Key Papers on Eye Health - Johnson & Johnson · Key Papers on Eye Health Introduction Lifestyle factors have been linked to many general health conditions and there is widespread

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Key Papers on Eye Health

Introduction

Lifestyle factors have been linked to many general health conditions and there is

widespread awareness of the many benefits of a healthy diet, regular exercise, and

avoiding smoking and excessive alcohol consumption. Yet until recently little

attention has been paid to the influence of lifestyle on eye health.

Growing evidence is now emerging for relationships between various exposures and

common eye diseases. For some potential risk factors, such as smoking, the

evidence is compelling, while associations with other behaviours are less well

supported in the literature or findings are contradictory.

Eye care professionals need to keep abreast of the latest thinking on lifestyle and

eye health in order to provide accurate advice to patients. This literature review is

intended as an introduction to this complex and fascinating subject. It describes

some of the landmark studies on eye health, summarises current research findings

and suggests resources for further information.

Contents Page

Recommended reading for general overview 2

Landmark studies 4

Smoking 6

Diet 12

Alcohol 23

Recreational drugs 27

Exercise 29

Obesity 31

Light exposure 33

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Recommended reading for general overview

Lifestyle and eye health Klein BE and Klein R. Lifestyle exposures and eye diseases in adults. Am J Ophthalmol 2007;144:6 961-969. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2157550&blobtype=pdf (full

text)

Extensive review of associations between lifestyle exposures/behaviours and eye disease

Reviews cataract, AMD, diabetic retinopathy, open angle glaucoma, trauma, dry eye, refractive error by risk factor

Some exposures, such as smoking, are significantly associated with risk of several different diseases

Although data are imperfect, lifestyle alterations may reduce risk of eye disease at little or no risk to the individual

Fletcher AE (2009). Healthy Ageing: The Eye. In: Stanner et al (eds). Healthy ageing: the role of nutrition and lifestyle. Wiley-Blackwell, Oxford, 2009.143-158.

Comprehensive review of research on the relationship between lifestyle exposures and the risk/development of age-related eye diseases

Reviews association between UV exposure, smoking and nutrients with age-related macular degeneration (AMD) and cataracts

Considers research findings in the context of public health advice.

Conclusions: - Smoking is a major risk factor for cataract and macular

degeneration - There is moderate evidence that high exposures to sunlight are

associated with increased risk of cataract and AMD - High dietary intakes of antioxidants can protect against AMD and

cataract. Although the evidence is inconsistent, data suggests that vitamin C and the carotenoids lutein and zeaxanthin play a critical role in eye health. Overall evidence supports general healthy eating guidelines for the consumption of fruit and vegetables and oily fish

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General / Lifestyle – Resources

Feeling great, looking good. A guide to how a healthy lifestyle can help prevent sight loss. RNIB, 2006. http://www.rnib.org.uk/xpedio/groups/public/documents/PublicWebsite/public_healthreportp.pdf The Healthy Sight Institute http://www.healthysightinstitute.org/ Royal College of Ophthalmologists. Ocular public health http://www.rcophth.ac.uk/about/public/public-health NHS Choices. Looking after your eyes http://www.nhs.uk/livewell/eyehealth/pages/lookingafteryoureyes.aspx

Synonyms Key

AMD Age-related Macular Degeneration

ARM Age-related Maculopathy

AREDS Age Related Eye Disease Study

ETS Environmental Tobacco Smoke

POAG Primary Open Angle Glaucoma

PSC Posterior Sub Capsular

DES Dry Eye Syndrome

FA Fatty Acids

EPO Evening Primrose Oil

NHS National Health Service

UVR Ultra Violet Radiation

HEI Healthy Eating Index

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Landmark studies

The Age-Related Eye Disease Study (AREDS)

https://web.emmes.com/study/areds/ (dedicated website)

Sponsored by the US National Eye Institute (http://www.nei.nih.gov/amd/)

Investigated natural history and risk factors of age-related macular degeneration (AMD) and cataract

Randomised, placebo-controlled, clinical trial evaluating effect of high-dose antioxidants and zinc supplementation on progression of AMD and cataract

AREDS followed 4,700 subjects in US with varying stages of AMD from January 1998. The NEI has since launched AREDS2 involving 100 clinical centres and c4,000 study participants ages 50 - 85 who have AMD. Participants will be followed for 5-6 years. http://www.areds2.org/

Key findings: High levels of antioxidants and zinc significantly reduce the risk of advanced AMD and associated vision loss but have no significant effect on the development or progression of cataract.

AREDS Bibliography: https://web.emmes.com/study/areds/biblio/biblio.pdf

Beaver Dam Eye Study

http://www.bdeyestudy.org/node/1 (dedicated website)

Funded by the NEI to investigate prevalence and incidence of age-related cataract, AMD and diabetic retinopathy and their causes

Now examining relationship of long-term exposures (eg, blood pressure, lipid levels, exposure to UV-light, and medications) to these eye conditions

Began in 1989 in Beaver Dam, Wisconsin and involved c5,000 subjects aged 43-84 years at baseline, followed at 5, 10, 15 and 20 years. Key findings: Association of cigarette smoking with cataract and AMD. Also looked at dry eye – smoking, caffeine use and multivitamins among factors investigated but with conflicting results. Blue Mountains Eye Study

http://www.cvr.org.au/bmes.htm (summary of study and findings)

First large population-based assessment of visual impairment and common eye diseases of a representative older (49-97) Australian community sample

Assessed visual impairment, cataract, AMD, glaucoma, other vascular retinopathy, other general health measures.

Also questioned on types of food they consumed

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The Blue Mountains Eye Study followed 3,654 subjects in Australia from 1992-1994 and followed surviving participants at 5, 10 and 15 years. A further 1,206 took part in an extension study in 1999-2000. Key findings: Increased risk of nuclear cataract with smoking and heavy alcohol, while higher dietary intakes of protein and vitamins were protective. For cortical cataract, alcohol intake and higher dietary polyunsaturates were protective. Sunlight exposure, smoking and higher dietary salt were all associated with a higher risk of posterior subcapsular cataract. Four-fold increased risk of late-stage AMD among smokers than past or non-smokers, and 10-year earlier onset than non-smokers. Higher fish consumption protective against AMD but increased risk with higher consumption of dietary fat. Diabetes associated with higher rates of obesity.

List of abstracts: http://www.cvr.org.au/abstracts.htm

Among other major studies:

Los Angeles Latino Eye Study

http://www.nei.nih.gov/news/pressreleases/080904.asp (press release with findings)

Funded by NEI, the largest, most comprehensive epidemiological analysis of visual impairment in Latinos conducted in the US

Assessed risk factors for eye disease and measuring health-related and vision-related quality of life

Investigated prevalence of visual impairment, blindness, cataract, glaucoma, diabetic retinopathy, and AMD

LALES followed 6,300 Latinos, primarily Mexican-Americans, aged 40 and older from the Los Angeles area. Results first reported in 2003. Key findings: Showed differences in eye disease prevalence between ethnic groups. Risk factors for visual impairment included low education and unemployment. Unmarried status associated with increased risk of glaucoma but no association found for smoking or alcohol use. Smoking and heavy alcohol consumption, particularly beer, associated with greater risk of advanced AMD List of publications: http://www.labmeeting.com/papers/author/los-angeles-latino-

eye-study-group

See also Rotterdam Eye Study and others. List of some Eye Disease Prevalence

Studies: http://www.nei.nih.gov/EYEDATA/pbd_studygroup.asp

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Smoking

Overview: Smoking is an important factor in eye health. Many studies have indicated a role for smoking in the incidence and progression of AMD. Smoking is also consistently associated with nuclear cataract but there is limited evidence of a relationship with other types of cataract. Data on smoking and glaucoma, diabetic retinopathy and dry eye are inconclusive. Contact lens wearers who smoke have an increased risk of microbial keratitis compared to non-smokers. Awareness of the link between smoking and eye disease is low and there is currently an untapped opportunity for ECPs to educate patients on this issue. In view of the known effects on general health, sensible advice is not to smoke.

