Macular Degeneration

When I was very young, a friend of mine told me her sister was beginning to learn Braille. I instantly thought, “Oh, she is blind too.” But it turned out that her sister had developed wet macular degeneration and at the time I didn’t know anything about the process or the stigmatism people with this disease face because they are considered blind, but in fact have quite a bit of usable vision. I was able to learn a great deal about it when I recently attended a seminar on the topic.

Macular degeneration comes primarily in two forms: dry and wet. Dry macular degeneration is the most common, affecting 90 percent of patients. Its progression is slower than its counterpart, which has proved somewhat of a disadvantage to patients afflicted with it. Since wet macular degeneration progresses much more quickly, the focus of current research has been its treatment, despite the fact that the greatest percentage of patients suffer from the other form.

However, whichever form you suffer from, the beginning stages are the same. Macular degeneration seems to develop because of free radical injuries to the eye; free radicals are loose molecules which float throughout the body of any oxygen-breathing animal. Usually, they are neutralized by antioxidants, such as vitamins C and E. However, when they are not neutralized, their sheer numbers make it quite possible for them to injure some part of the body. After the initial injury has taken place, there tends to be inflammation in the eye. Traditionally, inflammation helps to heal the injury, but because of the structure of the eye, it tends to make these sorts of injuries worse. Eventually, the inflammation grows to such a point that it becomes difficult for waste materials to leave the eye and for valued nutrients to enter it, resulting in reduced vision.  

There is one important distinction which I think must be made when speaking of “vision loss” with macular degeneration. The area affected by the disease is the macula, or center of the retina. Peripheral vision is primarily left intact, meaning that much of the time, individuals with macular degeneration can appear, for all intents and purposes normal. For instance, a person may not be able to read a word because of where the point of affected vision is within the eye. However, they may be able to read an eye chart perfectly, since they only have to distinguish one letter at a time.

After the initial similarity between the two types they diverge quite a bit in terms of symptoms. With wet macular degeneration, the blood vessels beneath the retina break. There is traditionally a barrier which separates these vessels from the retina itself. However, after the onset of the disease, they multiply until they put so much pressure on the barrier that it breaks. After these blood vessels come in to contact with the retina and break, vision loss begins to occur. With dry macular degeneration, small white spots called drusins form. While these also form with wet, it is the breaking of the blood vessels and the barrier between them and the retina that causes the vision loss. In dry however, these spots spread until they cover a substantial part of the eye. Eventually, they form something very similar to a scar and with this tissue covering the macula of the retina, the macula begins to atrophy.

There are a number of treatments for the wet form of macular degeneration. The most successful have been two drugs, lucintus and avastin, which are injected directly into the eyeball. These drugs target a protein needed for the making of new blood vessels. This means that the blood vessels stop multiplying, which can often arrest vision loss. The catch to these drugs is that they are not a permanent solution. You must have new injections every 1-3 months for them to continue to be successful and there is no clear evidence on how long this can continue before they stop working entirely. Lucintus is the most expensive drug of the two, which has led to the widespread use of avastin. The two drugs are now being compared in a wide-ranging study to see if there is any difference in effectiveness.

Dry macular degeneration is more difficult to treat.  The greatest breakthrough was made by the Age Related Eye Diseases Study (AREDS), which found that a combination of antioxidant vitamins could slow the progression of the disease. They found the best combination to be 500 milligrams of vitamin C, 400 milligrams of vitamin E, 15 milligrams of beta-carotene and 80 milligrams of zinc to be taken daily. Now, however, beta-carotene is being called into question and many doctors are taking it out of the formula.

There are many side effects of macular degeneration which are not related directly to the blind but are of a more psychological nature. Macular degeneration affects mainly seniors. Many seniors are terrified of the concept of blindness; they and their families are unaware that people with vision loss can still live full, independent lives. Another thing which seniors are sometimes not aware of simply because of how macular degeneration is explained in the literature is that it does not result in total blindness; instead, it results in the loss of central vision. The first thing to go is face recognition, which means that often, when an older family member cannot recognize people, the family believes they are suffering from cognitive impairments rather than searching for another cause. For people who have relied on vision all their lives, a deep depression can often set in. Many psychiatrists don’t understand this depression because the patient isn’t “totally blind,” but the fact is that loss of any significant amount of vision in a society geared for sighted people can be crippling without the correct training.

There are also difficulties associated with training seniors in rehabilitation.  If seniors have mild to moderate hearing loss, they may use their vision to learn and interpret things. Once the vision begins to go, new ways must be found for teaching them. Also, they may need modifications most blind people would not, like a support cane for balance or grab bars in their bathrooms. It never occurred to me, but vision must be used quite a bit to keep from tripping and this is especially important for seniors, who can sustain serious injuries in a fall. Without the vision, they will need other resources to be safe.

There is no way to prevent macular degeneration. However, there are steps which can be taken to lower your risks. Smoking puts you at a much greater risk for the disease because of the large amount of free radicals in the toxins of cigarettes. Omega-6 acids in large quantities also put you at risk.  However, these are much trickier to avoid than cigarettes because Omega-6 acids are in vegetable oil, which is in almost every packaged food, including many foods that are advertised as “healthy.” When the presenter of the seminar and a friend went to a convenience store, they only found a few food items that did not contain vegetable oil, including catsup, mustard and relish.

To put into perspective how many Omega-6 acids we are ingesting compared to what we should be: the recommended ratio of omega-6 to omega-3, which are the acids found in things like nuts and fish oil, is 4 to 1 per day. Our ingested ratio per day is more like 20 to 1. To offset this imbalance, you can cut back on packaged foods as much as possible; cook with olive oil as much as possible, since it is the vegetable oil with the least omega-6; and either through supplements or food, ingest about 1000 milligrams of Omega-3.

If you would like more info on preventing macular degeneration or living with it if you already have it, go to: www.hadley.edu. Click on the link that says seminars and then click on past seminars. If you scroll down, you should find it fairly quickly. The presenter was thorough and articulate, and it is an enlightening program if you have the time to listen.