Today, I received a letter from a patient with a copy of  an recent article linking aspirin use with blindness caused by age-related macular degeneration (AMD).  She was understandably concerned and asked in her letter whether or not she should stop taking aspiring.  I thought a post on the subject would be helpful for other patients who are similarly worried.

Macular degeneration is the leading cause of blindness for Americans older than 55 years old.  The macula is the center most part of the retina responsible for the fine central vision.  I always tell patients that the retina is like the camera film of the eye, but now with digital cameras, I’m not really sure what the equivalent would be!  In any case, the retina is the inner lining of the eye and its cells record visual input and translate it to send back to the brain.  The macula is a small pigmented area right in the in center of the retina.

Anatomy of the eye

Below is actually a photography of the retina of my left eye.

And, here’s a depiction of the difference between a normal retina on the left side, dry AMD in the middle and wet AMD on the right.

There are 2 forms of macular degeneration – dry and wet.  Most cases of macular degeneration (80-90%)  are the dry form.  In dry macular degeneration, there is an accumulation of “drusen” underneath the retina.  These drusen, essentially represent the “garbage by products” of the retina and over time the deposits can interfere with the function of the macula.  Though the dry form of macular degeneration is less severe and causes less vision loss, there is also no treatment for it.

The wet form of macular degeneration is caused by leakage of abnormal blood vessels underneath the retina (neovascularization).  The blood vessels leak fluid and cause an elevation of the macula and disruption of central vision.   Vision loss can be quite rapid and severe.  However, for this form of macular degeneration, there are treatments available with anti-VEGF injections (Macugen, Avastin). The retina specialist will inject these medications directly into the eye and they help halt the formation of the abnormal, leaky blood vessels under the macula.  Typically, these injections must be repeated every six weeks.

So, what’s the link between aspirin and macular degeneration?  The article was published by the Journal of American Medical Association – Internal Medicine and it looked at roughly 2400 participants and followed them over a 15 year period.  The patients were examined 4 times and asked to complete at baseline assessing aspirin use, cardiovascular disease status, and AMD risk factors.  The authors found that regular low dose aspirin use is associated with a 2.5 fold increased risk of wet (but not dry) AMD.  By the end of the study period, 24.5 percent of the study participants had developed “wet,” or neovascular, age-related macular degeneration. But researchers found that a greater proportion of regular aspirin users had the disease as they followed up throughout the years than the aspirin non-users.  This study does not prove that aspirin causes macular degeneration.  It simply shows there is an association between the two.

A related commentary in the same journal, points out flaws of the study, which undermine the results, and call for additional studies.  They write, ” the strength of evidence is not sufficiently robust to be clinically directive.”  Meaning, the evidence is not strong enough from this study to make changes in clinical care, further prospective, randomized studies are indicated.  Previous studies investigating AMD and aspirin have been inconclusive.

Bottom line – physicians should take this study into account when prescribing aspirin for their patients for prevention of cardiovascular events.  The benefits of initiating aspirin therapy (prevention of heart attacks or possibly cancer) must be weighed against the risks (development of AMD and bleeding), as with any treatment.  Whether or not to start aspirin should be a discussion each patient has with their physician, now with additional information regarding AMD.  Patients who use aspirin for pain control, may want to do so with caution, given this association.

 

Anatomy of the eye

 

You may have friends that say “I have macula.”  What they mean is they have macular degeneration.  Symptoms include:

  • Shadows, blurriness, or holes in the center of vision.
  • Straight lines appear wavy.
  • Trouble seeing details both up close and at a distance.
  • Difficulty telling colors apart, especially ones close in hue.
  • Vision can be slow to come back after bright light exposure.
    People with severe macular degeneration lose their central vision and see the world as depicted below.

In macular degeneration, there is scarring and bleeding in the macula area of the retina.  There  is a spectrum of macular degeneration.  Some patients who have it do not have any visual symptoms at all.  There are two types – dry and wet.  The dry form of macular degeneration, is less severe, yet there’s also no real treatment for it.  It’s considered the early stage of macular degeneration and the only form of treatment is preventative (no smoking, take vitamins such as Ocuvite, which is available at Costco).  The Age-Related Eye Disease Study (AREDS for short) is one of the few studies which proves a beneficial effect of taking a combination of vitamins (Vitamin C, E, beta carotene, zinc and copper) in preventing the progression of macular degeneration.

The wet form, is the more advanced form of macular degeneration.  It’s called “wet” because the blood vessels leak and cause bleeding underneath the macula.

Though this is the worse form of macular degeneration to have, there is treatment for it.

  1. Laser treatment  used to seal off the leaky blood vessels.
  2. Anti-angiogenesis agents – The newest form of treatment are injections (anti-VEGF) which work by slowing the growth of the leaky blood vessels.  Examples of these injections include – Avastin and Lucentis.  Typically, these injections must be performed every 1-2 months or the blood vessels will regrow.

