Macular Degeneration; Macular RegenerationMacular Degeneration; Macular Regeneration
John is a well-known radio personality and film producer with a wealth of knowledge and experience in the nutritional field. To his frustration, and despite a healthy diet and nutritional supplementation, he had progressed from the typical dry macular degeneration with small hard shiny deposits in the retina, and a loss of nearly 2 lines of visual acuity (20/30+) over several years, to the more serious wet macular degeneration with scarring, retinal bleeding and inflammation surrounding degenerating retinal drusen in the left eye at the age of 65. Wet macular degeneration often affects one eye first and the other within several years. Visual acuity in the left eye had progressively dropped from 20/30+ at the beginning of 1997 to 20/80, a disturbing 50% loss of vision, in a period of just 6 months. Very concerned about the rapid deterioration in John’s vision, Harvard trained retinal specialist, Dr. Bruce Ballon immediately set up an emergency appointment for John to fly to Honolulu for laser cauterization of the leaking blood vessels. As noted in his clinical records, he “explained that ‘time is of the essence’, and loss of central VA (visual acuity may progress rapidly from wet AMD (Age-related Macular Degeneration) if laser is indicated and not performed.” He also noted “that he may permanently lose the opportunity to delay progression of AMD (by laser tx) by postponing tx now.” John, however, having had many positive experiences over the years with nutrition, elected to give natural vision care one last, but concerted effort to save his vision, knowing that with laser there would certainly be some additional damage to retinal tissue, even with the hoped for outcome of ‘delayed progression’.
John obtained a copy of Dr. Swartwout’s summary of the nutritional literature on macular health and followed the recommendations carefully. He was already eating lots of fresh vegetables from his own garden, taking a good multi-vitamin and an anti-oxidant complex specifically designed for the eyes. He added eye drops containing Vitamins A, C and E as well as silver and MSM. To his daily supplement program he added bioflavonoids from pine, grape, bilberry and other sources, as well as a blend of mixed carotenoids. He also decided to add a small dose of ginkgo, avoiding higher doses because of the bleeding in his retina. He also increased his levels of carotenoids and vitamins B complex (especially B6 and biotin), C, D and E as well as minerals calcium, magnesium, zinc picolinate and selenium. To this he added flora, flax, shark cartilage, milk thistle, coQ10, carnitine, alpha lipoic acid, NAC and MSM. He was concurrently taking saw palmetto.
For years, John had also been taking an aspirin product containing caffeine for his headaches. When he learned that aspirin could contribute to his retinal bleeding, he stopped taking this product as part of his total healing program. He was pleased to find that after being on the whole regimen for 4 to 5 weeks, the headaches actually subsided.
At John’s last checkup with Dr. Ballon, the noted retinologist was extremely pleased with John’s response, stating that he had never seen such fast recovery in 12 years of practice. He reported that the retinal drusen were no longer swollen and decomposing. Not only had the bleeding, inflammatory and degenerative processes been halted completely, but to Dr. Ballon’s amazement, even the retinal scarring was being reversed. In fact, John’s remarkable improvement had made such an impression on him that Dr. Ballon described his case on a radio show several days later to illustrate the potential of our growing understanding of nutrition to heal the eyes and recover lost vision. John’s vision had been fully restored to the previous level of 20/40.
Dr. Ballon writes "...Mr. DeCosta has had dramatic improvement in his vision despite having had wet macular degeneration. The improvement in his vision occurred after beginning intensive use of powerful antioxidants, vitamins and herbl treatment, including Ginkgo Biloba, bilberry and grape seed extract. He gave me a copy of the report that you had written on this topic, and I appreciate all of the work that you did on a subject that obviously needs more research, but is very promising for patients who have very few alternatives."
At 80 years of age, Verna of Honokaa, Hawaii had become one of the statistics. After suffering loss of her central vision in both eyes due to wet macular degeneration, she was classified as legally blind, with vision of only 20/400 in the right eye and 20/200 in the left eye.
In searching for answers to her plight, she was referred to Dr. Swartwout by a Doctor who had done extensive work with vision improvement in the South Pacific. Wanting to do everything she could to save her remaining sight and, if there was any chance, to improve her vision through natural means, she contacted Dr. Swartwout at the Remission Foundation.
Consulting together using Dr. Swartwout’s methods, a monthly program was developed and modified periodically to keep Verna on track with the most helpful supplements and dietary changes at each stage of her healing and regenerative process. After one year, her ophthalmologist almost couldn’t believe his eyes - or hers! The bleeding has completely stopped in both eyes, and the vision has been restored to 20/70 and 20/50. Thanks to her diligence in applying natural vision care, Verna is no longer blind, and looking forward to turning 83!
What is the Macula?
The macula, or macula lutea (“yellow spot”), is the central part of the retina, responsible for our detailed vision. This is the part of the eye we look with, and is necessary for reading, writing, identifying faces and many other detailed visual tasks that most people take for granted. Slower reading with aging is one of the early signs of macular degeneration.
Aging spots can start to appear on the retina as early as the teenage years, becoming more common in people in their 30’s and 40’s. The 30% of adults who have these drusen deposits are at increased risk to develop macular degeneration. The incidence of macular degeneration increases from under 1% for people under 50 to over a quarter of the population over age 75. In all, over 15 million Americans have macular degeneration, with 167,000 new cases added each year. It is the leading cause of irreversible blindness in this country. Many different features can be involved, including vascular insufficiency, retinal pigment epithelial (RPE) disorganization, degeneration and cell death, accumulation of lipofuscin within retinal cells, deposition of materials such as soft (hydrophobic, associated with pre-wet ARM) and hard (hydrophilic, associated with dry ARM) drusen, hypoxia, choroidal neovascularization, RPE detatchment, and fibrotic scar formation, but primarily the condition is divided into two types. The two basic types of macular degeneration are dry (85%) and wet (about 15%). Most cases of progress slowly, while less than 10% progress rapidly, and these are of the wet type. 85% of those with the wet type become legally blind, while only 12% of those with the dry type experience vision loss to this degree of 20/200 or less in the better eye. The wet type can follow as a progression of lipophilic soft-drusen ocurring in the dry type. Some cases of wet macular degeneration are treatable by laser surgery, but the treatment itself cannot effectively seal up a leaking blood vessel without at the same time permanently destroying the retinal nerve fibers that pass through that area. This is why laser treatment actually worsens vision, as reported by the National Eye Institute, and any ability to slow the progression of disease does not appear until at least a year after surgery. One surgeon states, “it is now increasingly evident that laser treatment will not significantly reduce the severe visual loss experienced by most patients with this macular disease. . . .Preventive measures, such as nutritional supplements and light filtration, should also be investigated in the hope of decelerating progressive, atrophic degeneration and perhaps of reducing the conversion rate from nonexudative (“dry”) to exudative (“wet”) disease.”
