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20/20 and BEYOND Vision Protection and Performance with Nutritional Supplementation Ryan H. Powell, O.D. Kansas City, MO [email protected]
20/20 and BEYONDVision Protection and Performancewith Nutritional Supplementation
Ryan H. Powell, O.D.
Kansas City, MO
46 Year Old Karen• Mom has advanced AMD – is
she currently taking shots? “NO – they stopped them”
• “she can see the sidewalk elevation changes, but she can’t see any detail”
• Karen’s eyes – no sign of drusen, dark adapt testing slightly more than 5 mins.
• Blue eyes• What’s your plan…??
Lets talk about the ChallengeWe know:
1. Carotenoid supplementation is beneficial to our visual function and performance
2. Macular carotenoids reduce the oxidative stress on our retina which coorelates with improved macular degeneration outcomes
3. Significant amounts of research support the impact of Carotenoids on cognitive function
4. We know that Meso-Zeaxanthin is the most pronounced of the 3 in our fovea
.......so……are our patients taking carotenoid supplements? IF not, why not?
The Patient has to Understand the Value. You have to Deliver the Value.
• What are Carotenoids?
• Why are they important to your eyes, your vision and your visual performance?
• Lets review the science so we can educate our patients and help them!
Dr. James Stringhamcurrently holds the post of Research Scientist at Duke University Medical School.
Professor John Nolan is the Principal Investigator of the Macular Pigment Research Group at the Waterford Institute of Technology in Ireland.
Carotenoids
• Definition: any of a class of mainly yellow, orange, or red fat-soluble pigments, including carotene, which give color to plant parts such as ripe tomatoes and autumn leaves.
• Absorb light energy• over 600 carotenoids in nature • 50 carotenoids in our diet• Only 14 detected in serum• Only 3 carotenoids found in the
macula– SPECIFICITY !
Carotenoids in our DietIn the U.S., the typical dietary intake is only 1.4 mg of lutein and zeaxanthincombined per day
US Dept of Ag reports that 1 bowl of spinach from 1953 has same nutritonal content as 43 bowls of spinach in 2000
The Evolution of Carotenoids and AMD
• Age-Related Eye Disease Study (AREDS 1 (2001) & 2)– AREDS I (2001): vit A (beta-carotene), C,E, zinc, copper
• 25% risk reduction from Intermediate to Advanced
– AREDS II (2013): C, E, zinc, copper, 10 L, 2 Z• Additional 10% reduction in progression risk
• Meso-Zeaxanthin Ocular Supplementation Trial (MOST)2015: Meso-Zeaxanthin is most pronounced carotenoid in Fovea
• Central Retinal Enrichment Supplementation Trial (CREST) – AMD: adding MZ to AREDS 2 formula maximizes vision – Normal: statistically significant improvement in Contrast
Sensitivity when MZ included
MOST trial44 healthy subjects. 22 consume 10.6 mg
of MZ, 5.9 mg of Lutein and 1.2 mg of Zeaxanthin, the other 22 consume placebo everyday for 6 months
Monthly visits measure MPOD at .25, .5,1 and 1.75 degrees and serum levels were measured
Statistically significant increase in serum levels of L & Z
MPOD at .25 and .5 degrees increased significantly
Supplements increase serum levels and MPOD, greatest increase in this study was the level of MZ at .25 degrees
THE FOVEA HAS MORE PRONOUNCED MesoZeaxanthin than Lutein OR Zeaxanthin
CREST AMD Study
• Does supplementation with L,MZ,Z in a 10:10:2 ratio combined with 500 mg vit C, 400 mg vit E, 25 mg zinc and 2 mg copper for 24 months compared to L,Z 10:2 plus vit C, vitE, zinc and copper (AREDS II)
• Early/Intermediate AMD experienced significant improvement across 24 out of 32 tests of vision (glare, reading acuity, reading speed, NEI overall vision score questionaire) when Meso-zeaxanthin was added to the formula
• AREDS 2 + MZ leads to better vision than AREDS 2 formula
Macular Carotenoids
• Lutein, Zeaxanthin AND
Meso-Zeaxanthin
• Found in the Henle Fiber Layer
of the fovea
* Pre-receptoral (filtration)
Carotenoids and Macular Degeneration
Reducing High Energy Wavelength visible light (Blue- Light) absorption by the Retinal Pigment Epithelial Cells
Protection of the RPE
Reduce Oxidative Stress
Blue Light Absorption and
Anti-Oxidant Impact are key to macular
degeneration benefits
Meso-Zeaxanthin is Key
Lets Talk Performance
Case study: UGA baseball player (3rd baseman)
Subject:
20 YOWMUGA baseball player
BMI: 27.420/15 OU SCMPOD: 0.17
Complains of sensitivity to bright light, difficulty
sometimes visually “picking up” ball after leaving pitcher’s hand
Measures used in Carotenoid Science
• MPOD – macular pigment optical density
• Contrast Sensitivity– Owsley and Sloane (1987): Contrast
Sensitivity at middle and low spatial frequencies (e.g. 6 cpd) was significant predictor of real-world object detection and identification. Faces, road signs, basic objects
• CFF (critical flicker frequency)– At what frequency can you still tell
that a light is flashing and not a solid light
• Glare Radiance – the tolerance for glare produced by light
Contrast threshold for 6 cpd at baseline: 3.0%Photostress recovery time: 11.9 secsNominal disability glare radiance: 71.6Critical Flicker Frequeny CFF: 23.75 HzCoincident Anticipation Timing accuracy: 59.4%
Visual performance data at baseline:
White LEDs (separated by less than 1 inch) are sequentially illuminated
Exact start time cannot be predicted
Speed of each trial is randomized
Subject’s task is to push the response button when s(he) believes the light will be coincident with the white strip of tape (see picture)
Very difficult…average accurate performance: ~40-50%
“Correct” responses are those where the timing of the button press corresponds to the light directly in line with the white tape or those immediately to the left or right.