Smoking and eye health - General

Solberg Y, Rosner M and Belkin M. The association between cigarette smoking and ocular diseases. Surv Ophthalmol 1998;42:6:535-47.

http://www.surveyophthalmol.com/article/S0039-6257(98)00002-2/abstract

Claims most chronic ocular diseases, with possible exception of diabetic retinopathy and glaucoma, appear to be associated with smoking

Cataract and AMD, the leading causes of severe visual impairment and blindness, are directly accelerated by smoking

Smoking is direct cause of tobacco-alcohol amblyopia

Increased risk of blindness should be added to arguments against smoking Lois N, Abdelkader E, Reglitz K et al. Environmental tobacco smoke exposure and eye disease. Br J Ophthalmol 2008;92:10 1304-10. http://bjo.bmj.com/content/92/10/1304.abstract (abstract)

Literature review on environmental tobacco smoke (ETS) and eye disease

Says active smoking has been proposed to be a risk factor in AMD, Graves ophthalmology, glaucoma, uveitis, refractive errors, strabismus, tobacco-alcohol amblyopia, non-arteritic ischaemic optic neuropathy, Leber optic neuropathy and diabetic retinopathy but literature on some conditions scarce

Data on ETS and eye disease insufficient to draw conclusions but should be addressed in future studies

Smoking and AMD Thornton J, Edwards R, Mitchell P et al. Smoking and age-related macular degeneration: a review of association. Eye 2005;19:935-44. http://www.nature.com/eye/journal/v19/n9/abs/6701978a.html (abstract)

UK-based review of epidemiological evidence associating smoking with AMD

Of 17 studies reviewed, 13 found a statistically significant association

2-3X increased AMD risk in current smokers compared with never-smokers

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Evidence of dose-response, temporal relationship and reversibility of effect

Cigarette smoking likely to have toxic effects on the retina

Highlights lack of awareness about the risks of developing eye disease from smoking among both healthcare professionals and the general public.

AREDS Research Group. Risk factors associated with age-related macular degeneration. A case-control study in the age-related eye disease study: Age-Related Eye Disease Study Report Number 3. Ophthalmology 2000;107:12 2224-32.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11097601 (full text)

AREDS participants aged 60-80 ranging from no AMD to advanced AMD in one eye

Those with drusen, neovascular AMD or geographic atrophy were more likely to be smokers

Avoidance of smoking may reduce the risk of developing AMD

Prevention of vision impairment may be used as a motivating factor to help them modify this risk factor

Klein R, Klein BE and Moss SE. Relation of smoking to the incidence of age-related maculopathy. The Beaver Dam Eye Study. Am J Epidemiol 1998;147:2 103-10. http://aje.oxfordjournals.org/cgi/reprint/147/2/103 (full text)

Men who smoked more cigarettes were more likely to develop early AMD than men who had smoked less

Current smokers (men and women) had higher odds of developing large drusen after 5 years than those who had never smoked or had quit

Smoking appears to be related to the incidence of some lesions associated with early age-related maculopathy.

Smoking and cataract Kelly SP, Thornton J, Edwards R et al. Smoking and cataract: review of causal association. J Cataract Refract Surg 2005 31:12 2395-404. http://www.jcrsjournal.org/article/S0886-3350(05)00527-4/abstract (abstract)

UK-based review of 27 epidemiological studies on smoking and cataract

Found strong association, particularly for nuclear cataract

Smoking associated with 3-fold increase on risk for incident nuclear cataract

Limited evidence of an association between smoking and posterior subcapsular cataract, and little or no association with cortical cataract

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Klein BE, Klein R, Linton KL et al. Cigarette smoking and lens opacities: the Beaver Dam Study. Am J Prev Med 1993;9:1 27-30. http://www.ncbi.nlm.nih.gov/pubmed/8439434?ordinalpos=14&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum (only available abstract)

Frequencies of more severe nuclear sclerosis increased with packyears of cigarette smoking in women and men

Frequencies of posterior subcapsular opacities also increased in both sexes with increased packyears

No significant effect on cortical opacities

Smoking was associated with past cataract surgery Cumming RG and Mitchell P. Alcohol, smoking and cataracts: the Blue Mountains Study. Arch Ophthalmol 1997;115:10 1296-303.

http://archopht.ama-assn.org/cgi/reprint/115/10/1296 (pdf)

Investigates associations between alcohol consumption, tobacco smoking, and cataract

Those who had ever smoked cigarettes had a higher prevalence than non-smokers of more severe nuclear and posterior subcapsular cataracts

Association between pipe smoking and nuclear cataract was stronger than the association with cigarette smoking

Smoking and glaucoma Edwards R, Thornton J, Ajit R et al. Cigarette smoking and primary open angle glaucoma: a systematic review. J Glaucoma 2008;17:7 558-66. http://journals.lww.com/glaucomajournal/Abstract/2008/10000/Cigarette_Smoking_and_Primary_Open_Angle_Glaucoma_.9.aspx (abstract)

Review of 11 epidemiological studies on smoking and POAG

Found mostly poor methodology and little evidence for a causal association

Further, high-quality studies needed

Highlights importance of warning ophthalmic patients of the dangers of smoking and providing cessation support, because clear evidence of links between smoking and other ocular and systemic diseases

Smoking and diabetic retinopathy Moss SE, Klein R, Klein BE. The 14-year incidence of vision loss in a diabetic population. Ophthalmol 1998;105:6 998-1003.

http://www.ophsource.org/periodicals/ophtha/article/S0161-6420(98)96025-0/abstract (abstract)

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Examines potential risk factors for vision loss among younger onset insulin-dependent diabetics

Loss of vision associated with more pack years smoked

Smoking and dry eye Moss SE, Klein R and Klein BE. Long-term incidence of dry eye in an older population. Optom Vis Sci 2008;85:8 668-74. http://journals.lww.com/optvissci/pages/articleviewer.aspx?year=2008&issue=08000&article=00011&type=abstract (abstract)

Part of Beaver Dam Eye Study

Estimates 10-year incidence and risk factors in older population aged 43-86

No significant association between dry eye and smoking (or caffeine use) Smoking and contact lens-associated microbial keratitis Stapleton F, Keay L, Edwards K et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology 2008;115:10 1655-62. http://www.ophsource.org/periodicals/ophtha/article/S0161-6420(08)00307-2/abstract (abstract)

Establishes risk factors for contact lens-related microbial keratitis

Odds ratio for daily wear users was 2.96X in current smokers compared to non-smokers

Painter J and Crossland M. Smoking, eye disease and smoking cessation strategies. Optometry in Practice 2006;7:147-154. http://www.college-optometrists.org/coo/download.cfm?uuid=BD03536F-6565-4EB2-97D43BE8D2F97BB5&type=oip (full text)

Reviews smoking and AMD, cataract, glaucoma, other optic nerve disease, other eye disease

Outlines ‘five As’ approach to smoking cessation in primary care, NHS Stop Smoking Services and nicotine replacement therapies

Smoking cessation – attitudes of optometrists and public

Thompson C, Harrison RA, Wilkinson SC et al. Attitudes of community optometrists to smoking cessation: an untapped opportunity overlooked? Ophthalmic Physiol Opt 2007;27:4 :389-93.

http://www3.interscience.wiley.com/journal/118520621/abstract?CRETRY=1&SRETRY=0 (abstract)

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Few community optometrists routinely asked about smoking habits: only 6.2% at new patient consultations, and 2.2% at follow-up visits

Reasons given: not their role, lack of time and forgetting to ask

Overall 67.6% community optometrists wanted to improve their knowledge of smoking and visual impairment with 56.2% requesting further training

Untapped opportunities to develop brief interventions to promote smoking cessation services in community optometry settings.