As always prevention is the best medicine, when it is instituted in time and in adequate measure. Since less than 1% of those with macular degeneration have progressed to the point of legal blindness, most are in a position to greatly benefit from prevention. Also, while macular degeneration typically affects only one eye at first, within four years 23% of people are already experiencing problems in the other eye, again pointing to the need for timely and adequate preventive measures.
‘Dr. William R. Hazzard, Director of the Center on Aging at Johns Hopkins Medical Institutions notes that “Much of what we have accepted as inevitable in aging may indeed not be so.” If we are able to determine the effects of nutrition, the environment, and various behavior patterns, the older individual may be able to continue functioning at a level consistent with that of the younger individual.’
Smoking presents a definite stress to nerve cells such as those in the macula. Nicotine destabilizes nerve cell membranes. Smoking also reduces the quality of circulation both by triggering vasoconstriction and by increasing cholesterol levels. Each cigarette uses up 25 mg of Vitamin C, increasing the risk of retinal damage from sunlight. Smoking should be avoided completely in all forms of macular degeneration. Smokers increase their risk of ARM by 2.5 times. The average age at which smokers are affected is 64 versus 71, so quitting smoking could add 7 more years of good vision to your life. Smoking is also a significant risk factor for recurrent choroidal neovascularization.
Caffeine also impairs nerve cell health and the quality of circulation. Between 20 and 30 percent of Americans consume over 500 mg/day, which is equivalent to more than 2 cups of coffee. Caffeine causes vasoconstriction, hypertension, and results in a 13% reduction in blood flow to the retina.
Dry macular degeneration tends to occur more in nutritionally deficient hyperopic (farsighted) eyes in which sunlight, a photo-oxidative stress (by production of superoxide radicals) is most intensely focused on the cells behind the retina, where the initial damage and atrophy begins in dry macular degeneration, with impairment of the phagocytic abilities of the retinal pigment epithelial cells, resulting in build up of hard drusen deposits. This represents an accumulation of lipofuscin at a cellular level within the retina due to either UV exposure or some other oxidative stress beyond the antioxidant protection capacity of the tissue. When superoxide dysmutase (SOD) levels are adequate with proper nutritional support, and with freedom from cellular toxicity, normal exposure to sunlight may not present a danger by itself.
Wet ARM appears more related to excessive and denatured protein as well as excessive and improper fats in the diet, along with other micro-nutritional considerations.
Other factors which have long been thought to be linked to macular degeneration include atherosclerosis, diabetes, hypertension, fatigue, stress, and infections. Carotid artery stenosis and other vascular occlusive disease which restricts nutrition and oxygen to the retina contributes to macular degeneration. The growth of new blood vessels associated with the wet type is particulary related to retinal hypoxia as the trigger.
Pulsatile ocular blood flow (POBF) measurement via intraocular pressure pulse monitors choroidal circulation. POBF is lower in exudative AMD than in non-exudative AMD or normal subjects. Lower choroidal blood flow may induce choroidal neovascularization via angiogenic factor induced by hypoxia.
Mori F. Pulsatile ocular blood flow and choroidal blood flow in age-related macular degeneration [Article in Japanese] Nippon Ganka Gakkai Zasshi. 2003 Nov;107(11):674-7. PMID: 14661540
Vascular resistance and lack of perfusion of the choroid is a factor in triggering choroidal neovascularization (CNV) to restore oxygenation, but this can lead to scar formation with long-term reduction in perfusion. POBF in eyes with drusen is lower than fellow eyes with CNV, but higher than fellow eyes with disciform scar.
Condition Phase POBF Significance
CNV 3 1217 (SD 476) microl/min p = 0.024
Drusen 2 1028 (385) microl/min
Drusen 2 1278 (341) microl/min p<0.001
Disciform scar 1 999 (262) microl/min
Chen SJ, Cheng CY, Lee AF, Lee FL, Chou JC, Hsu WM, Liu JH. Pulsatile ocular blood flow in asymmetric exudative age related macular degeneration. Br J Ophthalmol. 2001 Dec;85(12):1411-5; 1399-400. PMID: 11734510
POBF and ocular Pulse Amplitude (PA) in exudative AMD are lower than in non-exudative AMD and normal subjects.
Condition Phase POBF Significance PA Significance
Dry-AMD 2 607.0 microl/min p = 0.02* 2.2 mm Hg p = 0.04*
Normal 4 547.4 microl/min p = 0.01* 2.0 mm Hg p = 0.01*
Wet-AMD 1 372.7 microl/min 1.2 mm Hg
*comparison with Wet
Mori F, Konno S, Hikichi T, Yamaguchi Y, Ishiko S, Yoshida A. Pulsatile ocular blood flow study: decreases in exudative age related macular degeneration. Br J Ophthalmol. 2001 May;85(5):531-3. PMID: 11316708
Laser Doppler flowmetry monitors choroidal blood velocity, volume and flow in the fovea for dry AMD with 10+ large drusen and visual acuity 20/32 or better. Dry AMD choroidal blood volume is 33% below normal. Flow in dry AMD is 37% below normal. Blood flow pulsatility is 6% higher than normal in dry AMD (not significant).
Condition Phase Volume Significance Velocity Flow Significance
Normal 4 0.36 +/- 0.11 P = 0.005 0.44 +/- 0.07 13.7 +/- 3.5 P = 0.0005
Dry AMD 2 0.24 +/- 0.08 0.44 +/- 0.10 8.7 +/- 3.1
Grunwald JE, Hariprasad SM, DuPont J, Maguire MG, Fine SL, Brucker AJ, Maguire AM, Ho AC. Foveolar choroidal blood flow in age-related macular degeneration. Invest Ophthalmol Vis Sci. 1998 Feb;39(2):385-90. PMID: 9477998
Digital indocyanine green (ICG) angiograms show posterior zones of low or zero choroidal blood flow in 95% of wet ARM cases. Five patterns seen are horizontal (32%), vertical (14%), bipartite (9%), tripartite (31%), and quadripartite (9%). Choroidal neovascularization is always within or at the edge of the zone.
Goldberg MF, Dhaliwal RS, Olk RJ. Indocyanine green angiography patterns of zones of relative decreased choroidal blood flow in patients with exudative age-related macular degeneration. Ophthalmic Surg Lasers. 1998 May;29(5):385-90. PMID: 9599363
Pulsatility of ocular arteries is higher in AMD ( ; [, respectively]; and ). End-diastolic blood flow velocity of the short posterior ciliary arteries decreased in AMD. Increase of pulsatility and decrease of velocity of the short posterior ciliary arteries in AMD shows an increase of vascular resistance.
