and obesity among adults exceeds 50% in 17 EU member states (OECD, 2014).
• Defined as body mass index (BMI) of 30 or over, obesity is increasingly discussed as a risk factor for sight loss.
• Obesity has been linked to increased risk of developing common eye diseases;
independent of its association with diabetes, studies have shown that BMI or other measures of adiposity are predictive of cataract.
• Not all associations between obesity and eye disease are consistent.
• Obesity is a significant and growing public health issue and increases the risk of many health conditions with ocular effects, such as hypertension and diabetes.
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Obesity
Patient Resources
Feeling great, looking good. A guide to how a healthy lifestyle can help prevent sight loss. RNIB, 2006. NHS Choices, Obesity NHS Choices, Lose Weight National Obesity Forum RNIB, Obesity and sight loss Diabetes UK, Prevention of Type 2 diabetes: reducing risk factors Obesity, World Health Organisation Clinical Tip Where appropriate, mention that obesity increases the risk of health conditions with ocular effects, such as hypertension and diabetes.
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Obesity References
Obesity – General
Cheung N and Wong TY. Obesity and eye diseases. Surv Ophthalmol 2007;52:2 180-95.
• Little known about ocular manifestations of obesity but has been linked with cataract, glaucoma, AMD and diabetic retinopathy
• Studies support association between obesity and risk of age-related cataract • Strong evidence obesity associated with elevated IOP • No consistent association between obesity and AMD or diabetic retinopathy • Present literature inadequate to establish any convincing associations • Whether weight loss reduces the risk of eye diseases remains unresolved • Because of potential public health impact of obesity, there is greater need to understand its
ocular effects. • Click here for abstract
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Obesity and AMD
Adams MK, Simpson JA, Aung KZ et al. Abdominal obesity and age-related macular degeneration. Am J Epidemiol 2011; 173:11 1246-55.
• Examines associations between adiposity (waist/hip ratio) and AMD prevalence in adults aged 40-69 years
• Abdominal obesity is an AMD risk factor for men despite a survivorship effect • Inverse association for women may reflect weaker true positive associations.
• • Click here for abstract
AREDS Research Group. Risk factors associated with age-related macular degeneration. A case-control study in the age-related eye disease study: Age-Related Eye Disease Study Report Number 3. Ophthalmology 2000;107:12 2224-32.
• AREDS participants aged 60-80 ranging from no AMD to advanced AMD in one eye • Only those with neovascular AMD were more likely to have increased BMI.
• • Click here for full text
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Obesity and Cataract
Pan C-W and Lin Y. Overweight, obesity, and age-related cataract: a meta-analysis. Optom Vis Sci 2014;91:478-483.
• Examines association of overweight/obesity with age-related cataract • Total of 163,013 subjects aged 40-84 from six prospective cohort studies • Obesity was associated with increasing risk of nuclear, cortical and posterior subcapsular
cataract • Overweight was only associated with increasing risk of PSC cataract • Randomised controlled trials needed to examine effectiveness and cost-effectiveness of
weight reduction in obese populations to decrease risk of age-related cataract. •
• Click here for abstract Ye J, Lou LX, He JJ et al. Body mass index and risk of age-related cataract: a meta-analysis of prospective cohort studies. PLoS 2014;9:2 e89923.
• Meta-analysis of 17 studies to evaluate association between BMI and risk of age-related cataract (ARC)
• Pooled relative risks of ARC were 1.08 for overweight and 1.19 for obesity compared with normal weight
• Trend for subjects with high BMI to develop posterior subcapsular cataracts.
• Click here for abstract Lim LS, Tai E-S, Aung T et al. Relation of age-related cataract with obesity and obesity genes in an Asian population. Am J Epidemiology 2009;169:10 1267-1274.
• Population-based study among Singaporean Malay adults • Obesity significantly associated with cortical cataract but not nuclear cataract • Results did not support causal association between obesity and cortical or posterior
subcapsular cataract • Fat mass- and obesity-associated gene may be involved in the pathogenesis of nuclear
cataract.