Bidwell G, Dahu A, Edwards R et al. Perceptions of blindness related to smoking: a hospital-based cross-sectional study. Eye 2005;19:9 945-8.

http://www.nature.com/eye/journal/v19/n9/abs/6701955a.html (abstract)

Survey of adult patients attending UK district general hospital ophthalmology, general surgery, and orthopaedic clinics

Only 9.5% of patients believed smoking was definitely or probably a cause of blindness, compared with 92.2% for lung cancer, 87.6% for heart disease, and 70.6% for stroke

About one-half of smokers stated that they would definitely or probably quit smoking if they developed early signs of blindness

Link between smoking and eye disease should be publicised

Moradi P, Thornton J, Edwards R et al. Teenagers' perceptions of blindness related to smoking: a novel message to a vulnerable group. Br J Ophthalmol 2007;91:5 605-7.

http://bjo.bmj.com/cgi/content/full/91/5/605 (abstract)

Survey of teenagers attending four organised social events

Only 5% believed smoking caused blindness, whereas 15%, 27% and 81% believed that smoking caused stroke, heart disease and lung cancer

Subjects were significantly more fearful of blindness than other conditions

More teenagers said they would stop smoking on developing early signs of blindness compared with early signs of lung or heart disease.

Teenagers should be made more aware of the ocular risks of cigarette smoking as a novel public health measure

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Smoking – Resources

Smoking and sight loss. RNIB, 2008. Factsheet. http://www.rnib.org.uk/xpedio/groups/public/documents/publicwebsite/public_ehwsmoking.hcsp

RNIB helpline: 0845 766 9999

Quitline. Website, helpline 0800 00 22 00 and QUIT pack. http://www.quit.org.uk/

National Smoking website: http:\\www.givingupsmoking.co.uk and hotline 0800 169 0169 Royal College of Ophthalmologists factsheets (with population statistics) http://www.rcophth.ac.uk/docs/college/patientinfo/Smoking_and_Eye_Disease.pdf http://www.rcophth.ac.uk/docs/college/patientinfo/Smoking_your_Sight_Away.pdf NHS Choices. Smoking http://www.nhs.uk/LiveWell/Smoking/Pages/smokingnewhome.aspx

Department of Health – advice on Tobacco http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Tobacco/index.htm

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Diet

Overview: Eating a healthy, balanced diet will provide all of the nutrients required to keep the body healthy and may help maintain eye health. Due to antioxidant activities in the eye, many studies on diet and eye health have focused on a potential role for the antioxidant vitamins C and E and the carotenoids (plant pigments) B-carotene, lutein and zeaxanthin, especially in AMD and cataract. Research has investigated the effect of these nutrients within the diet (ie within foods) and/or when taken as dietary supplements. Research on this topic is derived from both from observational and intervention studies; it is important to take study design into account when interpreting research outcomes, especially when causal links cannot be established. Overall, epidemiological data provide evidence for a protective effect of high antioxidant intakes (such as vitamins C and E) against AMD and cataract. Some observational data suggest higher dietary intakes of carotenoids, especially lutein and zeaxanthin, may protect against cataract and AMD. However, research in this area is inconsistent; the US Food and Drug Administration has concluded there is insufficient evidence to support a protective role of lutein and zeaxanthin for risk of cataract and AMD. A diet high in omega-3 fat and low in total fat may decrease the risk of developing AMD and slow its progression. Intervention studies have shown that a specific high dosage of antioxidants could help to reduce the risk of advanced AMD for people who already have moderate AMD, although high doses of supplements are contraindicated in some groups (eg smokers). Intervention studies have generally found no benefit of vitamin supplementation on cataract. Controlled intervention trials have shown that foods high in omega-6 fatty acids may improve dry eye symptoms in women and some dietary supplements are also effective in managing dry eye. Overall, a healthy, balanced diet can protect against age-related eye disease; evidence supports general dietary guidelines for the consumption of a diet rich in fruit and vegetables, especially fruit high in vitamin C and vegetables high in lutein and zeaxanthin. It is important that nutrients are obtained through a healthy, balanced diet; vitamin/mineral supplements are not a substitute and are of no proven benefit in the prevention of age-related disease. Those diagnosed with AMD and considering supplements are advised to consult their doctor. A healthy, balanced diet will also help to protect against other conditions associated with eye health such as obesity, diabetes and hypertension.

Note: Studies in this section are classified by experimental design to help readers exercise caution, where necessary, when interpreting research outcomes. The authors would like to acknowledge Kiran Rahelu, Nutrition Specialist, for her expert review and input to this section.

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Diet and Age-Related Macular Degeneration Observational studies Dietary supplements and AMD Klein BE, Knudtson MD, Lee KE et al. Supplements and age-related eye conditions: the Beaver Dam Eye study. Ophthalmology 2008;115:7 1203-8. http://www.ophsource.org/periodicals/ophtha/article/S0161-6420(07)01029-9/abstract (abstract)

Investigates association of vitamin, mineral, and non-vitamin, non-mineral supplements with age-related cataract, AMD and high IOP

Little evidence of any significant associations except for small protective effect for cortical cataracts by vitamins A and D, zinc, and multivitamins and increased odds of late AMD

Late AMD associated with incident use of vitamins A, C, and E and zinc. This may reflect advice by family, friends, and health care providers about benefits of AREDS-like supplements

Diet / dietary supplements and AMD

Flood V, Smith W, Wang JJ et al. Dietary antioxidant intake and incidence of early age-related maculopathy: the Blue Mountains Eye Study. Ophthalmology 2002;109:12 2272-8.

http://www.ophsource.org/periodicals/ophtha/article/S0161-6420(02)01263-0/abstract (abstract)

Investigates associations between dietary intake, including modest supplement intake, of antioxidant vitamins and zinc at baseline and 5-year incidence of early age-related maculopathy (ARM)

No associations found between baseline intake of alpha-carotene, beta-carotene, beta-cryptoxanthin, lutein and zeaxanthin, lycopene, retinol, vitamin A, and zinc, and 5-year incidence of early ARM

Increasing baseline intakes of vitamin C, from diet and supplements, associated with increased risk of early ARM

No evidence of protection associated with usual dietary antioxidant or zinc intakes (including use of supplements) on 5-year incidence of early ARM

Diet and AMD Chiu C-J, Klein R, Milton RC et al. Does eating particular diets alter risk of age-related macular degeneration in users of the age-related eye disease study supplements? Br J Ophthalmol 2009;93:1241-1246. http://bjo.bmj.com/cgi/content/abstract/bjo.2008.143412v1 (abstract)

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Part of AREDS

Progression to both dry and wet AMD was 25% less likely among those eating a diet rich in omega-3 fatty acids (DHA or EPA).