Ophthalmic artery P = 0.24
Temporal short posterior ciliary arteries P = 0.06
Central retinal artery P = 0.02
Nasal short posterior ciliary arteries P = 0.002
Friedman E, Krupsky S, Lane AM, Oak SS, Friedman ES, Egan K, Gragoudas ES. Ocular blood flow velocity in age-related macular degeneration. Ophthalmology. 1995 Apr;102(4):640-6. PMID: 7724181
One indication that the supply of good nutrition to the macula or the detoxification of the involved cells is a key factor in the disease is that the first genetic link to macular degeneration is a gene controlling a transport molecule. It is thought that this molecule is responsible for transporting some toxin or waste product out of the retinal cells.
Nutritional Factors in Macular Degeneration
Free radical pathology is a key feature of macular degeneration. The macula is the most metabolically active tissue in the body, and therefore produces the most free radicals. It is simultaneously the most dependent upon adequate circulation, not only to deliver oxygen, but antioxidant and other nutrients as well as to remove metabolic waste products.
There are hundreds of research studies that show nutritional factors play a role in macular health. Many specific nutrients may be helpful in macular degeneration. In treating a series of 60 patients with macular degeneration using the nutrients discussed below, over half sustained improvements in visual acuity. With aging, there is reduced intestinal absorption and cellular uptake and utilization of nutrients. These factors should be addressed in addition to supplementation. An increased intake of fresh, ripe organically grown fruits and vegetables is also highly recommended along with changes suggested by the following research data.
Fats and oils:
30% of the fat molecules in the brain and retina are docosahexaenoic acid (DHA), a long-chain fatty acid containing 6 double bonds. In the photoreceptor cells specifically, DHA comprises 60% of the fats. DHA is made in the body from essential omega 3 fatty acids found in such foods as dark green leafy vegetables, walnuts, and flax seeds. During developmental and degenerative processess, however, the body cannot make adequate amounts of DHA, and dietary supplementation becomes essential to develop, maintain, or regenerate normal visual acuity. Infants supplemented with DHA develop 1 to 2 lines better visual acuity during their first 6 months of life. DHA is available pre-formed in fish oil (e.g. EPA/DHA, salmon oil) and in more expensive vegetarian DHA capsules derived from algae.
A low-fat diet may reduce the risk of macular degeneration. A diet with as little as 10% of calories from fat has been suggested with avoidance of red meat and dairy products. Avoidance of margarine and other hydrogenated (trans) oils is especially important in wet macular degeneration. Beneficial sources of essential fatty acids (EFA) include Efacom, Evening primrose oil (EPO), EPA, DHA, Borage, Flax, Hemp seed (organic) and Black currant oils. It can take 6 months to a year to clear up effects of hydrogenated oils after they are eliminated from the diet. Soft drusen are hydrophobic deposits of apparently undigestible fats. Increased EFAs and reduced trans, hydrogenated, rancid and oxidized fats in the diet may help to reduce drusen formation, or perhaps permit long term reduction in accummulated deposits since EFAs loosen the structure of fat soluble cell membranes, while cholesterol, for example increases rigidity. Also, increased titers of lipid peroxides in the blood, even periodically, are associated with increased risk of vitreous syneresis with resultant pre-retinal gliosis and maculopathy. High LDL levels are strongly linked to wet ARM and cystoid macular edema (CME).
The length of the carbon chains in fatty acids is also a factor, with long chain triglicerides (LCT) increasing risk of macular degeneration while medium chain triglycerides (MCT) reduce risk. Palmitic acid found in avocado, and linoleic acid found in safflower, corn and peanut oil are problematic. EPA, found in small, cold water ocean fish like sardines and herring is beneficial.
Deficiency of omega-3 fatty acids is known to cause impaired vision in animals. When dietary levels are inadequate, omega-3 fatty acids are recycled in the retina. Animal studies show that with age omega-3 levels in the eye begin to fall. Visual dysfunction in low birth weight infants has been linked to the lack of omega-3 fatty acids in cow’s milk in contrast to breast milk. Visual acuities improve when omega-3 fatty acids from fish oil are included in the diet. Omega-3 fatty acids improve nerve function while also improving circulation with reduced cholesterol, thinner blood and prevention of blood clots. To prevent lipid peroxidation of such essential fatty acids, increased supplemental levels of antioxidants are also required (e.g. vitamins C, E and beta carotene). This is especially important since lipid peroxidation plays a role in macular degeneration. When treated with omega-3 fatty acid infusions for 4 weeks, 85% of macular degeneration patients over age 70 experienced improved vision. A dosage of 1500 to 2000 mg/day for 2 weeks followed by a maintenance level of 1,000 mg/day of omega-3 fatty acids is suggested.
Protein & Amino Acids
Most macular degeneration patients eat their protein “well done” or reheated, destroying important B vitamins including vitamin B6. Medium rare would be preferrable for health, provided that one is eating a healthy animal. Meats such as pork which can only safely be eaten well done should be avoided.
L-carnitine helps improve the transfer of EFAs accross the cell membrane. The preferrable form is Acetyl-L-Carnitine.
Taurine is found in high concentrations in the retina, especially in the photoreceptor cells. Taurine stabilizes cell membranes and regulates the movement of ions across the membrane. It seems to protect cells against UV damage, changes in ion concentrations and even toxins. Taurine thus plays an important role in rejuvenation and regeneration of retinal cells. Dietary taurine deficiency causes degeneration of photoreceptor cells in cats. In monkeys, deficiency of taurine causes morphological change to the photoreceptor cells as well as decreased visual acuity. Rats given a drug that blocks taurine uptake showed changes in RPE and photoreceptor cells as well as electroretinographic (ERG) findings similar to damage from excess UV exposure. Taurine is considered a non-essential amino acid because it can be made from cysteine, but the amounts humans are capable of manufacturing is very small. For example, children fed a diet without taurine show low plasma taurine and abnormal ERG’s, with restoration of normal blood levels and retinal function in most cases upon taurine supplementation. Animal studies also show that retinal degeneration caused by its removal from the diet are reversed with taurine supplementation. A study in adults also showed low levels of taurine produced in the urine when the diet was low in this ‘non-essential’ amino acid. Animal studies also show a decline in taurine with age. Bacterial dysbiosis (imbalance) in the intestinal tract may result in deficiency of this important amino acid. A supplemental dose of 100 mg/day of taurine has been recommended.
Cysteine, Methionine, N-acetyl cysteine & Glutathione:
Cysteine is important for retinal health maintenance, but deficiency can result from an imbalance in the intestinal bacterial flora. N-Acetyl-Cysteine (NAC) supplementation provides a stable form of cysteine with antioxidant activity. Like selenium and riboflavin, it increases production of glutathione, one of the most important antioxidants in the eye. Glutathione prevents lipid peroxidation and oxidation of sulfhydryl groups on proteins. Retinal cells grown in vitro without glutathione become weak, while those provided glutathione remain healthy. ARM patients have glutathione levels 58% lower than people without retinal degeneration. A daily dose of 100 mg of NAC is recommended. DMSO and MSM also supply usable organic sulfur.
