Keeping Your Eyes Healthy in the New Year
January 29, 2020
1:00 p.m. EST
The information provided in this transcription is a public service of BrightFocus Foundation and is not intended to constitute medical advice. Please consult your physician for personalized medical, dietary, and/or exercise advice. Any medications or supplements should be taken only under medical supervision. BrightFocus Foundation does not endorse any medical products or therapies.
Please note: This Chat has been edited for clarity and brevity.
MICHAEL BUCKLEY: Hello, I’m Michael Buckley with BrightFocus Foundation. Welcome to, or welcome back to, the BrightFocus Chat. This is our first of the year 2020, so our topic today is “Keeping Your Eyes Healthy in the New Year.”
Today’s guest is new to the BrightFocus Chats. He’s Dr. Yasha Modi; he’s an assistant professor at the ophthalmology department at NYU Langone Health in New York City, and he’s also a surgeon at Tisch Hospital in New York City. If you’re new to the BrightFocus Chats, welcome and thank you. Once a month, we have an opportunity to spend about 30 or 40 minutes with a leading expert on vision disease and eye health. So, I’d like to turn to a first-time guest at BrightFocus, Dr. Yasha Modi. Welcome. Would you like to just tell us a little bit about what you do at NYU Langone Health?
DR. YASHA MODI: Yes. Thank you so much for having me on the Chat. You said it perfectly. I’m a retina specialist at New York University; I also do retina surgery and uveitis, which is an inflammation of the eye, and I’ve been working at NYU for about 4 years. Prior to that, I was at the Cleveland Clinic, and it’s a really great institution. I would get to work with some amazing colleagues, taking care of some very difficult retina patients.
MICHAEL BUCKLEY: How did you end up working in vision health?
DR. YASHA MODI: Well, you know, that’s a great question. Frequently, in medical school, we don’t really have the opportunity to see a lot of ophthalmology and vision health care. I come from a long lineage of ophthalmologists—believe it or not, I’m a sixth-generation ophthalmologist, so it’s been in my family for quite some time. And then, I started studying it more in medical school and really liked it. Specifically, I like a lot of the disease states of retina, which is what ultimately brought me to be a retina surgeon.
MICHAEL BUCKLEY: That’s great. Sixth generation—that’s amazing! The goals of the BrightFocus Chats are to educate our patients on the latest developments in research in the field, and I know there’s a new AMD medicine that’s on the market. Would you be able to tell us a little bit about what it is and how it works?
DR. YASHA MODI: Absolutely. We have a few different drugs currently available for the treatment of the wet form of macular degeneration—or the exuded form of macular degeneration—and the newest one to the market is a medication called brolucizumab, and the trade name is called Beovu®. This is made by Novartis. It got FDA approval at the end of 2019, and it now has its own drug code, which means that this can be appropriately billed through insurance, like Medicare and private insurances, and allows us the opportunity to treat patients with macular degeneration with another drug that may have efficacy. This was a medication that actually is very, very similar to the other ones. The other medications are called aflibercept (or Eylea®) and ranibizumab (or Lucentis®), and then there’s an off-label use called Avastin® (or bevacizumab). So, we have four different drugs available to us now, and tall of them actually work by blocking one molecule called VEGF, or vascular endothelial growth factor. VEGF is the driving force for producing the wet form of macular degeneration, and this drug sort of tries to stop that progression to allow the retina to eventually dry, for fluid to be diminished, and to lower the likelihood of bleeding. Every time we have a new drug on the market, it increases the opportunity for us to effectively treat patients with wet macular degeneration.
MICHAEL BUCKLEY: Well that’s great, and you said it’s now covered by Medicare and private insurance?
DR. YASHA MODI: That’s right. When a drug gets FDA approval, the logistics of ordering the medication and getting it delivered to the clinic and getting reimbursed for the medication oftentimes lag behind, and so there’s something called a J code, which essentially means that there’s a definitive way to bill for the medication. So now, doctors have only recently had the opportunity to actually start implementing this drug into their clinical practices.