• Click here for abstract
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Obesity and Glaucoma
Ramdas WD, Wolfs RCW, Hofman A et al. Lifestyle and risk of developing open-angle glaucoma. Arch Ophthalmol 2011;129:6 767-772.
• Looks at whether lifestyle-related risk factors, such as socioeconomic status, smoking, alcohol consumption, and obesity, are associated with POAG
• Obesity appears to be associated with a higher IOP and lower risk of developing POAG. These associations were only present in women
• Other lifestyle-related factors were not associated with POAG. •
• Click here for abstract •
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Light exposure overview
• Effects of sunlight exposure on the human body are a major focus for current research. There are some benefits to exposing the body to ultraviolet light (UV) and also strong evidence that shielding the skin from UV is beneficial.
• There is no known benefit to UV on the eye. UV light has been shown to be a contributory factor in various ocular conditions and the benefits of protection from the transmission of UV are well recognised.
• UV exposure may cause damage to the retinal pigment epithelium. An association with AMD has been suggested but further evidence is needed. Sunlight exposure is a risk factor in cataract and is also implicated in pterygium and pinguecula.
• Short-wavelength radiation and the blue light hazard impact photoreceptor and retinal pigment epithelium function. There is no clinical evidence to date on the ocular impact in humans of blue light on the eye.
• Appropriate advice on UV protection is needed to help promote long-term ocular health. UV radiation may be a hazard to eyes all day and all year, and advice for eye protection differs from that for skin protection.
• UV-blocking contact lenses* covering the limbus can play a useful role in protecting against the transmission of UV in conjunction with wraparound sunglasses and a wide-brimmed hat.
• Increased time spent outdoors may be a simple strategy to reduce the progression of childhood myopia, although further randomised controlled trials are needed.
*All ACUVUE® Brand Contact Lenses have Class 1 or Class 2 UV blocking to help provide protection against transmission of harmful UV radiation to the cornea and into the eye. UV absorbing contact lenses are NOT substitutes for protective UV absorbing eyewear such as UV absorbing goggles or sunglasses because they do not completely cover the eye and surrounding area.
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Light exposure
Patient Resources
Ultraviolet (UV) Radiation and Your Eyes, All About Vision website College of Optometrists, Sun and Sunshine The Healthy Sight Institute RNIB, Protect your eyes from the sun Clinical Tip Mention that UV has been shown to be a contributory factor in various ocular conditions. Explain the benefits of protecting the eyes from UV transmission and the protective measures available. Discuss with patients the association between time spent outdoors and childhood myopia, and encourage parents to have their young children spend more time outdoors to help prevent myopia onset
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Light Exposure References
Light Exposure and Eye Health – General
Yam JC and Kwok AK. Ultraviolet light and ocular diseases. Int Ophthalmol 2014;34:2 383-400.
• Reviews association between UV light and ocular diseases • Eyelid malignancies, photokeratitis, climatic droplet keratopathy, pterygium, and
cortical cataract strongly associated with UV exposure • Limited evidence for pinguecula, nuclear/posterior subcapsular cataract, ocular surface
squamous neoplasia, and ocular melanoma limited • Insufficient evidence to determine whether AMD is related to UV exposure • Appropriate clothing, wearing hats, and UV blocking spectacles, sunglasses or contact lenses
are effective measures for UV protection.
Click here for abstract Hammond BJ, Johnson BA and George ER. Oxidative photo degradation of ocular tissues Exp Eye Res 2014;129C:135-150.
• Different mechanisms have evolved in lens, cornea, and retina to ameliorate light-mediated oxidative damage but are ill-matched to handle modern conditions: poor diet and longer lifespans (and accompanying diseases)
• Steps must be taken to protect the eye from the damaging effects of light. • Preventative measures include minimising actinic light exposure, providing exogenous
filtering (eg through use of protective lenses), and enhancing antioxidant defences (eg through increased dietary intake of antioxidants)
• UV-filtering contact lenses might be a particularly good option since, unlike most spectacle lenses, they filter light from all angles.
