Smoking, antioxidant supplementation and dietary intakes among older adults with age-related macular degeneration over 10 years

Adherence of patients with age-related macular degeneration to AREDS 2-recommended nutritional supplements

BACKGROUND

The Age-Related Eye Disease Study 2 (AREDS 2) proved the benefit of vitamin and mineral supplementation in preventing advanced age-related macular degeneration (AMD). AREDS 2 supplements are indicated for patients with either bilateral intermediate AMD (AREDS category 3) or unilateral neovascular AMD (AREDS category 4).

AIMS

The aims of this telephone survey were to identify the rate of adherence of patients to AREDS 2 supplements and the factors associated with non-compliance in these patient groups.

METHODS

A patient telephone survey was conducted in an Irish tertiary care hospital. Patients were identified by chart review, and their AREDS categorization was reconfirmed. A telephone consultation was conducted with each patient to assess their compliance with the micronutrient supplements.

RESULTS

We identified 120 patients who met the AREDS criteria for supplementation. Of these, 103 patients were graded as category 4, and 17 patients were graded as category 3. Almost a fifth (18%) were current smokers. Under two-thirds (60%) of the patients were taking AREDS 2 supplements. Of the remainder, 83% of patients did not recall being advised of their benefit. The cost was cited by 10% of patients as a reason for non-compliance.

CONCLUSION

The ophthalmologist not only has a duty of care to treat the neovascular complications of AMD, but they must also strive to improve patient compliance with AREDS supplements. The cessation of smoking needs to be actively promoted in order to stop preventable vision loss in patients with AMD.

Emerging therapeutic strategies for unmet need in neovascular age-related macular degeneration

Neovascular age-related macular degeneration (nAMD) is a major cause of visual impairment and blindness. Anti-vascular endothelial growth factor (VEGF) agents, such as ranibizumab, bevacizumab, aflibercept, brolucizumab and faricimab have revolutionized the clinical management of nAMD. However, there remains an unmet clinical need for new and improved therapies for nAMD, since many patients do not respond optimally, may lose response over time or exhibit sub-optimal durability, impacting on real world effectiveness. Evidence is emerging that targeting VEGF-A alone, as most agents have done until recently, may be insufficient and agents that target multiple pathways (e.g., aflibercept, faricimab and others in development) may be more efficacious. This article reviews issues and limitations that have arisen from the use of existing anti-VEGF agents, and argues that the future may lie in multi-targeted therapies including alternative agents and modalities that target both the VEGF ligand/receptor system as well as other pathways.

Exploring challenges to nutrition intervention adherence using COM-B model among patients with wet age-related macular degeneration: a qualitative study

OBJECTIVES

To explore challenges to nutrition intervention adherence using the Capability, Opportunity and Motivation-Behaviour (COM-B) model among wet age-related macular degeneration (AMD) patients. These factors should be considered in the development of potential support and intervention programmes to address these problems.

DESIGN

A qualitative study was conducted with one-to-one and face-to-face interviews with wet AMD patients using a semi-structured question guide. Data were analysed based on COM-B model: capability (physical and psychological), opportunity (physical and social) and motivation (reflective and automatic).

SETTING

Southwest Hospital of Chongqing Province in China.

PARTICIPANTS

A convenient and purposive sample of 24 wet AMD patients were recruited.

RESULTS

The themes and subthemes were identified: psychological capability: (1) insufficient knowledge of nutrition; (2) misconceptions about the disease and treatment; (3) knowledge conflict; physical capability: (1) physical restriction; (2) limited access to nutrition knowledge; physical opportunity: (1) communication between providers and patients; (2) health insurance and extra charges; (3) food environment; social opportunity: (1) stigma of disease; (2) family influence; reflective motivation: (1) self-efficacy; (2) attitude; (3) outcome expectancies; (4) lack of professional support; automatic motivation: (1) difficulties in changing eating habits; (2) mindset.

CONCLUSION

Medical staff should pay much attention to the process of patients' nutrition intervention. In addition, it is also necessary to develop professional and internet-based intervention to modify the dietary behaviour and improve the management skills of the patients.

Assessment of patient education materials for age-related macular degeneration

Purpose

Age‐related macular degeneration (AMD) is a leading cause of vision loss. It is helpful for patients living with AMD to understand the prognosis, risk factors and management of their condition. Online education materials are a popular and promising channel for conveying this knowledge to patients with AMD. However, the quality of these materials—particularly with respect to qualities such as ‘understandability’ and ‘actionability’—is not yet known. This study assessed a collection of online materials about AMD based on these qualities of ‘understandability’ and ‘actionability’.

Methods

Online education materials about AMD were sourced through Google from six English‐speaking nations: Australia, New Zealand, USA, UK, Ireland and Canada. Three Australian/New Zealand trained and registered optometrists participated in the grading of the ‘understandability’ and ‘actionability’ of online education materials using the Patient Education Materials Assessment Tool (PEMAT).

