Dr. Sunir Garg – Macular Degeneration

Macular Degeneration—one more age-related issue to stay on top of as we get older. According to Dr. Sunir Garg, this eye disease is a common condition and the leading cause of vision loss for older adults. A retina specialist and professor of Ophthalmology at Philadelphia’s Wills Eye Hospital, Dr. Garg is also a spokesperson for the American Academy of Ophthalmology.

I thank Dr. Garg for answering my questions about this eye condition…

What is macular degeneration? 

Macular degeneration is an eye disease that causes damage to the macula and blurs the central vision. People with this disease cannot see fine details, whether they are looking at something close or far. But their peripheral (side) vision will still be normal. Losing the central vision can make it harder to see faces, read, or drive.

What is the macula? 

Everyone has a macula. If the eye is like a camera, the front of the eye is the lens, where we develop cataracts as we get older. The back of the eye has the film—or sensor—called the retina. Smack dab in the center of the retina is the macula. It’s the part of the eye that gives us our straight-ahead sharp vision, our good reading and driving vision.

How would we know when the macula is not performing correctly? Or is deteriorating? 

It can vary. Some folks will describe blurriness of their vision. Many things might cause this, including dry eyes or the need for glasses. Others complain letters and numbers look distorted, wavy, or crooked. 

But some patients with macular degeneration might not notice a problem. Unlike a knee or a shoulder, which can start to hurt if they give us trouble, the macula will never hurt. All it does is affect our vision.

The brain typically works by picking and choosing the good parts of vision from each eye and combining them in the brain. If one eye is damaged and slacking off, the person may not notice it unless they happen to cover one of their eyes. That’s something I encourage a lot of my patients to do once a week. Cover the right eye and then the left eye to ensure nothing is amiss with the vision. The American Academy of Ophthalmology recommends everyone over 40 see an ophthalmologist annually—ideally—but definitely every two years. The physician will pick up conditions like macular degeneration before most people notice a problem. 

Is dilation necessary to determine if there is a problem? 

Yes and no. Because the macula is smack dab center, we can get a reasonable idea of what’s going on even if the patient is not dilated. However, we will have a much better view of the eye when it is dilated. As people get older, we advocate for a dilated exam because it gives us a better idea of what the eye looks like. It gives us a good baseline to monitor people for change. 

Can an optometrist check for this issue, or is it important to see an ophthalmologist? 

We work with our optometry colleagues to help our patients get the best care possible. For many people with otherwise healthy eyes, seeing an optometrist is a comfortable, convenient, and accessible thing to do. As people age and develop more changes in the macula, ophthalmologists are well-positioned to help and guide and put things in context. Not all macula changes are worrisome. Some changes can look like macular degeneration but are actually “less worrisome” diseases.

Please describe macular degeneration. 

Everybody with macular degeneration starts with the dry type. Even if you go on to develop the wet form, you still have the dry type, which accounts for most cases. 

One of the things that people don’t necessarily appreciate is the macula and the retina are the most active tissues of any part of the entire body. When we move our eyes around, look close, look in the distance, our vision is seamless. We can see dark and light at the same time, we can see colors at the same time. If I move my eyes from left to right everything immediately pops into focus. But that requires a lot of effort and a lot of energy. 

The cells see something, fire a signal to the brain, and then reload and get prepared to see again within a fraction of a second. And to do that requires a lot of energy and a lot of blood supply. 

When our cells are working and seeing, the cells—like machinery and humans— make waste products. Specific cells take care of the retina and mop up these waste products. But in people with macular degeneration, either the macula is making too much waste product or the caretaking cells can’t keep up.  What results is a build-up of waste products—little yellow spots called drusen. Drusen are similar to the liver spots we get on our hands as we age. 

When we see folks with macular changes, we look at the number of those spots. If an individual has a few tiny spots, that’s very common for all age groups. We don’t worry about those people. If a patient has several larger spots, we become a bit more concerned.

How fast does this condition advance? 

Very slowly. While people may experience vision loss all of a sudden, the condition deteriorates over the course of years. If an individual visits an ophthalmologist once a year, the doctor can tell where they are on the timeline. Once we see a patient two or three times, we can get a sense of the condition’s trajectory. Of course, not all eyes progress at the same rate. 