CAT: Coincidence Anticipation Timing
Measurement of Disability Glare, PhotostressRecovery
0 3 6 9 12
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
0.55
MP
OD
(46
0 n
m),
30' r
etina
l ecce
ntr
icity
Time (months)
Results from 1-year, 22 mg / day L, Z, & MZ intervention
MPOD Increases
0 3 6 9 12
58
60
62
64
66
68
70
72
74
% a
ccu
rate
resp
on
ses
Time (months)
Results from 1-year, 22 mg / day L, Z, & MZ intervention
Coincident Anticipation Timing Improves
0 3 6 9 12
65
70
75
80
85
90
95
100
105
110
115
120
Nom
inal ra
dia
nce
Time (months)
Results from 1-year, 22 mg / day L, Z, & MZ intervention
Detect the Target with Bright Light around itGlare Tolerance Improves
Results from 1-year, 22 mg / day L, Z, & MZ intervention
Discerning Vision Improves
0 3 6 9 12
23.5
24.0
24.5
25.0
25.5
26.0
26.5
27.0
27.5
CF
F (
Hz)
Time (months)
Results from 1-year, 22 mg / day L, Z, & MZ intervention
Vision Improves
Vi
0 3 6 9 12
1.8
2.0
2.2
2.4
2.6
2.8
3.0
Pe
rcen
t co
ntr
ast
thre
sh
old
(6
cpd
)
Time (months)
Results from 1-year, 22 mg / day L, Z, & MZ intervention
Light Exposure Recovery Improves
0 3 6 9 12
8.5
9.0
9.5
10.0
10.5
11.0
11.5
12.0
Ela
psed tim
e (
seconds)
Time (months)
Photostress Recovery Time
2 secs exposure
Time to Resolve the image
Anecdotal Observations from Baseball Player Study Subject
“I can see the ball better. A lot of times I can see the general spin of the ball right out of the pitcher’s hand”
“Much easier to deal with the sun, and stadium lighting during night games.
“On bang-bang plays, things seem to almost slow down – I can really focus on hard-pull ground balls”
“I feel like I have a lot more control – you know, like I am really there, in the moment. Makes me feel a lot more confident”
Game-based metrics
Conclusions of Baseball player case study
• Macular carotenoid status influences several parameters of visual performance• Speed of processing / timing / eye-hand coordination• Contrast sensitivity• Visual performance in glare; recovery from glare
• All of these can benefit sports performance• Any sport that relies on visual input…!
• Athletes tend to have relatively low MPOD• Appear to respond very favorably to macular carotenoid supplementation
• Perhaps due to good overall health• Can augment MPOD significantly in short time period (~ 6 months – 1
year)• Noticeable effects (assuming consistent supplementation
regimen) as quickly as 3 months
*These effects can facilitate a conversation with patients about nutrition / supplementation*
Cognitive Function and Carotenoids
• Elizabeth J. Johnson, PhD – Jean Mayer USDA Human Nutrition
Center on Aging at Tufts University in Boston
“As a result of the past 10 years of research, we now know that carotenoids are preferentially placed in the brain (frontal and occipital cortex), particularly lutein and zeaxanthin”
Cognitive Function and Carotenoids
• Neuronal Synapses in Infants are more efficient when Lutein is in the CSF and even more efficient when L and Z are in the CSF
Deliver to your Patients
Would you take a Carotenoid supplement? Do you already take one? Should your patients have the option?My personal experience – light sensitivity. Focus. Visual Comfort.
My Patients58 Year old W/F. Lots of time outdoors. Lives the farm life. No drusennoted on exam. Light eye color.
Benefits from Nutritional Supplementation: reduced glare and light sensitivity, anti-oxidant protection to macula, improved Contrast Sensitivity, possible benefits to cognitive function/neuronal synaptic activity
My Patients
The Family. Active kids. Sports. College. Work on the Computer.
My Patients
• 45 year old dad
• Works on a computer much of the day
• No Eyeglasses
• Work out often
• Kids are active in sports -baseball
My Patients
65 year old white male. Previously noted Drusen OS only. Peri-macular. Taking an OTC AREDS 2 supplement
Thank You
• Questions? Ideas? Best Practices?
• How are you implementing in your practice?
Ryan H. Powell, O.D.
vseyecare.com
@icarethoughts4u
CREST Study
• Central Retinal Enrichment Supplementation Trial –Normal, healthy eyes
Question: Does supplementation with L,Z,MZ in a 10:2:10 ratio over 12 months enhance visual function compared to placebo
Outcomes Normal: Compared to Placebo, statistically significant improvements from baseline CS were detected at 6 cpd and 1.2 cpd. Improvement in CS was commensurate with the observed increases in retinal concentrations of these carotenoids
CREST study
• Primary Outcome Measure: Contrast Sensitivity Testing at 6 cycles per degree– Owsley and Sloane (1987): Contrast Sensitivity at
middle and low spatial frequencies (e.G. 6 cpd) was significant predictor of real-world object detection and identification. Faces, road signs, basic objects• CS determines to be a better predictor of performance
than age!
• VA was not a significant contributor to real-world visual performance