Results

This study analysed a total of 75 online materials. The mean ‘understandability’ score was 74% (range: 38%–94%). The ‘understandability’ PEMAT criterion U11 (calling for a summary of the key points) scored most poorly across all materials. The mean ‘actionability’ score was 49% (range: 0%–83%). The ‘actionability’ PEMAT criterion A26 (using ‘visual aids’ to make instructions easier to act on) scored most poorly across all materials.

Conclusion

Most education materials about AMD are easy to understand, but difficult to act on, because of a lack of meaningful visual aids. We propose future enhancements to AMD education materials—including the use of summaries, visual aids and a habit tracker—to help patients with AMD improve their understanding of disease prognosis, risk factors and eye assessment schedule requirements.

A Systematic Review of Clinical Practice Guidelines for Age-related Macular Degeneration

BACKGROUND

In response to the recommendations of the World Health Organization (WHO) World report on vision, the WHO is developing a Package of Eye Care Interventions (PECI) to support the integration of eye care into health systems within countries. This study was done to systematically review clinical practice guidelines (CPGs) related to age-related macular degeneration (AMD) to provide evidence-based recommendations.

METHODS

All AMD-related CPGs published between 2010 and 2020 were reviewed and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

RESULTS

Of 3778 CPGs identified, 48 underwent full-text screening and eight underwent quality appraisal. Five National Institute for Health and Care Excellence (NICE, UK) guidelines for AMD were finally selected for data extraction. Intravitreal anti-vascular endothelial growth factor (VEGF) treatment was strongly recommended for advanced, active neovascular AMD based on high-quality evidence. Photodynamic therapy and laser photocoagulation were not recommended as an adjunct to anti-VEGF therapy as first-line treatment for AMD. Recommendations on other interventions, including epiretinal brachytherapy, miniature lens system implantation, and limited macular translocation, were weak and evidence mostly came from low-quality case series studies. Hence these interventions were recommended to be used only with special arrangements or research. Existing evidence on treating geographic atrophy was limited, an implantable miniature telescope might be an effective intervention to improve vision but was still under investigation.

DISCUSSION

Current CPGs recommend anti-VEGF therapy for patients with late active neovascular AMD, while other interventions should be used with caution and further researches are warranted.

Telephone-Delivered Dietary Intervention in Patients with Age-Related Macular Degeneration: 3-Month Post-Intervention Findings of a Randomised Controlled Trial

There is an evidence-practice gap between the dietary recommendations for age-related macular degeneration (AMD) presented in the literature and those practiced by patients. This study reports on the 3-month post-intervention results of a randomised controlled trial (RCT) evaluating telephone-delivered counselling to improve dietary behaviours among AMD patients. A total of 155 AMD patients (57% female, aged 78 ± 8 years; control: 78, intervention: 77), primarily residing in New South Wales, Australia, were recruited. Participants completed a baseline questionnaire and a short dietary questionnaire (SDQ-AMD). The intervention included an evidence-based nutrition resource and four monthly calls with a dietitian. Immediately post-intervention, intervention participants repeated the SDQ-AMD and completed a feedback form. At 3 months post-intervention, both study arms repeated the SDQ-AMD. Statistical analyses included t-tests and McNemar's test. Intervention participants reported satisfaction with the tailored phone calls, nutrition resource and nutrition education provided. At 3 months post-intervention, there was no statistically significant difference between study arms in the proportion of participants meeting the dietary goals nor in intake (mean servings ± SE) of total vegetables (primary outcome) and other key food groups; however, there was a significantly higher intake of nuts (secondary outcome) (3.96 ± 0.51 vs. 2.71 ± 0.32; p = 0.04) among participants in the intervention versus control group. Within the intervention arm, there were also significant improvements in intakes of the following secondary outcomes: dark green leafy vegetables (0.99 ± 0.17 vs. 1.71 ± 0.22; p = 0.003) and legumes (0.69 ± 0.10 vs. 1.12 ± 0.16; p = 0.02) and intake of sweets and processed/prepared foods (8.31 ± 0.76 vs. 6.54 ± 0.58, p = 0.01). In summary, although there were few dietary differences between study arms at 3 months post-intervention, the intervention involving four monthly calls was acceptable and helpful to the participants. This type of intervention therefore has the potential to provide people with AMD the needed support for improving their nutrition knowledge and dietary practices, especially if continued over a longer period.