If you develop macular degeneration in one eye, are you apt to develop it in the other eye also? 

Yes, this is one of those things where, if you see it in one eye, it will almost always develop in the other eye. If it’s not there today, it will likely be there in the not-too-distant future. 

Is there a treatment?

Practice a healthy lifestyle. Get blood pressure, weight, and cholesterol under control. Diet and exercise really are the golden ticket to almost everything. Plus, these help with blood pressure, which plays a role in macular degeneration. 

For some patients, certain vitamins may be beneficial. 

Is there anything we can do to prevent it? 

Age, gender (female), race (Caucasian), and smoking are the highest risk factors. Stop smoking! Diet plays an important role. In research studies, patients with the lowest risk of developing macular degeneration eat at least three servings of dark green leafy vegetables—broccoli, spinach, kale, collard greens—a week, plus a large variety of other fruits and vegetables. They also consume foods high in omega-three fatty acids—fatty fish, almonds, walnuts, chia seeds. Eating real foods is much more helpful than taking Omega 3 fatty acid supplements. Cardio three times a week also meaningfully reduces the risk of developing macular degeneration. And helps slow it down once you have it. 

Often older patients come in with their adult children, who are understandably concerned about what their parents are going through. These are some of the things I encourage the children to do to stop macular degeneration from developing in the first place. 

I’ve known people in their 70s and 80s who’ve had macular degeneration and eventually lost their sight altogether. Is this still common, or has medical science evolved so vision can be saved? 

We are much better off today than 10 or 15 years ago. Back then, macular degeneration was a horrible disease and everyone with it would lose their vision. Today, by catching it early, we can start patients with extremely helpful vitamins that reduce vision loss by 25-30 percent. We have slightly different treatments for wet macular degeneration which can often stop, and even reverse, some of the changes. In the last month or two, we’ve had our first-ever treatment for more advanced dry macular degeneration. None of these things are as good as not having the disease, of course, but these treatments really do help many of our patients to continue to see for the rest of their lives. 

Is this disease hereditary? 

The disease has a genetic component, but just because a parent has the disease doesn’t mean the child is destined to get it. Of the various risk factors, exercise, diet, and smoking are stronger risk factors than genetics, although genetics can definitely play a role.

An eye doctor once told me blue-eyed individuals are more prone to macular degeneration, while brown-eyed persons are more susceptible to glaucoma. Is there any truth to that? 

That idea has been around for a number of years and contains very conflicting data. Blue-eyed people are generally Caucasian, and those folks are at a higher risk of developing macular generation. Lighter-colored eyes are not destined to get this disease by any means. 

My in-laws had an Amsler grid tacked on their refrigerator. They’d look at it every so often to check their vision. Is this something you recommend? 

An Amsler grid is basically the outline of a checkerboard. Most ophthalmologists can give you a copy to take home, or you can print one off a website. Cover one eye at a time, checking for distortion or waviness of the lines. Bathroom tiles, Venetian blinds, door jams, and brickwork are good substitutes. Although this method is not as good as some of our modern technologies to monitor for change, it’s an easy way to pick up early vision changes.

We see many ads on television for eye vitamins. Do you recommend those to patients as they get older?

I think a multivitamin every day is a great thing. However, the AREDS 2 formula vitamins—a very specific eye vitamin that can be helpful in preventing vision loss—should only be taken if a person has been diagnosed with moderate or advanced macular degeneration by their ophthalmologist. People should not take this vitamin if they’re worried about the disease, if a parent has had it, or if they have some mild aging changes. These vitamins can lead to other problems, including an increased risk of urinary tract infections. 

Your one new thing, large or small, you’ve discovered lately?

I am a coffee snob! I love it in the morning, take pride in it, and have every coffee gizmo known to man! Recently I purchased an Aeropress. I’d describe it as a large syringe meets a French press. It’s a super simple, lightweight gadget that makes the cleanest, tastiest cup of coffee I’ve ever had. I’m now a huge proselytizer of this thing. I’ve given it to friends and family members for birthdays, and everyone seems to love it. 

Photos courtesy of Dr. Garg

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