A high omega-3 diet combined with a low glycaemic index (GI) carbohydrate intake reduced the risk of progression to advanced disease even further, cutting it by 50%

Eating two to three servings of oily fish, such as salmon, tuna, mackerel and herring every week, would achieve the recommended daily intake of omega 3, cutting the risk of both early and late stage AMD

Chong EW, Robman LD, Simpson JA et al. Fat consumption and its association with age-related macular degeneration. Arch Ophthalmol 2009;127:5 674-80.

http://archopht.ama-assn.org/cgi/content/abstract/127/5/674 (abstract)

Evaluates associations between past dietary fat intake and AMD prevalence

Higher trans-unsaturated fat intake associated with increased prevalence of late AMD

Higher omega-3 fatty acid intake inversely associated with early AMD

Olive oil intake associated with decreased prevalence of late AMD

No significant associations for intakes of fish, total fat, butter, or margarine

Diet low in trans-unsaturated fat and rich in omega-3 fatty acids and olive oil may reduce risk of AMD

Tan JS, Wang JJ, Flood V et al. Dietary fatty acids and the 10-year incidence of age-related macular degeneration. Arch Ophthalmol 2009;127(5):656-665. http://archopht.ama-assn.org/cgi/content/abstract/127/5/656 (abstract)

Part of Blue Mountains Eye Study

Assesses relationship between baseline dietary fatty acids and 10-year incident AMD

One serving of fish per week associated with reduced risk of incident early AMD, primarily among those with less than median linoleic acid consumption

Similar findings for intake of long-chain omega-3 polyunsaturated fatty acids

One to two servings of nuts per week associated with reduced risk of incident early AMD

Supports protection against early AMD from regularly eating fish, greater consumption of omega-3 polyunsaturated fatty acids, and low intakes of foods rich in linoleic acid. Regular consumption of nuts may also reduce AMD risk

Seddon JM, Rosner B, Sperduto RD et al. Dietary fat and risk for advanced age-related macular degeneration. Arch Ophthalmol 2001;119:1191-1199. http://archopht.ama-assn.org/cgi/content/abstract/119/8/1191 (abstract)

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Case-control study evaluating relationship between intake of total and specific types of fat and risk for advanced AMD

Higher intake of specific types of fat, including vegetable, monounsaturated, and polyunsaturated fats and linoleic acid, rather than total fat intake may be associated with a greater risk for advanced AMD

Diets high in omega-3 fatty acids and fish were inversely associated with risk for AMD when intake of linoleic acid was low

Smith W, Mitchell P and Leeder SR. Dietary fat and fish intake and age-related maculopathy. Arch Ophthalmol 2000;118:401-404.

http://archopht.ama-assn.org/cgi/content/abstract/118/3/401?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=leeder+sr&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT (abstract)

Assesses whether dietary intake of fat or fish is associated with age-related maculopathy (ARM) prevalence

Higher frequency of fish consumption was associated with decreased odds of late ARM

Subjects with higher energy-adjusted intakes of cholesterol were significantly more likely to have late ARM, with an increased risk for late ARM for the highest compared with the lowest quintile of intake

The amount and type of dietary fat intake may be associated with ARM

Chong EW, Simpson JA, Robman LD et al. Red meat and chicken consumption and its association with age-related macular degeneration. Am J Epidemiol 2009;169:7 867-76.

http://aje.oxfordjournals.org/cgi/content/abstract/169/7/867 (abstract)

Higher red meat intake positively associated with early AMD

Odds ratio for consumption of red meat > or =10 times/week versus <5 times/week was 1.47

Similar trends seen with higher intakes of fresh and processed red meat.

Consumption of chicken > or =3.5 times/week versus <1.5 times/week was inversely associated with late AMD

Different meats may differently affect AMD risk and may be a target for lifestyle modification

Intervention studies

Intervention studies currently underway include AREDS 2. http://www.areds2.org/

AREDS Study Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol 2001;119:10 1417-36.

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http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11594942 (full text plus corrections and comments)

Investigates effects of antioxidant and zinc supplementation on progression of AMD in subjects (median age 69 years) with intermediate ARM or late AMD at baseline

Significant odds reduction for development of advanced AMD with antioxidants plus zinc supplementation.

Persons older than 55 years in high-risk group, and without contraindications such as smoking, should consider taking a supplement of antioxidants plus zinc such as that used in this study

Evans J. Antioxidant supplements to prevent or slow down the progression of AMD: a systematic review and meta-analysis. Eye 2008;22:6 751-60. http://www.nature.com/eye/journal/v22/n6/abs/eye2008100a.html (abstract)

Examines evidence from 3 randomised, placebo-controlled trials investigating whether antioxidant vitamin or mineral supplements prevent development of AMD or slow progression

No evidence that antioxidant (vitamin E or beta-carotene) supplementation prevented AMD

Antioxidant (beta-carotene, vitamin C, and vitamin E) and zinc supplementation slowed progression to advanced AMD and VA loss

People with AMD, or early signs, may experience some benefit from taking supplements as used in AREDS trial

Potential harms of high-dose antioxidant supplementation must be considered. These may include increased risk of lung cancer in smokers (beta-carotene), heart failure in people with vascular disease or diabetes (vitamin E) and hospitalisation for genitourinary conditions (zinc)

Diet & Cataract Observational studies Dietary supplements and cataract (see also above)

Kuzniarz M, Mitchell P, Cumming RG et al. Use of vitamin supplements and cataract: the Blue Mountains Eye Study. Am J Ophthalmol 2001;132:1 19-26.

http://www.ajo.com/article/S0002-9394(01)00922-9/abstract (abstract)

Investigates relationships between use of vitamin supplements and three principal cataract types

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Long-term use of multivitamins, B group and vitamin A supplements associated with reduced prevalence of nuclear or cortical cataract

Strong protective influence on cortical cataract from use of folate or vitamin B12 supplements

Diet and cataract Tan AG, Mitchell P, Flood VM et al. Antoxidant nutrient intake and the long-term incidence of age-related cataract: the Blue Mountains Eye Study. Am J Clin Nutr 2008;87:6 1899-905.

http://www.ajcn.org/cgi/content/full/87/6/1899 (full text)

Investigates relationship between antioxidant nutrient intakes measured at baseline and 10-year incidence of age-related cataract

Dietary antioxidants, including beta-carotene, zinc, and vitamins A, C, and E, assessed.

Higher intakes of vitamin C or combined intake of antioxidants had long-term protective associations against development of nuclear cataract in this older population.

Cumming RG, Mitchell P, Smith W. Diet and cataract: the Blue Mountains Eye Study. Ophthalmology 2000;107:3 450-6.

http://www.ophsource.org/periodicals/ophtha/article/S0161-6420(99)00024-X/abstract (abstract)

Part of Blue Mountains Eye Study

To investigate relationships between a wide range of macro- and micronutrients and the three main types of cataract in older people

Higher intakes of protein, vitamin A, niacin, thiamin, and riboflavin were associated with reduced prevalence of nuclear cataract

Intake of polyunsaturated fats was associated with reduced prevalence of cortical cataract

No nutrients were associated with posterior subcapsular cataract

Moeller SM, Taylor A, Tucker KL et al. Overall adherence to the Dietary Guidelines for Americans is associated with reduced prevalence of early age-related nuclear lens opacities in women. J Nutr 2004;134:1812-1819. http://jn.nutrition.org/cgi/content/full/134/7/1812 (full text)

Part of Nurses’ Health Study

Examines whether adherence to the dietary guidelines was associated with a lower prevalence of age-related nuclear lens opacities in

Diet quality defined according to 1) daily number of servings of fruits, vegetables, and whole grains; 2) Recommended Foods Score (RFS); and 3) Healthy Eating Index (HEI)

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Women in the highest quartile category of HEI scores were significantly less likely to have nuclear opacities than those in the lowest category

Taylor A, Jacques PF, Chylack LT et al. Long-term intake of vitamins and carotenoids and odds of early age-related cortical and posterior subcapsular lens opacities. Am J Clin Nutr 2002;75:3 540-549. http://www.ajcn.org/cgi/content/full/75/3/540 (full text)

Part of Nurses’ Health Study

Assesses relationship between usual nutrient intakes and age-related cortical and posterior subcapsular (PSC) lens opacities

