PreserVision’s formula matches
the one recommended by the
AREDS 2 study.

Adding AMD nutraceuticals to your arsenal of therapeutics benefits your patients and ups your bottom line.

From spectacles and contacts to co-managing cataract surgery, we help maintain the refractive state necessary for good vision over the course of a patient’s lifetime. With the advent of therapeutics, the majority of optometrists treat glaucoma to maintain retinal thickness and function. So it is with nutraceuticals and age-related macular degeneration (AMD). Nutritional supplements that are rich in antioxidants can provide protection against chronic conditions, such as AMD, as well as support overall eye health (see “Supplements for Eye Health At-A-Glance,” on p. 28 for specific ones). I would encourage all practitioners to have an integrated strategy in their offices to help patients understand and receive the proper nutraceuticals to help prevent and even lessen the severity of AMD.

In our office, we start in the examination room with a basic discussion of the macula and the rising risk of macular degeneration with advancing age, usually while reviewing the patient’s fundus photos. In addition, we carry nutraceuticals and recommend tailored programs for each patient. The basic, and most complete, program is a multivitamin which includes the AREDS 2 formulation with a “triglyceride” omega-3 (fish oil) formulation. For those patients who already take a multivitamin and don’t want to change, we have a lutein/zeaxanthin supplement which can be taken along with their current multivitamin. We also recommend an omega-3 supplement if they are not already taking one. If they are, then we discuss the difference between “ethyl ester” and “triglyceride” forms of fish oil.

There are two major formulations for concentrated omega-3 supplements: trigycleride and ethyl ester. Research has shown that the triglyceride formulation is 70% more bioavailable than the less expensive ethyl ester formulation, so it makes sense to recommend a supplement in a triglyceride form. The problem is that manufacturers are not required to state the formulation on the label. One way to tell the two apart is by comparing the cost. Triglyceride processing is more expensive than the ethyl ester development, and that cost is transferred to the consumer. Another way is to try the Styrofoam cup test. Cut an omega-3 capsule open with a pair of scissors, then pour the oil into a Styrofoam cup. An ethyl ester formula will actually eat or melt the Styrofoam; a triglyceride omega-3 will not. This demonstration can be done easily (and impressively) in front of the patient. Bottom line: recommend a triglyceride form of omega-3.

MacuHealth LMZ3
contains lutein,
zeaxanthin, and
meso-zeaxanthin to
increase macular

The 2001 Age-Related Eye Disease Study (AREDS) showed that a formulation of certain vitamins and minerals could reduce the risk of developing AMD. AREDS 2 was initiated in 2006 to improve on the original AREDS formulation, with the following changes:

•Lutein and zeaxanthin replaced beta carotene. All three are carotenoids and antioxidants. Though beta-carotene was included in the original formulation because it was a precursor of vitamin A, which is essential for vision, two large National Cancer Institute studies found that beta-carotene might increase lung cancer risk for smokers. The carotenoids lutein and zeaxanthin have been shown to be beneficial for people with AMD.
•Omega-3 fatty acids were added. Previous studies had shown that a dietary intake of lutein/zeaxanthin and omega-3s was associated with a lower risk of developing AMD.
•The amount of zinc was reduced. Some nutritional experts had expressed concern over the recommended amount of zinc in the original formulation, so the recommended dose was lowered for AREDS 2.

Even before results from the AREDS 2 study were announced many eyecare practitioners were recommending omega-3s and lutein/zeaxanthin supplements. Now that the National Eye Institute has said that it will not perform further AREDS studies due to cost and diminishing return on investment, following other literature to keep an eye out for newer formulations and research is even more important.

AREDS and AREDS 2 Formulations
AREDS Formulation (2001)
500mg Vitamin C
400 I.U. Vitamin E
15mg beta-carotene
80mg zinc as zinc oxide
2mg copper as cupric oxide
No omega-3 fatty acids
AREDS 2 Formulation (2014)
500mg Vitamin C
400 I.U. of Vitamin E
10mg lutein; 2 mg zeazanthin
25mg zinc as zinc oxide
2mg copper as cupric oxide
100mg of omega-3 fatty acids
(350mg DHA/650mg EPA)

The most recent development is the discovery and availability of meso-zeaxanthin supplements. Studies have shown that meso-zeaxanthin in combination with lutein and zeaxanthin can increase macular pigment better than lutein and zeaxanthin alone. Only two companies have acquired the patent rights to include meso-zeaxanthin in their supplements, and our office has been recommending one of these supplements for all of our dry AMD patients as well as our high-risk patients. In fact, one of my patients who took meso-zeaxanthin/lutein/zeaxanthin and omega-3 together showed remarkable improvement of the dry retinal pigment detachments that is typical of dry AMD (see “Before” and “After” images, right).



BEFORE: Notice the large number of RPE detachments
typical of dry AMD in this cirrus macular scan. This
condition was basically stable with the patient taking
traditional AREDS 2 regimen.
AFTER: This image exhibits marked reduction in size and number of RPE detachments six months after the patient started taking meso-zeaxanthin/lutein/zeaxanthin combined with a triglyceride omega-3.

Other helpful tools beyond fundus imaging include macular pigment measuring devices, such as ZeaVision’s QuantifEye MPS II,  which can help to identify patients with low levels of macular pigment, and  are often sold in tandem with particular vitamin lines. Another imaging tool is AdaptDx by Maculogix which measures a patient’s dark adaptation function, which is impaired in AMD.

I strongly encourage practitioners to recommend nutraceuticals and sell them directly to patients with AMD. Just be sure you are familiar with the formulation you carry or recommend. I will often schedule patients for a 15-minute appointment in which they bring in their vitamins so I can review what they are taking and advise them on what to add to comply with the AREDS 2 formulation. A recent study found that many over-the-counter formulations did not conform to AREDS 2 standards, so reviewing your nutraceuticals (see “AREDS and AREDS 2 Formulations,” on p. 18) is the best way to ensure your patients are receiving the proper doses to save their vision from the ravages of AMD.

Randall Sakamoto works in private practice in Honolulu, HI


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