• Click here for pdf Lucas RM. An epidemiological perspective of UV exposure ‒ public health concerns. Eye & Contact Lens 2011;37:4 168-175.
• Unlike for skin, exposure to UV radiation has only adverse effects on the eyes • UV-related eye diseases are common, disabling, and cause a considerable disease burden
worldwide • Acute high-dose UV exposure causes photokeratitis and photoconjunctivitis • Low-dose chronic exposure is risk factor for cataract, pterygium, and squamous cell
carcinoma of the cornea and conjunctiva • Some evidence for other conditions, including ocular melanoma and AMD • Proposed health benefits of vitamin D through appropriate skin exposure to UV or vitamin D
supplementation are as yet unclear. •
• Click here for abstract
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Cullen AP. Ozone depletion and solar ultraviolet radiation: ocular effects, a United Nations Environment Programme perspective. Eye & Contact Lens 2011;37:4 185-190.
• Longer life expectancy increases susceptibility to age-related eye diseases in which UV radiation plays a part
• Young people also need to be vigilant about sun exposure since some UV-related conditions are determined by early-life exposures
• Advocating eye protection for those living in areas with high ambient levels of solar UVB is important public health message
• Need for ocular UV protection will continue even when ozone layer fully recovers in approximately 2100.
• Click here for abstract
Sasaki H, Sakamoto Y, Schnider C et al. UV-B exposure to the eye depending on solar altitude. Eye & Contact Lens 2011;37:4 191-195.
• UV exposure in September when face directed toward the sun differed dramatically from measurements taken on top of head and those for eye taken later in year
• Although overall level is lower, higher solar altitude is associated with higher levels of UV when facing away from sun
• Using UV Index as indicator of need for eye protection can be misleading. Eye protection may be warranted throughout year.
• Click here for abstract Coroneo M. Ultraviolet radiation and the anterior eye. Eye & Contact Lens 2011;37:4 214-224.
• Peripheral light focusing (PLF) plays a role in the pathogenesis of pterygium and cataract • Understanding PLF has resulted in improved sunglass designs and developments in UV-
blocking contact lenses • Ocular UV fluorescence photography has demonstrated early (preclinical) ocular surface
evidence of solar damage • Diet may also play a role in ophthalmohelioses and in skin cancer.
• Click here for abstract
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Light Exposure and AMD
Sui GY, Liu GC, Liu GY et al. Is sunlight exposure a risk factor for age-related macular degeneration? A systematic review and meta-analysis. Br J Ophthalmol 2013;97:4 389-94.
• Reviews literature on association between AMD and sunlight exposure • Of 14 studies identified, 12 showed increasing risk of AMD with greater sunlight exposure,
of which six reported significant risks • Pooled odds ratio (OR) 1.379 and subgroup of non-population-based studies revealed
significant risk (OR 2.018, p=0.004). • OR significantly decreased with increasing gross domestic product per capita, most likely
due to better healthcare systems and protection from the sun.
• Click here for abstract Glickman RD. Ultraviolet phototoxicity to the retina. Eye & Contact Lens 2011; 37:4 196-205.
• Lifetime blue-light damage may contribute to the onset of degenerative diseases of the retina and retinal pigment epithelium (RPE)
• Some drugs may act as photosensitisers, promoting retinal UV damage • Phototoxicity may be reduced by dietary intake of antioxidants.
• • Click here for abstract
Chalam KV, Khetpal V, Rusovici R et al. A review: role of ultraviolet radiation in age-related macular degeneration. Eye & Contact Lens 2011;37:4 225-232.
• Relationship between UV and AMD is unclear although short wavelength radiation and blue light induce oxidative stress to RPE
• Epidemiologic evidence suggests trend towards association between excessive light exposure and AMD
• Antioxidant enzymes and macular pigments protect retina • Factors involved in UV exposure levels include geographical area, rural/urban dwelling,
ethnicity (melanin) and age. • Click here for abstract
Tomany SC, Cruickshanks KJ, Klein R et al. Sunlight and the 10-year incidence of age-related maculopathy: the Beaver Dam Eye Study. Arch Ophthalmol 2004;122:5 750-7.