For women aged <60, vitamin C intake of 362 mg/d or more associated with a 57% lower odds ratio of developing cortical cataract than intake <140 mg/d

Use of vitamin C supplements for 10 years or more associated with a 60% lower odds ratio than no vitamin C supplement use

Prevalence of PSC lens opacities related to total carotenoid intake in women who never smoked

Brown L, Rim EB, Seddon JM et al. A prospective study of carotenoid intake and risk of cataract extraction in US men. Am J Clin Nutr 1999;70:4 517-524. http://www.ajcn.org/cgi/content/full/70/4/517 (full text)

Examines association between carotenoid and vitamin A intakes and cataract extraction in men

Slightly lower risk of cataract extraction in men with higher intakes of lutein and zeaxanthin but not of other carotenoids or vitamin A

Men in highest fifth of lutein and zeaxanthin intake had 19% lower risk of cataract relative to men in lowest fifth

Among specific foods high in carotenoids, broccoli and spinach were most consistently associated with lower risk of cataract

Leske MC, Chylack LT and Wu SY. The Lens Opacities Case-Control Study. Risk factors for cataract. Arch Ophthalmol 1991;109:2 244-51. http://archopht.ama-assn.org/cgi/reprint/109/2/244 (full text)

Evaluates risk factors for age-related nuclear, cortical, posterior subcapsular, and mixed cataracts

Dietary intake of riboflavin, vitamins C, E, and carotene was protective for cortical, nuclear, and mixed cataract

Intake of niacin, thiamine, and iron also decreased risk

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Intervention studies

There have been very few controlled trials specifically investigating the effects of diet and supplementation on cataracts; other trials designed to investigate non-eye diseases have generally found no benefits of vitamin supplementation on cataract.

Diet & Diabetic retinopathy

Observational studies

Diet / dietary supplements and diabetic retinopathy

Mayer-Davis EJ, Bell RA, Reboussin BA et al. Antioxidant nutrient intake and diabetic retinopathy: the San Luis Valley Diabetes Study. Ophthalmology 1998;105:12 2264-70.

http://www.ophsource.org/periodicals/ophtha/article/S0161-6420(98)91227-1/abstract (abstract)

Examines the relationship between dietary and supplement intakes of vitamins C, E, and beta-carotene and risk of diabetic retinopathy.

387 participants with type 2 diabetes in San Luis Valley Diabetes Study

No protective effect was observed with antioxidant nutrients

Depending on insulin use, appeared to be potential for deleterious effects of nutrient antioxidants. Further research needed.

Diet & Glaucoma

Observational studies

Diet / dietary supplements and glaucoma

Pasquale LR and Kang JH. Lifestyle, nutrition and glaucoma. J Glaucoma 2009;18:6 423-8.

http://journals.lww.com/glaucomajournal/pages/articleviewer.aspx?year=2009&issue

=08000&article=00001&type=abstract (abstract)

Reviews modifiable lifestyle factors, such as exercise, diet, and smoking, that may influence intraocular pressure

Epidemiologic studies on lifestyle factors are few, and current evidence suggests no environmental factors clearly associated with POAG

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Diet & Dry Eye

Observational studies

Diet / dietary supplements and dry eye

Caffery B. Influence of diet on tear function. Optom Vis Sci 1991;68:1 58-72.

http://journals.lww.com/optvissci/Abstract/1991/01000/Influence_of_Diet_on_Tear_F

unction.10.aspx (pdf)

Review of ocular literature suggests sufficient dietary protein, vitamins A, B6 and C, potassium, and zinc may be necessary for normal tear function

Excesses of dietary fats, salt, cholesterol, alcohol, protein, and sucrose associated with or suggested as causes of tear dysfunction

No unequivocal link established between diet and remission of dry eye states in a well nourished population

Miljanović B, Trivedi KA, Dana MR et al. Relation between dietary n-3 and n-6 fatty acids and clinically diagnosed dry eye syndrome in women. Am J Clin Nutr 2005; 82:4 887-93. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16210721 (full text)

Investigates association between dietary intake of n-3 and n-6 fatty acids (FAs) and dry eye syndrome (DES) in women aged 45-84

Higher ratio of n-6 to n-3 FA consumption associated with significantly increased risk of DES. Tuna consumption inversely associated with DES

Higher intake of n-3 FAs associated with decreased DES incidence in women Intervention studies

Kokke KH, Morris JA and Lawrenson JG. Oral omega-6 essential fatty acid

treatment in contact lens associated dry eye. Cont Lens Anterior Eye 2008;31:3

141-6

http://www.contactlensjournal.com/article/S1367-0484(08)00003-9/abstract

(abstract)

Evaluates effects of evening primrose oil (EPO) on symptoms, signs and tear film characteristics in contact lens associated dry eye

Treated for 6 months with either EPO or placebo (olive oil)

EPO group showed significant improvement in symptom of 'dryness' at 3 and 6 months, and in overall lens comfort and tear meniscus height at 6 months

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Drouault-Holowacz S, Bieuvelet S, Burckel A et al. Antioxidants intake and dry eye syndrome: a crossover, placebo-controlled, randomized trial. Eur J Ophthalmol 2009;19:3 337-42.

http://www.ncbi.nlm.nih.gov/pubmed/19396775?ordinalpos=1&itool=EntrezSystem2.

PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RV

DocSum (PubMed abstract only)

Assesses whether 12-weeks of antioxidant dietary supplement (Oxybiane) improves signs and symptoms of DES

Breakup time and Schirmer scores significantly increased on placebo, and symptoms of burning, itching, foreign body sensation and redness improved

Oral antioxidants improve tear stability and quantity

Blades KJ, Patel S and Aidoo KE. Oral antioxidant therapy for marginal dry eye. Eur J Clin Nutr 2001;55:7 589-97. http://www.nature.com/ejcn/journal/v55/n7/abs/1601186a.html (abstract)

Assesses oral antioxidant supplement (Vitabiotics) for marginal dry eye

Tear stability and ocular surface status significantly improved at 1 month

Increased stability correlated with change in goblet cell population density

Tear volume not improved and dry eye symptoms subject to placebo effect

22

Resources on diet and eye health

NHS Choices. Eye health

http://www.nhs.uk/Livewell/Eyehealth/Pages/Lookingafteryoureyes.aspx

All About Vision website. Nutrition and vitamins for your eyes.

http://www.allaboutvision.com/nutrition/ British Nutrition Foundation. Healthy Eating. http://www.nutrition.org.uk/home.asp?siteId=43&sectionId=299&which=1 e

Overview: The effects of physical activity and active lifestyle on eye health are not well documented although these are important modifiable behaviours in maintaining general health. What evidence there is in the literature favours regular exercise, particularly when combined with a healthy diet and avoidance of smoking. Exercise may reduce the risk of sight loss from arterio-sclerosis, hypertension and diabetes. Practical guidelines on physical activity are given at the end of this chapter.

General Gale J, Wells AP and Wilson G. Effects of exercise on ocular physiology and disease. Surv Ophthalmol 2009;54:3 349-55.

