Assessing the Impact of Stress in Age-Related Macular Degeneration

Newswise, June 6, 2017– Age-related macular degeneration (AMD), the leading cause of vision loss among older adults in the United States, is often associated with psychological stress. 

A simple stress rating scale (the Perceived Stress Scale) is a valid and useful way to evaluate the connection between stress and progressive vision loss from AMD, according to a study in the March issue of Optometry and Vision Science, the official journal of the American Academy of Optometry. The journal is published by Wolters Kluwer.

"Because AMD is an inflammatory disease, we are studying the link between inflammation, stress, and AMD treatment outcomes," reported Bradley E. Dougherty, OD, PhD, of The Ohio State University College of Optometry. "In the end, we hope to better understand how general well-being influences disease outcomes."

Measuring Stress May Aid in Assessing the Life Impact and Progression of AMD--Patients with vision loss in AMD experience high rates of stress, anxiety, and other problems, including depression. Less is known about the relationship between the stress that AMD patients experience and the severity of their disease—for example, whether stress can cause AMD to worsen or not.

The Perceived Stress Scale (PSS) is a well-established stress rating scale that can predict objective biological markers of stress, as well as the risk of stress-related diseases. In previous studies, the PSS has been shown to be predictive of general markers of inflammation, including C-reactive proteins. In the new study, Dr. Dougherty and colleagues extend the use of this survey to determine how well it measures perceived stress in patients with vision loss due to AMD.

One hundred thirty-seven patients with AMD, average age 82 years, completed the ten-question PSS. Using a technique called Rasch analysis, Dr. Dougherty and colleagues evaluated the PSS's performance as a stress measure in AMD. About half of the patients filled out the stress questionnaire on a day when they received injections of anti-VEGF antibodies—a relatively new treatment that can slow the progression of the "wet" form of AMD.

Nine of the ten questions normally used with the PSS performed well with the patient group studied. These nine items were also able to separate between patients with higher versus lower levels of perceived stress. For some PSS items, responses differed according to patient age and visual acuity level.

However, the overall PSS score was not significantly related to the patients' visual acuity level. Average visual acuity in the better eye for this group of AMD patients was 20/50, with a range from near normal to very low vision.

"A psychometrically sound, easy-to-administer questionnaire such as the PSS is important for use with patients with AMD, given the evidence for increased rates of psychological symptoms in the population," Dr. Dougherty and coauthors write.

They note that stress-reduction approaches—for example, "mindfulness" interventions—have led to improved outcomes in patients with various health conditions.

Dr. Dougherty and colleagues also note that stress may be associated with increased inflammation and that AMD is an inflammatory disease—raising the possibility that stress may contribute to disease progression.

Future studies using repeated assessments with the PSS and measurement of inflammatory markers might provide evidence on how perceived stress levels affect the risk of AMD progression and worsening vision loss.

Click here to read “Measurement of Perceived Stress in Age-Related Macular Degeneration.”

Is More, Better? Finding The Balance Between Nutritional Supplements And Eye Health

Excess Lutein Supplements Linked to Formation of Crystal Deposits in the Eyes

Newswise, November 19, 2016— In the past decade, ophthalmologists have been prescribing nutritional supplements to be taken daily to prevent or slow vision loss from age-related macular degeneration (AMD). Now, using nutritional supplements for eye health has become more common. But does increasing the recommended dose increase your protection? 

A case report appearing online in JAMA Ophthalmology from the Moran Eye Center at the University of Utah reveals what can happen when a patient takes more of a supplement than their body needs.

In the article, Crystalline Maculopathy Associated with High-Dose Lutein Supplementation, principal investigator Paul Bernstein, M.D., Ph.D., describes a patient with no AMD or vision problems who was referred to the retinal clinic for crystal deposits in the macular region of the retina in both eyes.

With physician follow-up, it was learned that for the past eight years, the patient took a daily lutein supplement (20 mg) in addition to a diet rich in lutein, which included a broccoli, kale, spinach, and avocado smoothie every morning; she was therefore consuming much more than twice the recommended dose of lutein for an AMD patient (10 mg per day).

Lutein is part of the AMD prevention supplement regimen that was created based on results from the AREDS2 (Age-Related Eye Disease Study 2) clinical trial.

In that trial, researchers found that patients at high risk for visual loss from AMD who took lutein (10 mg) and zeaxanthin (2 mg) supplements reduced their risk of progressing to late stage AMD. Lutein and zeaxanthin are carotenoids—antioxidants made by plants—that are believed to neutralize light-induced damage in the eye.

Humans don’t make carotenoids, so they can only be added to the body by eating plants or taking supplements.

“When we looked at the patient’s carotenoid levels in serum, skin, and the retina, all measurements were at least two times greater than carotenoid levels in patients not taking nutritional supplements,” said Bernstein.

 “The patient quit taking the lutein supplement, but maintained her diet rich in lutein, and, after seven months, the crystals in the right eye disappeared.”