Vitamins and Minerals
Increased intake of vitamins and minerals reduces the risk of macular degeneration. Several studies show 25 to 35% less visual loss in those patients taking supplements. Studies also show increases in vision and even recession of neovascularization in wet macular degeneration.
One notable study showed that a combination of antioxidant vitamins as well as therapies to improve circulation clearly improved vision in macular degeneration compared to placebo treatment, which had no effect. They also found an enhanced effect when the two types of treatments were combined.
Helsinki Study Placebo Vitamins A & E Vasodilator Blood Thinner + Vitamins A & E
Better (2+ lines) 0% 33% 33% 67%
Stable 67% 52% 57% 28%
Worse 33% 15% 10% 5%
Later research in Germany showed that a combination of vasodilation and vitamins A & E also could actually improve vision in macular degeneration. Many other studies show risk reduction from various nutrients including vitamins E and C as well as beta carotene. Reduced risk is also shown with high blood levels of beta carotene, selenium, and vitamins C and E. Because the retina is the most metabolically active tissue in the body, it requires a high level of antioxidant defence. Levels that are protective against cataract may not be adequate to prevent macular changes. The levels generally available in foods and in typical supplements have no significant impact on macular degeneration. The average multi-vitamin contains potencies which have only a slight beneficial effect on ARM risk. Instead, optimal or even mega-doses are sometimes needed. This may be partially due to decreased digestive powers, reducing absorption of important vitamins, minerals and other nutrients. And since it can take up to nine months for retinal cone receptor cells to rejuvenate, clinical trials must be continued at least this long if potential improvement is not to be missed simply due to lack of persistence.
Vitamin A & Beta Carotene:
Vitamin A deficiency causes atrophy of the rods and cones in rats and retinal degeneration in trout. Loss of color vision discrimination in the central retina can indicate vitamin A deficiency. This is seen in 30% of patients with ARM. Low thyroid function (e.g. low basal body temperature according to Barnes) can interfere with the ability to metabolize beta carotene (pro-vitamin A) into vitamin A required for visual receptor cell function. Vitamin A supplementation is contraindicated, however, according to some, as it may compete with vitamins E and K for absorption. Yet, vitamin A deficiency exacerbates the retinal damage due to vitamin E deficiency. Thus if taking high doses of these fat soluble vitamins, it would be best to take them at separate meals for optimal utilization.
Beta carotene protects against photosensitivity problems in the skin and may protect the retina against photo-oxidative stress, too. Low blood levels of beta carotene virtually double the risk of macular degeneration. Increased dietary beta carotene is protective against macular degeneration. It has been recommended to take 20,000 to 40,000 units of beta carotene daily.
Two other carotenoids, lutein and zeaxanthin, found in high levels in collard greens and spinach, appear to reduce risk of macular degeneration as well, according to researchers at Harvard Medical School, after evaluating the diets of over 800 eye patients. Eating these dark green leafy vegetables at least once a week was enough to begin lowering risk, with a 46 percent reduction in risk at a frequency of 2 to 4 times a week, and even greater benefit at 5 to 6 times per week. A research team led by Dr. Stuart Richer, O.D., Ph.D. at the Veterans Medical Center in North Chicago finds that 10 mg a day of supplemental lutein reverses some parameters of macular degeneration. Nearly all of the patients supplementing lutein show improvement in contrast sensitivity, or reduction of blind spots. Take lutein separately from beta caroten, as the carotenoids compete for absorption.
Astaxanthin, the pink pigment in salmon, shrimp, lobster and, yes, flamingos is yet another carotenoid that is rapidly establishing its potency for macular health maintenance and repair. Astaxanthin is 550 times more powerful as an antioxidant than vitamin E and 10 times more than beta carotene (Lutein weighs in at 200 and zeaxanthin at 475). Unlike beta carotene, Astaxanthin crosses the blood-brain barrier, delivered directly to the retina and macula. And unlike its cousin, Canthaxanthin (used for a time in tanning supplements), it has not been found to clump into asymptomatic deposits in the retina. Astaxanthin protects nerve cells in the retina and brain from UV radiation and free radical damage. In fact, rhodopsin (photopigment) levels appear to increase with Astaxanthin supplementation, and these levels are protected from loss due to photic (light) stress. The recommended dosage of Astaxanthin (BioAstinTM) is 2 mg twice a day.
Lycopene is natural red pigment, a fat soluble antioxidant related to beta carotene, but with twice the antioxidant power, making it 10 times more powerful than vitamin E. It is found in high levels in tomatoes as well as in guavas, watermellon and pink grapefruit. Lycopene may be the skin’s primary protective antioxidant against age-related damage from UV radiation. People with a low dietary intake of lycopene have twice the risk of macular degeneration.
B Complex Vitamins
Vitamin B complex supplementation has been recommended. The B vitamins work synergistically. All twenty known B vitamins are found in Stamina Plus.
Riboflavin is a cofactor for the enzyme glutathione reductase which regenerates reduced gluthione. In healthy individuals who already consume more than the RDA of riboflavin, supplemenation of levels above the RDA increase glutathione reductase activity. Riboflavin deficient rats develop abnormal electroretinograms (ERG). Supplementation of 10 mg/day of riboflavin increases plasma glutathione by 83% resulting in improved antioxidant protection of the retina.
Niacin can help improve night blindness, which is often an early sign of metabolic stress in the retina.
Up to 50 mg/day of pantothenic acid has been suggested.
Virtually all cases of wet macular degeneration are severely low in vitamin B6. A daily dose of at least 50 mg twice a day of vitamin B6 has been recommended.
Biotin improves vision in some cases of macular degeneration within 1 to 2 weeks. Biotin is involved in EFA and carbohydrate metabolism. It also converts fungal growths with root-like rhizomes back into their non-invasive yeast forms. This could be a mechanism involved in neovascular membranes. Suggested dosage is 1000 mcg/day. Diabetics may need to reduce insulin doses, so blood sugar should be carefully monitored.
Vitamin B14 (Trimethylglycine, Betaine, or TMG) is recommended by the Remission Foundation to enhance circulation, which is related to virtually all macular degeneration. The macula of the eye is the highest oxygen-demanding tissue in the body, and oxygen is delivered by the blood vessels. TMG reverses atherosclerosis (while also elevating mood and helping ot prevent cancer) as one of the body’s most potent methyl donors. It recycles SAMe (S-Adenosyl Methionine) which would otherwise break down into Homocysteine, a toxic amino acid associated with atherosclerosis much more strongly than is cholesterol. TMG also recycles Homocysteine into methionine, and provides a protective methyl coating to protect the DNA from free radical damage. TMG is naturally derived from beets, but eating enough beets would add too much iron to the diet. msm tablets We now know that iron, even at ‘normal’ levels promotes free radical aging processes and reduces longevity. When TMG has used up its first of three methyl groups, it becomes dimethyl glycine, or DMG (see below).