Review of effects of acute exertion and regular physical activity on ocular physiology and disease

Intraocular pressure transiently reduced by dynamic exercise

Sources of different nutrients in the diet

Nutrient Dietary sources

Vitamin A Cheese, eggs, oily fish (such as salmon, fresh tuna and mackerel), milk, margarine, yoghurt. Carrots, dark green leafy vegetables and orange-coloured fruits (eg mangoes and apricots) contain carotenoids, which are converted to vitamin A in the body

Vitamin C Found in a wide variety of fruit and vegetables. Good sources include peppers, broccoli, Brussels sprouts, sweet potatoes, oranges and kiwi fruit

Vitamin E Plant oils such as soya, corn and olive oil. Nuts and seeds, and wheatgerm (found in cereals and cereal products)

Zinc Meat, shellfish, milk and dairy foods such as cheese, bread, and cereal products such as wheatgerm

Lutein, zeaxanthin Spinach, kale, broccoli, red, orange and yellow peppers, mangoes, bilberries and corn

Omega-3 fats Best sources are oily fish such as salmon, fresh tuna, trout and mackerel); vegetarian sources include vegetable oils, such as linseed, flaxseed, and rapeseed, and walnuts

Note: Patients should be advised to follow a healthy, balanced diet, in line with government recommendations (eg 5-a-day fruit and vegetable message), to obtain these nutrients; vitamin supplements are not a substitute for a healthy diet. See www.eatwell.gov.uk for a summary of government dietary advice.

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Alcohol

Overview: Although some studies have found an association between alcohol intake and common eye diseases, the literature in this area is not as compelling as it is for smoking. Moderate consumption of alcohol does not appear to have a negative impact on eye health and some studies suggest possible protective effects from moderate drinking. Avoidance of heavy drinking is recommended for eye and general health reasons, especially when combined with smoking or poor diet. Excessive alcohol intake should also be avoided in pregnancy since it can lead to foetal alcohol syndrome which includes ocular anomalies.

Alcohol and eye disease - General

Xu L, You QS and Jonas JB. Prevalence of Alcohol Consumption and Risk of Ocular Diseases in a General Population: The Beijing Eye Study. Ophthalmol 2009 116:10 1872 - 1879

http://www.ophsource.org/periodicals/ophtha/article/S0161-6420(09)00366-2/abstract (abstract)

Examines associations between alcohol consumption and ocular diseases in 4,141 adults in China of whom 549 were moderate beer or wine drinkers

Alcohol consumption was not a significant risk factor for AMD, glaucoma, diabetic retinopathy, retinal vein occlusion, pterygium, trachoma, optic nerve atrophy, dry eye, cortical cataract, subcapsular posterior cataract or nuclear cataract

Wand S, Wang JJ and Wong TY. Alcohol and eye diseases. Surv Ophthalmol

2008: 53:5 512-25.

http://www.surveyophthalmol.com/article/S0039-6257(08)00113-6/abstract (abstract)

Literature on association between alcohol consumption and eye disease weak

Review shows no consistent evidence for a major role of moderate alcohol consumption in development/ progression of common eye diseases.

Effect of heavy alcohol consumption on different ocular conditions needs to be clarified

Hiratsuka Y and Li G. Alcohol and eye diseases: a review of epidemiologic studies. J Stud Alcohol 2001;62:3 397-402.

http://www.jsad.com/jsad/article/Alcohol_and_Eye_Diseases_A_Review of_Epidemiologic_Studies/1397.html (abstract)

Review of epidemiologic studies over two decades

Chronic alcoholism associated with increased risk of cataract, keratitis, colour vision deficiencies and corneal arcus

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Moderate alcohol use, however, possibly protective against AMD, cataract and diabetic retinopathy

Information on the patient's drinking history can be clinically valuable and should be collected on a routine basis

Alcohol and AMD

Chong EW, Kreis AJ, Wong TY et al. Alcohol consumption and the risk of age-

related macular degeneration: a systematic review and meta-analysis. Am J

Ophthalmol 2008;145:4 707-715.

http://www.ajo.com/article/S0002-9394(07)01013-6/abstract (abstract)

Review of evidence on alcohol consumption and risk of AMD

Of 441 studies identified, five cohort studies reviewed

Heavy alcohol consumption (more than three standard drinks per day) associated with increased risk of early AMD.

Association between heavy alcohol consumption and risk of late AMD inconclusive

Although this association seems to be independent of smoking, residual confounding effects from smoking cannot be excluded completely

Boekhoorn SS, Vingerling JR, Hofman A et al. Alcohol consumption and risk of aging macula disorder in a general population: the Rotterdam Study. Arch Ophthalmol 2008;126:6 834-9. http://archopht.ama-assn.org/cgi/content/full/126/6/834 (full text)

Looked at alcohol consumption among 4,229 subjects at risk of AMD

Did not find an association between overall or specific alcohol consumption and development of early AMD or dry or wet late AMD

Knudston MD, Klein R and Klein BE. Alcohol consumption and the 15-year cumulative incidence of age-related macular degeneration. Am J Ophthalmol 2007:143:6 1026-9. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17524768 (full text)

Part of Beaver Dam Eye Study

Heavy drinking (four or more drinks daily) related to 15-year cumulative incidence of pure geographic atrophy in men

No consistent associations with amount of beer, wine, or liquor consumption and incidence or progression of AMD

Alcohol consumption unlikely to strongly increase (or decrease) risk of AMD

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Alcohol and cataract

Cumming RG and Mitchell P. Alcohol, smoking and cataracts: the Blue Mountains Study. Arch Ophthalmol 1997;115:10 1296-303.

http://archopht.ama-assn.org/cgi/reprint/115/10/1296 (pdf)

Investigates associations between alcohol consumption, tobacco smoking, and cataract

Only adverse effect of alcohol was among smokers: people who smoked and drank heavily had increased prevalence of nuclear cataract

Ritter LL, Klein BE, Klein R et al. Alcohol use and lens opacities in the Beaver Dam Eye Study. Arch Ophthalmol 1993;111:1 113-117.

http://archopht.ama-assn.org/cgi/reprint/111/1/113 (pdf)

History of heavy drinking related to more severe nuclear sclerotic, cortical, and posterior subcapsular opacities even after adjusting for other risk factors such as smoking

Moderate alcohol consumption associated with less severe nuclear sclerosis and participants who drank wine had less severe nuclear sclerosis and cortical opacities than those who did not

Increased consumption of beer related to increased risk of cortical opacities

Alcohol and dry eye

Moss SE, Klein R and Klein BE. Long-term incidence of dry eye in an older population. Optom Vis Sci 2008;85:8 668-74. http://journals.lww.com/optvissci/pages/articleviewer.aspx?year=2008&issue=08000&article=00011&type=abstract (abstract)

Part of Beaver Dam Eye Study

Estimates 10-year incidence and risk factors in older population aged 43-86

Incidence of dry eye less in subjects consuming alcohol

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Alcohol - Resources

Alcohol and the Eye. Royal College of Ophthalmologists

http://www.rcophth.ac.uk/docs/college/patientinfo/Alcohol_and_the_Eye.pdf

NHS Choices. Alcohol http://www.nhs.uk/livewell/alcohol/Pages/Alcoholhome.aspx Department of Health website – Alcohol Advice http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Alcoholmisuse/DH_085385

Government guidelines for alcohol consumption Men should drink no more than 3-4 units a day Women should drink no more than 2-3 units a day

A unit is half a pint of standard strength (3 to 5% ABV) beer, lager or cider, or a pub measure of spirit. A glass of wine is about 2 units and alcopops are about 1.5 units.

Heavy or binge drinking should be avoided; there is no strict medical definition for heavy drinking, although The Office of National Statistics defines heavy drinking as: - 8 or more units of alcohol per day for men - 6 or more units of alcohol per day for women

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Recreational drugs Overview: Misuse of drugs can result in a range of ocular effects. Marijuana decreases IOP but its medical value in glaucoma has not yet been investigated to the extent that it can be recommended as a therapeutic drug.

