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Not everyone needs to take eye vitamins

At a recent lecture that I gave to the Family Practice Department at Huntington Hospital in Huntington, New York, one of the doctors asked whether all people with retinal drusen need to take eye vitamins. My letter to the doctor is below. ========= Dear Doctor, Thank you for asking an excellent question about supplements for macular degeneration during my retinal lecture. Specifically, you asked whether patients with mild macular degeneration required high dose nutritional supplements for their AMD. I am sorry that under the time constraints that I was not able to give you a detailed response to your question during the lecture. Up to this date, there have been two approaches to this question. My approach is a third one which uses, I believe, the best evidence that we know. The National Eye Institute?s Age Related Eye Disease Study, completed in 2001, concluded that patients with intermediate-sized or larger drusen showed less chance of progression if they were treated with high dose nutritional supplements when compared with placebo. Although the benefit was only a 25% reduction in progression, it was the first study showing benefit to vitamin usage, which was presumably due to the very high doses used in AREDS versus previous studies. But, as you alluded, not ALL patients with intermediate-sized drusen will progress. So the treatment of everyone with intermediate and larger drusen is a bit like ?carpet bombing,? in which everyone gets the ?bomb? so that those who are going to progress will get the benefit of treatment as well, at least with the AREDS Formula. (Newer studies show more benefit when Lutein, Zeaxanthin and Omega-3 fatty acids are added.) [caption id="attachment_1135" align="alignright" width="300"] 5 Year Rate of Progression of AMD[/caption] To cope with this dilemma, Neal Bressler of the Wilmer (Johns Hopkins) Eye Institute in Baltimore and one of the original AREDS investigators, did an analysis of the original data from AREDS that tried to predict who would progress (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1473206/). Dr. Bressler came up with a four-point scale based only on the presence of large drusen and pigmentary changes, which he showed had predictive value for the progression to either wet or geographic (diffuse dry) macular degeneration. While Dr. Bressler?s article is helpful. I believe that it is a bit like closing the barn door after the horses have escaped. Patients who have large drusen and pigment have already progressed. So how do we find the patients at an earlier stage of disease who have only a few intermediate-sized drusen and determine who will progress and lose vision without treatment over the course of a lifetime? True, they all meet the AREDS criteria for treatment but should we place all of these patients on high-dose nutritional supplements? That would seem to place both a high medical and cost burden on patients who would not progress without treatment. The answer, I believe, is a hybrid approach. For those patients who demonstrate high-risk findings as delineated in Dr. Bressler?s study, clearly those patients should be on supplements. For patients with lesser findings, locating the ?needle in the haystack? can be determined by performing the Macula Risk test, a genetic assay for macular degeneration which we perform in our office by simply swabbing the inside right and left cheek. Even if a patient?s findings only include intermediate-sized drusen and no pigment ? patients who would score a zero on Dr. Bressler?s scale, - those patients should, in my opinion, be treated with macular degeneration vitamins if they score 3 or above on the genetic test 5-point scale. Warm Regards,

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