Vitamin B15 (Pangamic acid, Dimethylglycine, or DMG) has been recommended, although TMG provides all the benefits of DMG and more.
Low blood levels of vitamin C increase risk of macular degeneration by about 2 to 3 times. In rats, supplementation of vitamin C reduced retinal damage from excessive light exposure. For those with diabetes and individuals in normal health, vitamin C reduces intracellular sorbitol accumulation. Therapeutic doses of vitamin C and bioflavonoids usually reduce retinal swelling in wet macular degeneration within about a week. At least 750 mg/day to 1500 mg/day of supplemental vitamin C taken in divided doses (3 times a day) has been reported to be useful in most cases. Smokers should take at least an extra 500 mg/day for each pack of cigarrettes smoked, since this amount is destroyed by smoking.
Supplemental Vitamin C in the ascorbic acid form above 1500 mg/day can reduce absorption of important minerals including calcium, chromium and copper which usually are the rate limiting factors in the production of SOD. Ascorbic acid is specifically concentrated in the eye through the production of aqueous humor by the ciliary body. Thus intraocular levels can sometimes reach higher levels than any other part of the body, and in combination with sunlight can result in disruption of connective tissue structures.
Supplemental ascorbic acid over 2500 mg/day, even on a periodic basis, increases risk over 9-fold for vitreous syneresis and resulting pre-retinal gliosis and maculopathy as well as macular pucker and cellophane maculopathy.
Bioflavonoids can improve tissue integrity while providing antioxidant and anti-inflammatory protection. Quercetin, one of the most effective and best studied bioflavonoids, has been measured in the retina of cows at a concentration of 4 to 7 mcg/100 gm. Quercetin, found in red onions and ginkgo (see herb section), has properties similar to melanin, as it protects plants from damage due to solar radiation. Quercetin is the most potent bioflavonoid for preveting lipid peroxidation, such as that triggered in the retina by high energy photons. It works synergistically with taurine and vitamin E.
Rutin (from buckwheat) reduces capillary leakage in the retina.
Anthocyanosides (also called proanthocyanidins, procyanidolic oligomers, PCOs, leukocyanidins, pycnogenols, flavonoid complexes, and polyphenols), bioflavonoids found in bilberry, blueberry, grape, other fruit and vegetables, as well as extracts from pine bark (pycnogenol), the bracts of the lime tree, and the leaves of the hazel-nut tree, amplify retinal photoconduction. They have been shown to increase retinal enzymatic activity in rabbit studies. They improve retinal functions, such as dark adaptation, glare recovery, macular sensitivity, absolute visual threshold, night vision, and electrophysiological measures such as VEP (85% showed improvement) and ERG (40% showed improvement) even in people with normal, healthy eyes. This is an even more important benefit to patients with macular disease who are known to need double the normal light levels for reading. These powerful bioflavonoids also improve capillary integrity and reduce retinal bleeding and leakage in diabetic retinopathy. A standard therapeutic dose is 150 to 300 mg/day.
A total dose of 1,000 to 3,000 mg/day of bioflavonoids, such as from quercetin, bilberry or ginkgo (see herb section) has been recommended.
Vitamin D levels in the blood are reduced in pre-wet ARM.
Vitamin E stabilizes cell membranes, reduces the cell’s need for oxygen, increases blood flow through atherosclerotic blood vessels, decreases leakage from blood vessels, and provides antioxidant protection including preventing the loss of vitamin A by oxidation. Vitamin E deficiency causes macular degeneration in rats with increased lipofuscin granules deposited inside RPE cells. Vitamin E deficient monkeys show macular degeneration at the outer segments of the photoreceptor cells due to increased lipid peroxidation. Low blood levels of vitamin E double the risk of macular degeneration. Vitamin E supplementation improved visual acuity in 72% of people with senile dystrophy of the macula lutea. Another doctor reports that over 90% of his macular degeneration patients show improved vision, and that only 5% deteriorated with supplementation of vitamin E in combination with other nutrients. European research shows Vitamin E is 82% effective at preventing progression of Age Related Macular Degeneration. A daily dosage of 200 to 800 I.U. of natural vitamin E has been recommended. The only unprocessed and undiluted Vitamin E supplement is Unique E.
Vitamin K is important in blood clotting, and so may be beneficial in wet macular degeneration. Capsella bursa-pastoris (Shepherd's purse) is an excellent source.
Important electrolyte minerals including sodium, potassium and magnesium must be maintained in the proper stable ratios, especially in wet macular degeneration.
Calcium & Phosphorus:
The dietary ratio of calcium to phosphorus is reduced in pre-wet ARM. Supplementation with Microcrystalline Hydroxyapatite (MCHA or MCHC) Calcium is recommended to provide additional calcium, as this form stimulates active calcium absorption, doubling utilization of any calcium in the meal at the time the supplement is taken. Dissolving the supplement in the mouth is also beneficial for remineralizing the tooth enamel, and this form of calcium (the same form as found in bone) has been found to increase bone density 6% in both patients diagnosed with osteoporosis and patients taking steroid medications which cause osteoporosis.
Nonenzymatic glycosylation of tissue proteins may be a factor in macular degeneration in those with diabetes and perhaps even in those with more subtle sugar regulation problems. In this process glucose is bound irreversibly to protein making it more susceptible to further damage, while also interfering with its normal function. Sugar regulation can be improved in both hypoglycemia and hyperglycemia with chromium supplementation. Diabetics should monitor blood glucose levels carefully, since chromium can decrease the need for insulin or oral hypoglycemic drugs. This is may have a double benefit, since oral hypoglycemics such as diabinase and orinase are photosensitizing, resulting in increased light damage to the retina and higher rates of retinal disease.
Selenium, a cofactor in the antioxidant enzyme glutathione peroxidase, is normally found at high levels in the retina. Vision has been improved in macular degeneration with selenium therapy in combination with Vitamin E, with which it acts synergistically. A dosage of 100 to 200 mcg/day of Selenium supplementation has been recommended. The preferred form is organic L-selenomethionine rather than the cheaper mineral form, selenite.