While AREDS2 supplements are recommended to patients at higher risk for AMD, there has also been increased use in the general population. Bernstein’s advice for his patients is that “everyone should eat an ‘eye-healthy’ diet rich in colorful fruits and vegetables, and individuals should take an AREDS2 supplement if their ophthalmologist detects signs of AMD.”

This case report must followed up by a larger clinical trial before the results can be considered conclusive but it serves as an indicator that there may be negative effects from consuming lutein considerably higher than the recommended AREDS2 dose.

UAB Optometrist Improves Treatment and Care for Patients with Dry Eye

Newswise, August 10, 2016-– The Food and Drug Administration recently approved lifitegrast, a new eye drop for treating signs and symptoms of dry eye in adult patients. 

Kelly Nichols, O.D., Ph.D., a dry eye expert and dean of the University of Alabama at Birmingham School of Optometry, conducted research studies for the parent drug company to explore the efficacy and safety of lifitegrast in treating this eye condition that affects more than 16 million adults in the United States.

Inflammation associated with dry eye may eventually lead to damage to the surface of the eye.

“Dry eye is a common complaint to eye care professionals, with millions of U.S. adults experiencing the symptoms of this often chronic disease,” Nichols said.

“It is critical for eye care professionals to have a dialogue with patients who report symptoms because dry eye can be a progressive ocular surface disease.”

The twice-daily eye drop solution of 5 percent lifitegrast ophthalmic solution is the only prescription eye drop indicated for the treatment of both signs and symptoms of dry eye, and it is the first new dry eye prescription drop approved in the last 13 years.

Nichols and a team of researchers studied 1,181 patients, of whom 1,067 received lifitegrast in four placebo-controlled 12-week trials. Signs and symptoms were assessed at baseline and at weeks two, six and 12.

In all four studies, eye dryness was significantly reduced, with two of the studies showing improvements at week two.

Results from inferior corneal staining tests — used by physicians to detect abrasions on the cornea — showed improvement in three of the four studies.

Nichols continues to push for funding and advancement for dry eye research and treatment.

Prior to FDA approval of the lifitegrast eye drop, Nichols presented a congressional briefing in Washington, D.C., addressing research into dry eye for the National Alliance for Eye and Vision Research. She focused on the cause and potential therapies for dry eye that are being funded through the National Eye Institute and in private industry.

Focusing her research on all aspects of the eye, Nichols discussed the mechanics of the three layers of the tear film and the importance of each from the cornea outward:
• Mucin layer: helps tears adhere to the eye
• Aqueous layer or water layer: nourishes and protects the cornea
• Lipid or oil layer: lubricates and prevents evaporation and provides smooth refractive surface needed for optimal vision.

“We are unsure which of the 200-plus different lipids and 500-plus unique proteins are most important for protecting and lubricating the eye, and the absence or insufficiency of which results in dry eye,” Nichols said.

There are more than 30-plus new dry eye basic, translational and clinical studies being funded by the NEI/National Institutes of Health to further explore these lipids and proteins, with more than 50 papers being published monthly.

“Funding from NIH is helping the optometry world make significant strides in understanding the cause and treatment of dry eye,” Nichols said. “We still have a long way to go, but prevention and early detection are major goals. There is hope for dry eye patients worldwide.”

Diagnosis of dry eye is identified by an eye care professional based on careful evaluation of signs and symptoms, including dryness, discomfort, vision changes and damage to the surface of the eye. Specialty testing for dry eye is performed at the Dry Eye Relief Clinic at UAB Eye Care, in the School of Optometry.

Potential New Approaches to Treating Eye Diseases

Newswise, April 5, 2016— Potential new approaches to treating eye diseases such as age-related macular degeneration (AMD) are described in a new study, “IL-33 amplifies an innate immune response in the degenerating retina,” in the February Journal of Experimental Medicine.

AMD is a leading cause of vision impairment in old age, and is caused by the degeneration of cells in the retinal layer of the eye. Retinal cell death can be induced by phagocytic immune cells that infiltrate the tissue in response to injury or infection, but the molecular signals that trigger phagocyte invasion are largely unknown.

A team of researchers led by Hongkang Xi and Menno van Lookeren Campagne, of the Department of Immunology at Genentech, Inc., in South San Francisco, Calif., discovered that a pro-inflammatory signaling protein, or cytokine, called IL-33, plays a key role in recruiting phagocytes to damaged retina and inducing retinal degeneration.

Working with rats and mice, Xi and colleagues found that specialized retinal cells called Müller glial cells release IL-33 in response to retinal injury.

The cytokine then binds to its receptor on the surface of the Müller cells and induces the release of additional inflammatory proteins that attract phagocytes to the damaged retina. Blocking the IL-33 receptor inhibited this process and prevented injury-induced retinal degeneration.

The researchers also found that IL-33 levels are increased in the retinas of AMD patients, suggesting that the same pathway may occur in humans. Inhibiting IL-33 may therefore help treat AMD and other retinal degenerative diseases.

“This study for the first time shows increased expression of IL-33 in AMD and further demonstrates a role for glia-derived IL-33 in the accumulation of myeloid cells in the outer retina, loss of photoreceptors, and functional impairment of the retina in preclinical models of retina stress,” the authors note.