Recreational Drugs - General

McLane NJ, Carroll DM. Ocular manifestations of drug abuse. Surv Ophthalmol 1986;30:5 298-313. http://www.surveyophthalmol.com/article/0039-6257(86)90062-7/abstract (abstract - may be worth accessing full text)

Abuse of drugs, including some used clinically and others with no legal or clinical use, can cause ocular injury and disease

Ocular manifestations of drug abuse may be due to the substances themselves, to invasive methods of administration, or to injury suffered during states of altered consciousness

Grouping the drugs into five categories (opiates, marijuana, stimulants, depressants and hallucinogens), the authors describe the pharmacologic, congenital, toxic, infectious, embolic, and psychological ocular manifestations of their abuse.

Firth AY. Ocular sequelae from the illicit use of class A drugs. Br Ir Orthopt J 2004;1: 10-18. http://www.orthoptics.org.uk/journal/2004-abstracts (abstract)

Highlights changes in visual system of the class A drug abuser

Literature review of ocular/visual sequelae of more common class A drugs

Include stimulants (cocaine and crack cocaine), narcotics (heroin, morphine, methadone) and hallucinogenics (ecstasy, lysergic acid diethylamide, magic mushrooms, mescaline, phencyclidine)

Ocular sequelae affecting visual acuity, the eye and adnexa, ocular posture and ocular motility can result from recreational use of these drug(s)

Awareness of the consequences of illicit drug use should lead to more pertinent questioning during history-taking.

Sachs R, Zagelbaum BM and Hersh PS. Corneal complications associated with the use of crack cocaine. Ophthalmology 1993;100:2 187-91. http://www.ncbi.nlm.nih.gov/pubmed/8437825?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed (PubMed abstract only)

Case series of patients with corneal complications with crack cocaine use

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Crack cocaine users appear to represent a unique subset of young patients predisposed to infectious keratitis and corneal epithelial defects

Ophthalmologists and public should be aware of these associated complications

Recreational drugs and glaucoma Ben Amar M. Cannabinoids in medicine: A review of their therapeutic potential. J Ethnopharmacol 2006;105(1-2) 1-25

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T8D-4JGJJ86-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=801b975278d8779cb46cc542831d6927 (abstract)

Meta-analysis of 72 studies of therapeutic potential of cannabinoids

Cannabinoids (cannabis, marijuana, hashish) have therapeutic potential for range of conditions, including glaucoma

Recreational drugs − Resources

Drug misuse. NHS Choices http://www.nhs.uk/conditions/drug-misuse/Pages/Introduction.aspx Drug misuse. Department of Health http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Drugmisuse/index.htm Marijuana in the treatment of glaucoma. American Academy of Ophthalmology http://one.aao.org/CE/PracticeGuidelines/Therapy_Content.aspx?cid=9871fa42-cf40-4c1f-b05c-c816d5f93126

29

Exercise

Overview: The effects of physical activity and active lifestyle on eye health are not well documented although these are important modifiable behaviours in maintaining general health. What evidence there is in the literature favours regular exercise, particularly when combined with a healthy diet and avoidance of smoking. Exercise may reduce the risk of sight loss from arterio-sclerosis, hypertension and diabetes.

General Gale J, Wells AP and Wilson G. Effects of exercise on ocular physiology and disease. Surv Ophthalmol 2009;54:3 349-55.

Review of effects of acute exertion and regular physical activity on ocular physiology and disease

Intraocular pressure transiently reduced by dynamic exercise

For most patients exercise is beneficial to the eyes by reducing risk of central retinal vein occlusion and neovascular AMD, and by improving control of systemic hypertension and diabetes

Ophthalmologists should be advocates of regular exercise with appropriate eye protection.

Exercise and AMD

Knudtson MD, Klein R and Klein BE. Physical activity and the 15-year cumulative incidence of age-related macular degeneration: the Beaver Dam Eye Study. Br J Ophthalmol 2006;90:12 1461-3.

http://bjo.bmj.com/content/90/12/1461.abstract (abstract)

After controlling for other factors eg body mass index (BMI), people with active lifestyle (regular activity > or =3 times/week) at baseline less likely to develop exudative AMD compared with people without an active lifestyle.

Physical activity not related to early AMD or pure geographic atrophy

Suggests possible modifiable behaviour that might be protective against developing AMD

Exercise and diabetic retinopathy

LaPorte RE, Dorman JS, Tajima N et al. Pittsburgh Insulin-Dependent Diabetes Mellitus Morbidity and Mortality Study: physical activity and diabetic complications. Pediatrics 1986;78:6 1027-33.

http://pediatrics.aappublications.org/cgi/content/abstract/78/6/1027

Association of physical activity to diabetic complications in type I diabetics

Participation in team sports in high school or college not associated with decreased prevalence of severe retinopathy or blindness later in life

30

Exercise and glaucoma

Stewart WC. The effect of lifestyle on the relative risk to develop open-angle glaucoma. Curr Opin Ophthalmol 1995;6:2 3-9. (PubMed abstract only)

As yet, little modification of lifestyle (diet, drugs, emotion, activity, or risk factors for cardiovascular disease or diabetes) can be advised to reduce risk of developing chronic open-angle glaucoma

For patients in good general health, and motivated, an aerobic exercise program might provide small decrease in IOP

If modifiable risk factors become known, may give patient more control over disease by altering their lifestyle.

Qureshi IA. The effects of mild, moderate, and severe exercise on intraocular pressure in glaucoma patients. Jpn J Physiol 1995;45:4 561-9.

http://www.jstage.jst.go.jp/article/jjphysiol/45/4/561/_pdf

Small study investigating effects of walking, jogging, and running fast until exhaustion on IOP in normal and glaucomatous subjects

With all means of exertion, IOP decreased. Glaucoma patients had greater drop and longer duration of post-exercise recovery than normal subjects

Light exercise, such as walking, should be encouraged for glaucoma patients

Exercise - Resources

Exercise and eyesight. Royal College of Ophthalmologists http://www.rcophth.ac.uk/docs/college/patientinfo/Exercise_and_Eyesight.pdf Exercise. NHS Choices http://www.nhs.uk/conditions/exercise/Pages/Introduction.aspx British Heart Foundation http://www.bhf.org.uk/keeping_your_heart_healthy/staying_active.aspx

Government recommendations for physical activity Aim for 30 minutes of moderate intensity exercise at least 5 days a week

Moderate intensity means working hard enough to be breathing more heavily than normal and becoming slightly warmer, but not so intense that you are unable to talk and exercise at the same time

Examples of activity: brisk walking, gardening, cycling, swimming, dancing and jogging

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Obesity

Overview: Obesity, defined as body mass index (BMI) of 30 or over, is increasingly discussed as a risk factor for sight loss. It has been linked to increased risk of developing common eye diseases; independent of its association with diabetes, studies have shown that body mass index or other measures of adiposity are predictive of cataract. However, not all associations between obesity and eye disease are consistent. Obesity is a significant and growing public health issue and increases the risk of many health conditions with ocular effects, such as hypertension and diabetes.

Obesity and eye health – General

Cheung N and Wong TY. Obesity and eye diseases. Surv Ophthalmol 2007;52:2 180-95. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17355856 (full text)

Little known about ocular manifestations of obesity but has been linked with cataract, glaucoma, AMD and diabetic retinopathy

Studies support association between obesity and risk of age-related cataract

Strong evidence obesity associated with elevated intraocular pressure

No consistent association between obesity and AMD or diabetic retinopathy

Present literature inadequate to establish any convincing associations

Whether weight loss reduces the risk of eye diseases remains unresolved

Because of potential public health impact of obesity, there is a greater need to understand its ocular effects.