A qualitative exploration of Australian eyecare professional perspectives on Age-Related Macular Degeneration (AMD) care

Despite the existence of evidence-based recommendations to decrease risk and progression of Age-Related Macular Degeneration (AMD) for some time, self-reported practices suggest that eyecare professionals' advice and people with AMD's adherence to these recommendations can be very poor. This study uses qualitative methods to explore Australian eyecare professionals' perspective on barriers to effective AMD care. Seven focus groups involving 65 optometrists were conducted by an experienced facilitator. A nominal group technique was used to identify, prioritize and semi-quantify barriers and enablers to AMD care. Participants individually ranked their perceived top five barriers and enablers with the most important granted a score of 5 and the least important a score of 1. For each barrier or enabler, the number of votes it received and its total score were recorded. Barriers and enablers selected by at least one participant in their top 5 were then qualitatively analysed, grouped using thematic analysis and total score calculated for each consolidated barrier or enabler. In-depth individual interviews were conducted with 10 ophthalmologists and 2 optometrists. Contributions were audio-recorded, transcribed verbatim and analysed with NVivo software. One hundred and sixty-nine barriers and 51 enablers to AMD care were identified in the focus groups. Of these, 102 barriers and 42 enablers were selected as one of their top 5 by at least one participant and further consolidated into 16 barriers and 10 enablers after thematic analysis. Factors impacting AMD care identified through analysis of the transcripts were coded to three categories of influence: patient-centered, practitioner-centered, and structural factors. Eyecare professionals considered poor care pathways, people with AMD's poor disease understanding / denial, and cost of care / lack of funding, as the most significant barriers to AMD care; they considered shared care model, access, and communication as the most significant enablers to good AMD care. These findings suggest that Australian eyecare professionals perceive that there is a need for improved patient support systems and appropriately funded, clearer care pathway to benefit people with AMD.

Consumption of eggs and the 15-year incidence of age-related macular degeneration

BACKGROUND AND AIMS

A naturally rich source of lutein and zeaxanthin are eggs. There is scarce epidemiological data on the temporal association between total egg consumption and age-related macular degeneration (AMD) incidence. We aimed to establish the prospective and independent association between consumption of eggs with the incidence of AMD over a 15-year follow-up.

METHODS

In this population-based cohort study of 3,654 participants aged 49 + years examined at baseline, 2034 participants had complete information on baseline egg consumption and AMD signs over 15 years. AMD was determined from retinal photographs. Egg consumption was assessed using a semi-quantitative food-frequency questionnaire. Total egg intake was calculated through summing up intakes in all forms e.g. boiled, poached, fried, scrambled and/or omelette. We summarized total egg consumption into the following categories: ≤1 egg/week; 2-4 eggs/week; 5-6 eggs/week; and ≥1 egg/day.

RESULTS

At baseline, participants who consumed 2-4 eggs/week compared to those who consumed ≤1 egg/week (reference group) had reduced risk of incident late-stage AMD after 15 years: multivariable-adjusted odds ratio, OR, 0.51 (95% confidence intervals, CI, 0.28-0.92). Participants who consumed 2-4 eggs/week versus ≤1 egg/week at baseline had 62% reduced risk of developing neovascular AMD. Among those whose AMD onset was at or before the 10-year follow-up, consumption of 2-4 and 5-6 eggs/week was associated with 54% and 65% reduced risk of incident late AMD, respectively. When analyzed as a dichotomized variable, participants who consumed >1 egg/week versus ≤1 egg/week at baseline, had 46% reduced risk of developing late-stage AMD 15 years later: multivariable-adjusted OR 0.54 (95% CI 0.3-0.90). Non-significant associations were observed between egg consumption and incident early AMD.

CONCLUSIONS

Our findings suggest that moderate consumption of eggs significantly reduces the risk of developing incident late-stage AMD over 15 years.

Dietary intervention in patients with age-related macular degeneration: protocol for a randomised controlled trial

INTRODUCTION

Age-related macular degeneration (AMD) is a leading cause of blindness. After smoking, nutrition is the key modifiable factor in reducing AMD incidence and progression, and no other preventative treatments are currently available. At present, there is an evidence-practice gap of dietary recommendations made by eye care practitioners and those actually practised by patients with AMD. To address this gap, a telephone-delivered dietary intervention tailored to patients with AMD will be piloted. The study aims to improve dietary intake and behaviours in patients with AMD. This type of nutrition-focused healthcare is currently not considered in the long-term management of AMD and represents the first empirical evaluation of a telephone-supported application encouraging adherence to dietary recommendations for AMD.

METHODS AND ANALYSIS

140 participants with AMD will be recruited for this randomised controlled trial. Those lacking English fluency; unwilling to engage in the intervention or provide informed consent were excluded. Following the completion of the baseline questionnaire, participants will be randomised into one of two arms: intervention or wait-list control (70 each in the intervention and control groups). Intervention participants will receive a detailed mail-delivered workbook containing information on healthy eating behaviours that promote optimal macular health, as well as scheduled phone calls over 4 months from an accredited practising dietitian. Descriptive statistics and multivariate stepwise linear regressions analyses will be used to summarise and determine the changes in dietary intakes, respectively. Economic analysis will be conducted to determine intervention feasibility and possibility of a large-scale rollout.