MICHAEL BUCKLEY: That’s good. It’s nice to know that that seems to be settled for the future of patients, the convenience of patients. You mentioned your long lineage in ophthalmology. Do you have a sense of…our understanding—scientifically or treatment medically of AMD—has changed over the last 5 or 10 years or as long as you’ve been in practice? Are things better or different now?
DR. YASHA MODI: Certainly. I think that this an incremental addition to the armamentarium that we use to treat macular degeneration, but if we take a more global perspective—10 years or even 20 years—the difference between 20 years and 10 years has been just absolutely tremendous where patients 20 years ago with wet macular degeneration frequently ended up very, very quickly losing all of their central vision; the only forms available to us were really laser treatments back prior to the early 2000s. And then, the first anti-VEGF medications—the off-label use of Avastin and the on-label use of Lucentis—really revolutionized our entire understanding and treatment of the wet form of macular degeneration.
We’re starting to realize that…first of all, colloquially, we discuss macular degeneration as the “wet form,” where we have fluid accumulating under the retina or in the retina and bleeding, and then the “dry form” of macular degeneration, where we have atrophy or loss of tissue. And so, while we’re making great strides in the wet form of the macular degeneration, the only treatment we have currently for the dry form of the macular degeneration is, really, vitamins, which slow the progression to the wet form of the macular degeneration. So certainly, this is an incredible time for vision research in macular degeneration. There are a lot of very, very fascinating trials that are going on, and I think that the next 10 to 20 years are going to be just as interesting as the prior 10 to 20 years.
MICHAEL BUCKLEY: Well, great. That’s exciting. We’ve gotten several questions submitted in advance and already during today’s Chat about genetics. So just kind of starting off, you hear products advertised on TV about genetic testing and diseases. Is that applicable for macular degeneration?
DR. YASHA MODI: Well, first let’s just address the question: Is there a genetic disposition to developing age-related macular degeneration? And the answer to that is we certainly think so, but it’s not so much inherited in the traditional sense that if you have macular degeneration, your child has a 50-percent likelihood or a 25-percent likelihood of developing it.
The genetics are actually much, much more complex than this, and there are certain genetic mutations that have been associated to a higher likelihood of developing macular degeneration. Remember, there’s a difference between association and causation, where in this case, we’re not 100 percent certain that if you were to have these genetic mutations that you are 100 percent likely to develop macular degeneration. And given this uncertainty, given the fact that, currently, we don’t change our treatment paradigm from genetic testing, there’s no clinical reason at this point in time to genetically test for age-related macular degeneration. I frequently have patients who will take a 23andMe test, which are these sort of home genetic tests that we take, and they also look for the genetic loci or the genetic areas that are suggestive of macular degeneration, and they’ll come to me with these results, and there’s no way for us in the current state of affairs to predict their likelihood of developing macular degeneration.
MICHAEL BUCKLEY: And obviously, our audience worries about their kids’ and their grandkids’ future. We’ve got a question about juvenile macular degeneration. First of all, what is that, and is that something that would carry over into somebody’s older years?
DR. YASHA MODI: Certainly. If we think about features in the retina that look like macular degeneration but developed prior to 50 years of age, certainly, there are a host of other possibilities; more likely than not, this is not age-related macular degeneration, which we know is nearly almost completely uncommon to individuals under 50. And so, there’s something called dominant drusen, which means we inherit it in a way where we have a 50-percent likelihood of passing it down to our children, and that has similar features to macular degeneration. And then there are some other varieties. So, in those cases, the algorithm has become much, much more complex, oftentimes requires genetic testing to make a diagnosis, and that’s an entirely different category of disease than the age-related macular degeneration that you and I are currently talking about.