Habot-Wilner Z and Belkin M. Obesity is a risk factor for eye disease. Harefuah 2005;144:11 805-9, 821. http://www.ncbi.nlm.nih.gov/pubmed/16358658?ordinalpos=15&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum (PubMed abstract only)

Reviews effects of obesity on the four major blinding eye diseases: AMD,

diabetic retinopathy, cataract and glaucoma and shows obesity is a significant

risk factor for these diseases and hence to blindness

Obesity and AMD

AREDS Research Group. Risk factors associated with age-related macular degeneration. A case-control study in the age-related eye disease study: Age-Related Eye Disease Study Report Number 3. Ophthalmology 2000;107:12 2224-32.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11097601 (full text)

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AREDS participants aged 60-80 ranging from no AMD to advanced AMD in one eye

Only those with neovascular AMD were more likely to have increased BMI

Obesity and cataract

Lim LS, Tai E-S, Aung T et al. Relation of Age-related Cataract With Obesity and Obesity Genes in an Asian Population. Am J Epidemiology 2009;169:10 1267-1274.

http://aje.oxfordjournals.org/cgi/content/abstract/169/10/1267?maxtoshow=&HITS=1

0&hits=10&RESULTFORMAT=&fulltext=chong+ew&searchid=1&FIRSTINDEX=0&re

sourcetype=HWCIT

Population-based study among Singaporean Malay adults

Obesity significantly associated with cortical cataracts but not nuclear cataract

Results did not support causal association between obesity and cortical or posterior subcapsular cataract

Fat mass- and obesity-associated gene may be involved in the pathogenesis of nuclear cataract

Obesity − Resources

Feeling great, looking good. A guide to how a healthy lifestyle can help prevent sight loss. RNIB, 2006. http://www.rnib.org.uk/xpedio/groups/public/documents/PublicWebsite/public_healthreportp.pdf Exercise. NHS Choices, 2007. http://www.nhs.uk/conditions/obesity/Pages/Introduction.aspx Department of Health website, Obesity http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Obesity/DH_6585 National Obesity Forum http://www.nationalobesityforum.org.uk/

Government information on obesity Body mass index (BMI) is calculated by dividing a person’s weight measurement (kg) by the square of their height (m). In adults, a BMI of 25 to 29.9 means that person is considered to be overweight, and a BMI of 30 or above means that person is considered to be obese. The BMI score for children and adolescents is related to the UK 1990 BMI growth reference charts in order to determine a child’s weight status. Certain factors such as fitness, ethnic orgin and puberty can sometimes alter the relation between BMI and body fatness. In these cases other measurements such as waist circumference and skin fold thickness can also be collected to confirm a person’s weight status.

33

Light exposure Overview: UV light has been shown to be a contributory factor in various ocular conditions and the benefits of UV protection are well recognised. UV exposure may cause damage to the retinal pigment epithelium but an association with AMD has not been found. Light exposure is a risk factor in cataract and seems to be a greater risk in men. Appropriate advice on UV protection is needed to help promote long-term ocular health.

Light exposure and eye health – General Bergmanson JP and Sheldon TM. Ultraviolet radiation revisited. CLAO J. 1997;23:3 196-204. http://journals.lww.com/claojournal/Abstract/1997/07000/Ultraviolet_Radiation_Revisited.10.aspx (abstract)

Significant evidence suggests a correlation between ultraviolet radiation (UVR) exposure and conjunctival pterygium, photokeratitis, climatic droplet keratopathy and cataracts

There are compelling reasons to counsel our patients on the adverse effects of UVR and to offer them the various options available for UV protection

Light exposure and AMD Tomany SC, Cruickshanks KJ, Klein R et al. Sunlight and the 10-year incidence of age-related maculopathy: the Beaver Dam Eye Study. Arch Ophthalmol 2004;122:5 750-7. http://archopht.ama-assn.org/cgi/content/abstract/122/5/750

Examines association of sunlight exposure and indicators of sun sensitivity with the 10-year incidence of age-related maculopathy (ARM)

Those exposed to the summer sun more than 5 hours a day in teens, in 30s, and at baseline at a higher risk of increased retinal pigment and early ARM than those exposed less than 2 hours per day

More than 10 severe sunburns during youth more likely than those who experienced 1 or no burn to develop drusen

Use of hats and sunglasses at least half the time associated with decreased risk of soft indistinct drusen and retinal pigment epithelial depigmentation

Light exposure and cataract McCarty CA and Taylor HR. A review of the epidemiologic evidence linking ultraviolet radiation and cataracts. Dev Ophthalmol 2002;35:21-31.

34

http://www.ncbi.nlm.nih.gov/pubmed/12061276?ordinalpos=77&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum (PubMed abstract only)

Reviews epidemiologic evidence linking UV radiation and cataract

Majority of 22 studies reviewed support association between UV-B and the development of cortical cataract and perhaps posterior subcapsular cataract.

Data justify implementation of public health campaigns to raise public awareness of risk of cortical cataract due to ocular UV-B exposure

AREDS Research Group. Risk factors associated with age-related nuclear and cortical cataract: a case-control study in the Age-Related Eye Disease Study, AREDS Report No. 5. Ophthalmology 2001;108:8 1400-8. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=11470690 (full text)

Investigates possible risk factors for age-related nuclear and cortical cataracts in AREDS participants aged 60-80 years

Moderate cortical opacities were associated, at a borderline level of significance, with higher levels of sunlight exposure

Consistent findings now been reported across many studies for sunlight exposure

Cruickshanks KJ, Klein BE and Klein R. Ultraviolet light exposure and lens opacities: the Beaver Dam Study. Am J Public Health 1992;82:12 1658-62.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=1456342 (full text)

Examines exposure to sunlight and UVB and prevalence of lens opacities

Men with higher levels of average annual ambient UVB 1.36X more likely to have more severe cortical opacities than men with lower levels

UVB not associated with nuclear sclerosis or posterior subcapsular opacities in men

No associations with UVB exposure found for women

West SK, Longstreth JD, Munoz BE et al. Model of risk of cortical cataract in the US population with exposure to increased ultraviolet radiation due to stratospheric ozone depletion. Am J Epidemiol 2005;162:111080-8.

http://aje.oxfordjournals.org/cgi/content/full/162/11/1080 (full text)

Model of possible consequences for US cataract incidence of increases in UVB radiation due to ozone depletion

By 2050, prevalence of cortical cataract will increase above expected levels by 1.3-6.9%

With 5-20% ozone depletion, there will be 167,000-830,000 additional cases of cortical cataract by 2050

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Light exposure − Resources Ultraviolet (UV) radiation and your eyes, All About Vision website. http://www.allaboutvision.com/sunglasses/spf.htm UV and the eye. College of Optometrists. http://www.college-optometrists.org/index.aspx/pcms/site.Public_Related_Links.Eye_Health_Issues.UV_and_the_Eye/ The Healthy Sight Institute http://www.healthysightinstitute.org/

RNIB recommendations for eye protection against UV damage UV filters Use a UV filter that stops most of the harmful rays of the sun entering the eyes. Most prescription glasses and some contact lenses now have a built-in UV filter. Sunglasses Sunglasses with a CE mark show that they are made to an agreed European standard. There is also a British standard for sunglasses which should be looked for when buying them: BSEN 1836:1997. Going outside In the UK, on a day to day basis, UV exposure is very small. However people who spend lots of time outdoors may need protection. Those living in countries with more sun may also need to take more care. UV exposure is also much higher where there are more reflective surfaces, for example near water, so protect the eyes while at the beach, fishing, boating or on holiday. Snow also intensifies the amount of reflected UV light, so good protection is needed in these circumstances. Skiers and snowboarders should take particular care. Note: Government advice on sun protection for eyes and skin also includes wearing a wide-brimmed hat and wraparound sunglasses, spending time in the shade between 11am and 3pm, and taking extra care with children.

Literature review compiled by Alison Ewbank and Jane Veys, January 2010