Zinc & Copper:
Zinc is needed at higher concentrations in the eye than in most tissues. Zinc is required as a cofactor for enzymes linked to both day and night vision. Zinc is also necessary for Vitamin A metabolism, which is in turn necessary for retinal function (see Vitamin A section). Zinc has antioxidant activity and also stabilizes cell membranes. Zinc levels in the retinal pigment epithelium (RPE) decrease with age. Zinc levels in the retina affect the level of melanin, which protects against photo-oxidative damage, and is known to decrease after age 50. Dietary Zinc deficiency has been shown to cause abnormal retinal function in rats, as well as disruption of both RPE and photoreceptor cells. The macula degenerates when zinc is deficient. People over age 65 tend to get only 2/3 of the RDA for Zinc, while aging actually increases the need for zinc in order to maintain a positive zinc balance. Poor absorption of zinc can also be due to conditions affecting the digestive system including Crohn’s disease, alcoholism and pancreatitis. Double blind testing of 45 mg/day of zinc showed reduced loss of vision after 1 to 2 years. Vision has been stabilized and even improved in macular degeneration with zinc therapy. Up to 50 mg/day of Zinc supplementation has been recommended but prolonged use of levels over 25 mg should usually be accompanied by copper supplementation to prevent copper deficiency which can increase LDL cholesterol. Zinc and copper are both necessary in the proper ratio, for example in the production of SOD, so long term supplementation of either should include supplementation of the other in ratio, unless an excess condition, such as copper toxicity has been established. Copper, in excess, promotes free radical pathology, and should thus be avoided. One study also indicates excess serum zinc in macular degeneration. If testing shows zinc to be high, copper supplementation is suggested, and vice versa, to normalize the ratio. If both are low, both should be supplemented, and are best absorbed when taken at least 12 hours apart. Most atrophic, non-exudative (dry) ARM patients have been found to be low in zinc, copper or both, as well as being 18 times more likely than others their age to have low SOD, an enzyme dependent on both zinc and copper, and responsive to dietary intake of these trace minerals. A dose of 15 to 25 mg/day of zinc is suggested.
A daily dose of 20 mg of Manganese has also been suggested. Manganese picolinate is a well absorbed form available to professionals.
Sulfur is the third most prevalent mineral in the body, after Calcium and Magnesium. It is required for many processes, including liver detoxification (linked to eye health according to the observations of Traditional Chinese Medicine). Sulfur is also crucial in repairing damaged tissue, such as scarring found in the macula, where visual acuity has already been lost due to macular degeneration. Because of the detoxification effects (e.g. Mercury detoxification), it is recommended to begin gradually increasing the dosage of MSM (the most efficient source of organic sulfur) from a quarter teaspoon twice a day (dissolved in water) up to 3/4 teaspoon twice a day in water. The full daily dose can be added to a liter of water and drunk throughout the day at the rate of about 4 ounces every half hour. Because MSM has a bitter taste, this drink can be made more palatable by adding TMG (3 scoops per day), as its natural sweet taste helps balance the bitterness of MSM.
Remember, though, that bitter tasting foods and herbs stimulate the liver, which is important for healing the eyes. Be assured, also, that your taste buds regenerate every 30 days, so a remedy that tastes overly bitter to you when you start taking it, you may experience as quite strengthening and invigorating after a month or so.
Ginkgo biloba extract (GBE) provides antioxidant activity, enhances arterial circulation and improves cellular metabolism. It is effective in treating neurological problems related to aging. A six month double-blind study on senile macular degeneration showed improved visual acuity in 90% of test subjects, with none showing deterioration, while in the placebo group twice as many showed deterioration as compared to those improving. Ginkgo may benefit even wet macular degeneration by increasing choroidal blood flow, thereby reducing hypoxia as a stimulus for neovascularization, as well as increasing delivery of other therapeutic agents.
Convulvulus arvensis is available as Vascustatin, the most potent natural antineovascular/antiangioneogenesis remedy available. This is indicated in wet macular degeneration, especially where neovascularization is already documented.
(Vaccinium myrtillus) See section on bioflavonoids.
Shepherd’s purse (Capsella bursa pastoris) is an excellent natural source of vitamin K. Vitamin K promotes clotting, which is important in cases of retinal bleeding.
1,000 mg/day of garlic (Allium sativa) supplementation is recommended for its beneficial effects of normalizing hypertension and hypercholesterolemia while preventing blood clots that can block retinal circulation.
Maritime pine bark extract from the species Pinus maritima are widely recommended as a bioflavonoid source for retinal health. The trademarked name for this product is Pycnogenol. Many of the later studies on pycnogenol, however were actually performed with extracts from the less costly grape seed source. Both sources are highly beneficial. A non-solvent extract of American coastal white pine is available in Maxogenol.
Grape seeds, skin and wine extracts (Vitis vinifera) are an excellent source of bioflavonoids for the retina.
White Willow Bark (natural ‘Aspirin’):
Aspirin, originally derived from white willow bark (Salix alba), and still available in its herbal form, has been suggested as a remedy for dry ARM. Aspirin thins the blood, increasing blood flow to the retina. One study showed a 20% reduction in risk with aspirin use. It is definitely contra-indicated in wet ARM, however, as it can cause or exacerbate retinal bleeding. Levels as low as 75 mg/day can cause retinal hemorrhage, and other pain killers such as ibuprofen and non-steroidal anti-inflammatory drugs (NSAIDs) are no safer. Even dry ARM can convert to the more serious wet type, and those with hypertension are especially at risk, so anti-clotting and blood thinning benefits may be outweighed by the risk of side effects. The use of aspirin for prevention of macular degeneration is generally discouraged. When necessary, the use of herbal “aspirin” may be safer than using the synthetic form due to the presence of natural cofactors found in the herb such as bioflavonoids.
Glandulars & Hormones
Women who iatrogenically enter menopause before age 45 due to oophorectomy (surgical removal of one or both ovaries) show a four-fold increase in macular degeneration. This is not seen in spontaneous early menopause. Supplementation with ovarian tissue as a glandular or homeopathic sarcode should be considered.
Other research suggests that estrogen replacement therapy (ERT) after menopause may reduce the risk of macular degeneration. Due to negative side effects of ERT, many nutritionally oriented doctors are recommending supplementation of DHEA, a precursor to both adrenal and male/female hormones, as a more biocompatible alternative. Typical doses generally range up to 30 mg/day for men and 15 mg/day for women. Oral and cream products based on DHEA precursors in wild yam (dioscorea) and/or phyto-estrogens in soy are also recommended.
Thyroid glandulars or Armour Thyroid are natural sources of thyroid hormone as a replacement therapy. This can help stimulate liver function including vitamin A metabolism with beneficial effects on macular health. As with many hormone replacement therapies, dependency is a relatively high risk with this approach, but benefits may often outweigh this problem. Homeopathic thyroid sarcodes function more to stimulate thyroid function, minimizing risk of dependency, even when taken together with more concentrated glandular products.
Antiangioneogenesis factors present in shark cartilage and bovine cartilage may help prevent or reverse subretinal neovascular nets in the wet type of macular degeneration.
Interferon is sometimes used to treat wet macular degeneration. The effectiveness of high doses is questionable. It is also available in a homeopathic dose.