Now to the food part. Some research suggests that a diet rich in those antioxidants may be linked to a lower risk for eye diseases. One recent large study found that people whose diets were high in lutein and zeaxanthin were at lower risk of developing age-related macular degeneration (AMD) and of progression to advanced AMD, the vision-threatening form.  Another large study found that people with high lutein and zeaxanthin dietary intake were at lower risk for cataracts.

Patients always ask if dietary changes will help improve cataracts and macular degeneration.  And, while a healthy diet cannot reverse these changes, it may be able to help prevent macular degeneration and cataracts from becoming significant.  Lutein and zeaxanthin are found in dark, green leafy vegetables like spinach, kale and collard greens. The yolks of eggs also contain lutein. The antioxidants are also present in yellow and orange vegetables and fruits, like sweet potatoes, carrots and peaches. National health organizations recommend from five to 13 servings of vegetables and fruits per day, depending on age and gender. One serving equals one cup of salad greens, or one half a cup cooked vegetables or cut fruit, or one medium-size piece of fruit, or six ounces of juice.

So far, the jury is still out as to whether high dietary levels or supplements of these substances prevent or just slow the progression of age-related eye diseases.  More than one study has shown that vitamins, minerals and phytonutrients found in food offer advantages that are not available in pill form.  Still, eating fresh, whole foods supports a person’s general health, and taking a balanced multivitamin supplement is usually considered a good general health “insurance” practice.

Below are a couple recipes from our family to yours, to maximize your intake of spinach, kale and collard greens.

Now, I am not a huge kale fan, or at least I wasn’t.  But, my mother-in-law made this salad and it fast became one of my favorites.  The recipe is originally from her friend Joan Namkoong.

print recipeKale Salad

Ingredients:

  • Fresh kale
  • Sliced red onion
  • Kalamata or picholine olives, pitted and halved
  • Dried cranberries
  • Walnuts, broken into pieces
  • Balsamic dressing

Directions:

Use a mixture of regular kale, Red Russian kale, lacinato or other varieties and try to get young (small leaves) kale which is more tender.  Remove the leaves from the stems as you wash it; discard stems.  Stack the leaves and cut into fine shreds.  Use about 1 cup of shredded leaves per person.  Place in a salad bowl.

Add the onion, olives, cranberries and walnuts; toss with dressing.  You can toss this ahead of time and let it sit – the kale won’t wilt like other salad greens, making this a great salad for a buffet

Balsamic dressing

Ingredients:

  • ½ cup balsamic vinegar
  • 1 cup olive oil
  • 1 tablespoon honey or sugar
  • 2 teaspoons Dijon mustard
  • 1 teaspoon salt
  • ½ teaspoon black pepper

Directions:

Whisk all the ingredients together

Note:  3:1    oil : acid

Below is a recipe for a popular Indian dish you may have tried in an Indian restaurants.  This recipe is from my mother.

print recipeSaag Paneer (Indian spinach-cheese curry)

 

Ingredients:

  • 1 bag fresh spinach (frozen spinach can be substituted)
  • 1/2 large onion, chopped
  • 1/2 medium tomato, chopped
  • 2 cloves garlic, chopped
  • 1 inch ginger, finely chopped
  • 1/4 tsp turmeric
  • 1/4 tsp salt
  • 1/2 tsp ground coriander
  • 1/2 tsp ground cumin
  • 1 tsp garam masala
  • 1 Tbsp butter
  • 1 Tbsp oil
  • 1/3 package of paneer, cut into cubes.  (Paneer is simply home made cheese and can be bought frozen in any Indian grocery store, if you don’t want to go through the trouble of making it yourself.  There’s even one here in Hawaii.  Click here for the address.

Directions:

Heat the oil in a large saucepan.  Once warm, add the ginger and garlic and cook for one minute.  Add the onion and reduce the heat to low, cooking for 5 minutes.  Then, add the salt, cumin, coriander, and turmeric to the onion-garlic mixture, cooking for about 2-3 minutes.  Next, add the tomato, cooking it for an additional 2-3 minutes until the tomato begins to soften.  Add garam masala along with 1/4 cup water and cook for 5 minutes.

Add the spinach with 1 cup of water and saute until the spinach begins to wilt, turning off the heat.  Puree the spinach mixture with a hand held blender or remove from heat and blend in a food processor.

In a separate saucepan, heat the butter and paneer, turning constantly so it does not stick to the pan.  Add a pinch of turmeric, garam masala and salt to the paneer while frying.  When golden brown, turn off the heat and combine the paneer with the spinach mixture.

 

print recipeKale Smoothie (Our 2 year old drinks this!)

Ingredients:

  • 2 stems of kale
  • 1 cup of orange juice
  • 1 cup of frozen peaches
  • 1 cup of frozen pineapples
  • 1 6 ounce cup of yogurt (we use blueberry because it was in the fridge)
  • 5 ice cubes

Directions:

Blend together and serve

And, see, even our 2 year old likes it!

 

© 2011 Honolulu Eye Doctor & Mom Suffusion theme by Sayontan Sinha