• Examines association of sunlight exposure and indicators of sun sensitivity with 10-year incidence of ARM
• Those exposed to summer sun more >5 hours/day in teens, in 30s, and at baseline at higher risk of increased retinal pigment and early ARM than those exposed <2 hours/day
• More than 10 severe sunburns during youth more likely than those who experienced one or no burn to develop drusen
• Use of hats and sunglasses at least half the time associated with decreased risk of soft indistinct drusen and retinal pigment epithelial depigmentation.
• Click here for full text
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Blue Light Exposure and AMD
Algvere PV, Marshall J and Seregard S. Age-related maculopathy and the impact of blue light hazard. Acta Ophthalmol Scand 2006;84:1 4-15.
• Short-wavelength radiation and blue light hazard (excitation peak 440 nm) have major impact on photoreceptor and retinal pigment epithelium function
• In aphakic or pseudophakic eyes (with clear IOLs), high-energy (blue) and UV-A radiation strikes the retina
• Increased 5-year incidence of late AMD in non-phakic versus phakic eyes • Prophylactic measures are ‘yellow IOLs’, antioxidants and dietary.
Click here for full text
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Light Exposure and Cataract
McCarty CA and Taylor HR. A review of the epidemiologic evidence linking ultraviolet radiation and cataracts. Dev Ophthalmol 2002;35:21-31.
• Reviews epidemiologic evidence linking UV radiation and cataract • Majority of 22 studies reviewed support association between UV-B and the development of
cortical cataract and perhaps posterior subcapsular cataract. • Data justify implementation of public health campaigns to raise public awareness of risk of
cortical cataract due to ocular UV-B exposure.
• Click here for abstract AREDS Research Group. Risk factors associated with age-related nuclear and cortical cataract: a case-control study in the Age-Related Eye Disease Study, AREDS Report No. 5. Ophthalmology 2001;108:8 1400-8.
• Investigates possible risk factors for age-related nuclear and cortical cataracts in AREDS participants aged 60-80 years
• Moderate cortical opacities were associated, at a borderline level of significance, with higher levels of sunlight exposure
• Consistent findings now been reported across many studies for sunlight exposure. •
• Click here for full text •
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Light Exposure – Protection
Wolffsohn JS. The benefits of UV-blocking contact lenses. Optometry in Practice 2013;14:2 61-72.
• Peripheral light focusing reduced by wearing UV-blocking contact lenses • Combination of UV-blocking contact lenses, wraparound sunglasses and a wide-brimmed
hat may provide best protection from transmission of UV • Poor understanding of need to protect eyes against UV and options available Eye care
practitioners have an important public health role in raising awareness of risks of UV exposure and advising on eye protection.
• Click here for abstract
Giblin FJ, Lin L-R, Leverenz VR et al. A Class I (senofilcon A) soft contact lens prevents UVB-induced ocular effects, including cataract, in the rabbit in vivo. Invest Ophthalmol Vis Sci 2011; 52:6 3667-3675.
• Eyes irradiated with no contact lens protection showed corneal epithelial cell loss plus lens epithelial cell swelling, vacuole formation, and DNA single-strand breaks, as well as lens anterior subcapsular opacification
• Senofilcon A lenses protect nearly completely against UVB-induced effects, whereas lotrafilcon A lens showed no protection
• Use of these lenses is beneficial for protecting ocular tissues of rabbit against harmful effects of UVB light, including photokeratitis and cataract.
• • Click here for full text
Sliney DH. Intraocular and crystalline lens protection from ultraviolet damage. Eye & Contact Lens 2011;37:4 250-258.
• UV-absorbing contact lenses offer best UV eye protection provided they cover limbus • Sunglasses may disable the eyes' natural protective mechanisms of pupil constriction and
lid lowering • Ground reflectance (off snow and water) is a key factor in photokeratitis • UV-absorbing contact lenses offer best method for filtering needless exposure of UV
radiation of lens and limbus
• Click here for abstract
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Chandler H. UV absorption by contact lenses and the significance on the ocular anterior segment. Eye & Contact Lens 2011;37:4 259-266.