Human Growth Hormone and DHEA are suggested by Remission Foundation to support reversal of age-associated and degenerative processes. Homeopathic Human Growth Hormone can now be taken orally, as can Growth Hormone Releasing Hormone and IGF-1 (the active form of Growth Hormone). There is currently a virtual revolution occurring in natural medicine with the availability of growth factors which will most likely help to further stimulate the regeneration of specific tissues, such as the retina.
DHEA is available in several useful forms, the most interesting of which are sublingual life-formed DHEA Sulfate (absorbs about 6 times better than most synthetic DHEA on the market) and 7-Keto DHEA, which the body does not convert to sex hormones such as estrogen or testosterone.
Age related changes in the skin that are thought to be caused by exposure to excessive amounts of sunlight have been found to be more prevalent among those who have macular degeneration. For example, fishermen, who are exposed to both the open sky and reflected light from the water, show increased risk of ARM. One study found those who were exposed to more summer sun had double the rate of ARM, while those who always wore hats and sunglasses had a 40% decrease in the normal rate. Dense cataracts are associated with a 50% increase in the risk of macular degeneration, while slight cataract increases risk by 80%. Cataractous lenses absorb more light, particularly in the blue and UV portions of the spectrum. An increase in ARM with cataract may be showing that the inadequate antioxidant defences leading to cataract also increase risk for retinal damage, even from the diminished oxidative stress of high energy photons still penetrating the cataractous lens. Following cataract surgery, the risk of ARM jumps to 200%, while retinal aging is increased sixfold. Toward the equator the intensity of the sun is even greater. On a tropical island, it was observed that retinal changes appeared in just 4 months in outdoor workers.
UV-B radiation is ionizing, producing free radicals that, like the free radicals produced by aging, stress, toxicity and disease, can damage retinal cells if not first quenched or “scavenged” by antioxidants. Although not all studies link UV light to ARM, excess exposure to UV and blue light may contribute to macular degeneration in the absence of adequate antioxidant defences, while excess oxidative damage to cell membranes contributes to macular damage even in the absence of UV exposure. Unfortunately some 40% of sunglasses are mislabelled. UV coatings can be added to any eyeglass lens, however, and special contact lenses with UV absorption are also available. UV coatings appear clear to the eye. Inside the eye, Vitamin C acts as a natural UV filter, while the macula lutea (“yellow spot”) and the aging crystalline lens (which yellows with age) provide blue-blocking light filtration which may naturally slow the retinal aging process, as anti-oxidant defences dwindle. Blue light penetrates deeper into the eye than UV, and may be linked with drusen deposits in the part of the retina exposed directly to sunlight. Yellow, orange or brown wrap-around goggles designed to absorb blue light may be indicated in severe cases or following cataract removal, especially outdoors, but chronic use, such as indoors, may also stress central nervous system mechanisms responsive to light frequencies. One sunglass technology utilizes melanin, the natural brown pigment used in the body to protect against excessive UV energy. Black South Africans have a high level of melanin in the retina, and experience only a 1% incidence of ARM. People with blue eyes, which are blue precisely because they contain less melanin, show a rate of macular degeneration 20 times that of people with brown eyes. Melanin levels also decrease with aging especially after age 50.
Improved lighting increases reading speed for people with macular degeneration. A gooseneck lamp with a built in reflector to help focus light on the reading material is recommended by most low vision specialists along with an appropriate power magnifier (most often below 6X, but sometimes higher) and training in its correct use. One study, in which only 14% of the patients could read the newspaper without magnfication, showed 92% success with proper use of a magnifier.
Some commonly used remedies that can treat the symptoms of macular degeneration include:
Phosphorus for wet macular degeneration with retinal bleeding and dark spots in the vision. (also Sulphur).
Hyoscyamus for macropsia, which means objects appear larger (also Nux moschata) or micropsia.
Sepia (squid or cuttlefish ink) for women with black spots in the vision (also Glonoin or Natrum muriaticum).
Homeopathic remedies which may help reduce the central scotoma associated with macular degeneration include:
Aloe socotrina (aloe)
Thyroidinum (thyroid gland, sheep)
Retinal bleeding accompanying wet macular degeneration may be helped by:
Crotalus horridus (rattlesnake venom)
Possible remedies for black spots in the vision, which can be due to macular disease, include:
Agaricus muscarius (Amanita muscaria or fly agaric)
Argentum nitricum (silver nitrate)
Asclepias tuberosa (pleurisy root)
Aurum metallicum (gold)
Belladonna (Atropa belladonna or deadly nightshade)
Calcarea carbonica (calcium carbonate)
Camphora (Laurus camphora)
Carbo animalis (animal charcoal)
Chelidonium majus (Celandine)
Chlorum (chlorine gas in water)
Cimicifuga racemosa (black cohosh, snake root, Actea racemosa or Macrotys racemosa)
Cocculus indicus (Indian cockle)
Conium maculatum (poison hemlock)
Curare (arrow poison)
Dulcamara (Solanum dulcamara, bitter-sweet)
Elaps corallinus (coral snake)
Helleborus niger (black hellebore, Christmas rose)
Lilium trigrinum (tiger lilly)
Lycopodium clavatum (club moss spores)
Medorrhinum (gonnorhea nosode)
Melilotus officinale (yellow clover, sweet clover)
NATRUM MURIATICUM (sodium chloride, table salt)
Petroleum (crude rock oil)
Psorinum (scabies vesicle)
SEPIA SUCCUS (cuttlefish juice or squid ink)
Silicea terra (silica, flint)
Stramonium (Datura stramonium, Jimson weed, thornapple)
Syphilinum (luesinum, syphilis nosode)
Thuja occidentalis (arbor vitae)
Veratrum album (white hellebore)
Dark spots in the vision may indicate a need for:
Agaricus muscarius (Amanita muscaria, fly agaric)
Anacardium orientale (marking nut, malacca bean)
Asclepias tuberosa (pleurisy root)
Cactus grandiflorus (selenicereus, night-blooming cereus)
Carbolicum acidum (phenolum)
Carbo animalis (animal charcoal)
Cimicifuga racemosa (black cohosh, snake root, Actea racemosa, Macrotys racemosa)
Cocculus indicus (Indian cockle)
Conium maculatum (poison hemlock)
Elaps corallinus (coral snake)
Helliborus niger (black hellebore, Christmas rose)
Jatropha curcas (purging nut)
Kali carbonicum (potassium carbonate)
Medorrhinum (gonorrhea nosode)
Mercurius solubilis (mercury, quicksilver, mercurius vivus)
SULPHUR LOTUM (sublimatum)
Thuja occidentalis (arbor vitae)
For micropsia (objects appearing small), remedies may include:
Allium cepa (red onion, a source of quercetin)
Aurum metallicum (aurum colloidale, metallic gold)
Berberis vulgaris (barberry)
Camphora (Laurus camphora)
Carbo vegetabilis (vegetable charcoal)
Cyclamen europaeum (sow-bread)
Hyoscyamus niger (henbane)
Lycopodium clavatum (ground pine, club moss spores)
Medorrhinum (gonorrhea nosode)
Mercurius solubilis (mercurius vivus, mercury (Hg), quicksilver)
Mercurius corrosivus (sublimatus)
Opium (dried poppy latex)
Petroleum (crude rock oil)
Platinum metallicum (platinum)
Plumbum metallicum (lead (Pb))
Staphysagria (delphinium staphysagria, stavesacre)
Stramonium (Datura stramonium, jimson weed, thornapple)
Thuja occidentalis (arbor vitae)
For macropsia (objects appearing large), remedies may include:
Aethusa cynapium (fool’s parsley)
Apis mellifica (honey bee)
Atropinum purum aut sulphuricum
Berberis vulgaris (barberry)
Cannabis indica (hashish, marijuana)
Cannabis sativa (hemp, marijuana)
Conium maculatum (poison hemlock – no relation to the hemlock tree)
Euphorbium officinarum (Euphorbium resinifera)
HYOSCYAMUS NIGER (henbane)
Laurocerasus (cherry laurel)
Natrum muriaticum (table salt, sodium chloride)
Niccolum carbonicum aut metallicum (nickel)
NUX MOSCHATA (nutmeg)
Onosmodium virginianum (false cromwell)
Opium (dried poppy latex)
Oxalicum acidum (sorrel acid)
Physostigma (calabar bean)
Verbascum thapsus (mullein)
A classical homeopathic practitioner can evaluate your particular case (including symptoms seemingly ‘unrelated’ to your eyes) to determine which of these homeopathic remedies are more likely to benefit you at this time. Energetic testing may also indicate a particular resonance with one or more remedies, as well as the particular potency that will be most effective.