ETHICS AND DISSEMINATION

The study was approved by the University of Sydney Human Research Ethics Committee (HREC) (Reference: HREC 2018/219). Study findings will be disseminated via presentations at national/international conferences and peer-reviewed journal articles.

TRIAL REGISTRATION NUMBER

ACTRN12618000527268; Pre-results.

Adherence to a Mediterranean diet, lifestyle and age-related macular degeneration: the Coimbra Eye Study - report 3

PURPOSE

To characterize the lifestyle and nutritional risk profile associated with the Mediterranean diet in a Portuguese population with and without age-related macular degeneration (AMD).

METHODS

Nested case-control study (n = 883) within the Coimbra Eye Study, including 434 subjects with AMD and 449 age- and sex-matched subjects without AMD. All enrolled subjects underwent a full risk assessment, including lifestyle-related risk factors and a thorough food frequency questionnaire. This allowed us to build an adherence score to the Mediterranean diet (mediSCORE, range 0-9) constructed from individual food intakes. Food intake was also further analysed by conversion to micronutrient consumption.

RESULTS

Our results suggest that physical activity has a protective role in AMD [p = 0.018 after multivariate adjustment, OR: 0.69 (0.51-0.93)]. High (mediSCORE ≥6) was also found to be protective [p = 0.041, OR: 0.62 (95% CI: 0.38-0.97)]. Food group analysis unveiled a specific protective role for increased fruits consumption (p = 0.029). Finally, micronutrient analysis revealed a protective role associated with increased consumption of caffeine, fibres, beta-carotene, vitamin C and vitamin E (p < 0.05).

CONCLUSION

High mediSCORE appears to confer protection against the development of AMD in a Mediterranean population. This effect is driven by increased consumption of fruits and some antioxidant micronutrients, which emerged as statistically significant protective factors. Further studies are required to establish dietary recommendations with clinical application.

The impact of environmental contamination on the generation of reactive oxygen and nitrogen species - Consequences for plants and humans

Environmental contaminants, such as heavy metals, nanomaterials, and pesticides, induce the formation of reactive oxygen and nitrogen species (RONS). Plants interact closely with the atmosphere, water, and soil, and consequently RONS intensely affect their biochemistry. For the past 30 years researchers have thoroughly examined the role of RONS in plant organisms and oxidative modifications to cellular components. Hydrogen peroxide, superoxide anion, nitrogen(II) oxide, and hydroxyl radicals have been found to take part in many metabolic pathways. In this review the various aspects of the oxidative stress induced by environmental contamination are described based on an analysis of literature. The review reinforces the contention that RONS play a dual role, that is, both a deleterious and a beneficial one, in plants. Environmental contamination affects human health, also, and so we have additionally described the impact of RONS on the coupled human - environment system.

Macular degeneration and occupational risk factors: a systematic review

Purpose

Macular degeneration is a multi-factorial disease, leading cause of blindness for people over 50 years old in developed countries. To date, the knowledge on possible occupational factors involved in the development of the disease is scant.

Method

We performed a systematic scientific literature search on the association between macular degeneration and occupational risk factors searching the MedLine and Scopus databases.

Results

We examined 158 articles and, according to the inclusion criteria, 13 peer-reviewed studies evaluating occupational risk factors for macular degeneration or reporting the frequency of the disease in specific groups of workers were included in the review. Ten on thirteen articles evaluated the presence of macular degeneration in workers exposed to solar radiation. Only one study found that non-specific history of occupational chemical exposure was associated with the disease. Two studies showed an association between macular degeneration and the general category of “blue-collar” workers, but they did not identify the specific risk factors involved.

Conclusions

To date few studies have examined occupational risk factors for macular degeneration. Nevertheless, available data indicate that long-term occupational solar radiation exposure, in particular for its blue-light component, is associated with macular degeneration in outdoor workers.

Electronic supplementary material

The online version of this article (10.1007/s00420-018-1355-y) contains supplementary material, which is available to authorized users.

Genetic and environmental factors strongly influence risk, severity and progression of age-related macular degeneration

Age-related macular degeneration (AMD) is characterized by complex interactions between genetic and environmental factors. Here we genotyped the selected 25 single-nucleotide polymorphisms (SNPs) in 983 cases with advanced AMD and 271 cases with intermediate AMD and build an AMD life-risk score model for assessment of progression from intermediate to advanced AMD. We analyzed the performance of the prediction model for geographic atrophy progressors or choroidal neovascularization progressors versus non-progressors based on the 25 SNPs plus body mass index and smoking status. Our results suggest that a class prediction algorithm can be used for the risk assessment of progression from intermediate to late AMD stages. The algorithm could also be potentially applied for therapeutic response, and toward personalized care and precision medicine.