• UV-blocking contact lenses are especially pertinent for patients who have pterygia or pre-existing UV-induced lenticular damage, or who are exposed to high levels of UV in occupational/recreational activities
• Aphakic and pseudoaphakic patients may also benefit • Wearing UV-blocking contact lenses does not negate need for other strategies ‒ a
combination of sunglasses, a wide-brimmed hat and UV-blocking contact lenses offers the most complete protection.
• Click here for abstract
Walsh JE and Bergmanson JPG. Does the eye benefit from wearing UV-blocking contact lenses? Eye & Contact Lens 2011;37:4 267-272.
• UV-blocking contact lenses that cover limbus provide protection from all sources of ocular incident UV
• Using UV-blocking contact lenses greatly increases time wearer can be exposed to solar UV before toxic ocular dose is reached
• Scientifically rigorous, clinically applicable ocular protection factor metric is needed for eyewear, similar to that used for skin sun creams.
Click here for abstract
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Light Exposure and Myopia
Logan N. Myopia in practice: evidence for intervention. Optometry in Practice 2015;16:3 77-84.
• Reviews possible intervention strategies for myopia control • Strong evidence more time spent outdoors lowers risk of developing myopia • Mechanisms underlying protective effect of time outdoors as yet unclear • Around 2–3 hours a day outside of school hours seem to be sufficient to lower risk of
myopia significantly • Optometrists should encourage parents to have their young children spend more time
outdoors to prevent myopia onset. Click here for abstract
Flitcroft DI. The complex interactions of retinal, optical and environmental factors in myopia etiology. Prog Ret Eye Res 2012;31:6 622-60.
• Highlights potential benefits of interventions that can limit or prevent myopia progression • Under-appreciated level of complexity and interaction between environment, ocular optics
and eye shape needs to be considered when planning and interpreting results of clinical trials on myopia prevention.
Click here for abstract Sherwin JC, Reacher MH, Keogh RH et al. The association between time spent outdoors and myopia in children and adolescents: a systematic review and meta-analysis. Ophthalmology 2012;119:10 2141-51.
• Reviews 7 cross-sectional studies in meta-analysis and 16 studies in systematic review • Pooled odds ratio (OR) showed 2% reduced odds of myopia per additional hour of time
spent outdoors per week, equivalent to OR of 0.87 for additional hour of time spent outdoors each day
• Three studies found increasing time spent outdoors significantly reduced myopic progression.
• Click here for abstract
Deng L and Gwiazda J. Birth season, photoperiod, and infancy refraction. Optom Vis Sci 2011;88:3 383-387.
• Children born in photoperiod group with most daylight hours had slightly lower refractions than those in shortest photoperiod group
• Suggests light might play small role in refractive error of newborns.
• Click here for abstract
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Deng L, Gwiazda J and Thorn F. Children’s refractions and visual activities in the school year. Optom Vis Sci 2010;87:6 406-413.
• During school year, myopes spend significantly fewer hours than non-myopes on sports/outdoor activity and watched more TV than non-myopes
• During summer break, no differences found between refractive groups in any visual activity times
• Sports/outdoor activity during school year may protect against myopia • Sports/outdoor activity for myopes and non-myopes during summer break may contribute to
slowed eye growth in all children during these 3 months.
• Click here for full text Rose KA, Morgan IG, Ip J et al. Outdoor activity reduces the prevalence of myopia in children. Ophthalmology 2008;115:8 1279-1285,
• Higher levels of outdoor activity associated with more hyperopic refractions and lower myopia prevalence in 12-year-old students
• Students who combined high levels of near work with low levels of outdoor activity had least hyperopic mean refraction
• There were no associations between indoor sport and myopia • No consistent associations between refraction and measures of activity were seen in the 6-
year-old sample • Higher levels of total time spent outdoors, rather than sport per se, associated with less
myopia and a more hyperopic refraction, after adjusting for near work, parental myopia, and ethnicity.
• Click here for abstract
•
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