Beta carotene/serum (blood levels of beta carotene below 69 mg% approximately double the risk of macular degeneration).
Vitamin C/plasma (blood levels of vitamin C below 0.7 mg% increase risk of macular degeneration by a factor of 2 to 3 times over blood levels between 0.7 to 1.6 mg%)
Ascorbic Acid/WBC provides a more functional measurement of cellular vitamin C utilization.
Vitamin D3 (25,OH)/serum (low) is associated with pre-wet ARM.
Vitamin E/plasma (blood levels of vitamin E below 0.8 mg% double risk of macular degeneration compared to levels of 1.3 mg%)
Vitamin E/platelet provides a more functional measurement of vitamin E utilization.
Superoxide Dismutase/erythrocyte (ESOD), an important antioxidant enzyme, is 18 times more likely to be low (below 9.5 units/mg hemoglobin) in patients with dry macular degeneration than in other people of the same age, suggesting Copper and/or Zinc deficiency. Elevation is associated with pre-wet confluent soft drusen and choroidal degeneration of the macula.
EGPT (Erythrocyte Glutamate-Pyruvate Transaminase, elevated) is strongly linked to high intake of denatured (well-done) protein together with lack of vitamin B6 (which is lost in cooking). Transaminase titers are 67.5 times more likely to be elevated in active wet ARM than normal. High levels are also linked to pre-wet changes.
EGOT (Erythrocyte Glutamic-Oxaloacetic Transaminase) is another functional measure of vitamin B6 deficiency.
Zn/lymphocyte (Zinc) measures cellular zinc utilization.
Zn/hair (Zinc, low) in dry macular degeneration
Cu/hair (Copper, low) in dry macular degeneration
Lipid Peroxide/serum (free radicals)
LDL/serum (low density lipoprotein, also known as “bad” cholesterol) elevation is strongly linked to wet ARM and especially CME.
Linoleic acid to linolenic acid ratio/plasma (elevated) is related to pre-wet ARM.
D-glucaric acid/urine (high) is associated with pre-wet changes.
Clinical Testing Highlights
Foveal Reflex: Loss of the foveal reflex seen in direct ophthalmoscopy is probably one of the earliest signs of depletion of vitamin A levels in the macula. Later, loss of the pink area surrounding the fovea, as well as mottling of the pigmentation in the central retina can signal more severe vitamin A deficiency or even early macular degeneration. Edema can also show as an increase in hyperopia (farsightedness).
Amsler Grid is a test often used to evaluate macular degeneration, and even to monitor it at home. A low contrast Amsler Grid may be even more sensitive. (see illustration)
Contrast Sensitivity testing is sometimes more sensitive to changes in vision in macular degeneration, both deterioration and improvement, as compared to a standard Snellen letter chart alone.
Photostress testing: Glare recovery and adaptation to light and dark is often affected early in retinal disease. A simple test, which can even be performed as a self-test, is to look at a flashlight for 10 seconds and then see how long it takes to achieve normal visual acuity. This is done one eye at a time. If it takes over 30 seconds to achieve the level of vision you had before staring at the bright light, you probably have a problem, even if you do not have loss of central visual acuity under normal conditions. By starting early, preventive measures sometimes as simple as supplemental zinc or vitamin A may help restore this function to normal in many cases before it becomes more serious. In macular degeneration, the typical recovery time is 1 to 10 minutes.
Central Threshold Visual Fields testing is a very sensitive measure of visual function, although testing may be impaired by poor fixation ability if there is significant loss of central vision.
Focal Macular Electroretinogram (FME) is an ERG (Electroretinogram) specific to the central retina affected in macular disease. This is an objective test which may pick up problems in the electrical response of the macula to light stimuli.
C-reactive protein (CRP) is a blood measure of systemic inflammation. Adjusted multivariate analysis reveals the risk for AMD rises with CRP. Smokers in the highest CRP range have an odds ratio of 2.16 for AMD. JAMA 2004;291:704-710.
Group CRP Odds-Ratio
AMD-free 2.7 mg/L Median -
Advanced AMD 3.4 mg/L Median -
- 0.2 to 1.2 mg/L 1.00
- 1.2 to 2.7 mg/L 1.09
- 2.7 to 6.5 mg/L 1.24
- 6.5 to 117.0 mg/L 1.65
Never smoke 0.2 to 1.7 mg/L 1.00
Never smoke 1.7 to 4.5 mg/L 1.15
Never smoke 4.5 to 117.0 mg/L 2.03
Well-cooked protein intake over 1.8 times the RDA level increases risk of earlier onset of wet ARM. Elevated protein intake is associated with pre-wet ARM.
Ratio of dietary Calcium to Phosphorus is low in the pre-wet ARM population.
Macular Health Maintenance
Macular Degeneration is America’s leading cause of irreversible blindness.
91% of patients can improve their vision with at least one year of effort.
Improvements in vision can be sustained with life-long health optimization.