MICHAEL BUCKLEY: So, as we kind of move up the age ladder from the juvenile question, as folks get into their 40s, 50s, and 60s, is there anything they can do to either prevent or slow down AMD?
DR. YASHA MODI: That’s a great question, and the short answer is we only make recommendations in the current state based on associations. What I mean by that is there’s a large clinical study called AREDS, which is a study that looked at the utility of the vitamins that we currently take in macular degeneration. This study looked at associations between eating habits and various parameters and looked at who was likely to progress to more advanced forms of macular degeneration.
What came out of this is that we now recommend patients to eat a lot of leafy green vegetables and minimize their meat intake. This is the result of some of the features that suggest that there was a lower likelihood of those patients who have a diet high in leafy green vegetables of progressing to more advanced forms of macular degeneration. However, we don’t know that…there’s no current way to entirely prevent macular degeneration, and the only way that we can even potentially slow it down is with the use of some vitamins, which are the vitamins studied in the AREDS formation, that have been shown to lower the risk of progressing to the wet form of macular degeneration. That risk reduction is about 25 percent, which is not a trivial amount.
MICHAEL BUCKLEY: On that theme, Dr. Modi, is it possible to reverse any vision loss that may have already occurred?
DR. YASHA MODI: That’s a great question, and I think it depends a lot on how they’re initially presenting. If they present with a slow, progressive decline in vision from the dry form of macular degeneration, we currently do not have any treatments to either slow that down or to reverse the vision loss. However, some individuals who have the wet form of macular degeneration may notice immediate blurring or distortion of the vision, which are the key signs that suggest that somebody may have progressed to the wet form of macular degeneration. Early treatment with anti-VEGF medications—the medications we were just talking about—certainly cannot only slow that risk of losing vision but can actually significantly improve the vision. And so, the key in those circumstances is early detection and early treatment. So, for all of the listeners here, I certainly wouldn’t want to wait. If you were noticing blurry vision, I would call your doctor immediately within 24 to 48 hours to make an appointment, get seen, and get treated.
MICHAEL BUCKLEY: That’s great advice. You mentioned the wet AMD and the dry AMD. We have a few callers who are asking about geographic atrophy. I was wondering if you could explain that. Is that a third category, or is that a synonym?
DR. YASHA MODI: Geographic atrophy is essentially the end stages or the later stages of the dry form of macular degeneration. Essentially, the atrophy or the loss of tissue coalesces, and it starts to look almost like little countries on a map, which is why we call it geographic atrophy. It looks like these really well-demarcated areas of loss, and that is currently where a lot of our research has been focusing on—to try and slow the progression of that geographic atrophy—because, ultimately, that is what severely compromises central vision in patients with the dry form of macular degeneration.
MICHAEL BUCKLEY: We have a caller wondering: Can AMD spread from one eye to the other?
DR. YASHA MODI: It doesn’t spread in the sense of, like, a viral infection or something to that measure, but age-related macular degeneration is a bilateral disease process, meaning it affects both eyes. That could be pretty asymmetric in the beginning, meaning one eye is more advanced than the other eye. But if we truly have a diagnosis of age-related macular degeneration, we will have features popping up in the other eye.
MICHAEL BUCKLEY: Thank you. We have a couple of questions about other medications people might already be taking. We have a questioner from New York wondering about blood thinners. Does that have any impact positively or negatively on AMD?
DR. YASHA MODI: That’s a spectacular question, and a lot of that is we never stop individuals who are on blood thinners. Remember, a lot of the times the patients are on blood thinners because they are lifesaving, and there’s no evidence to show that the likelihood of bleeding is higher with patients on blood thinners. However, there are certain blood thinners where if the patient were to bleed, the size of the bleeding and the amount of the bleeding could be a fair amount more substantial in patients who are on blood thinners. The key is to realize, however, that the blood thinners are an essential part of life preservation. We can frequently end up dealing with the size of the hemorrhage and whatnot by using various treatments, including anti-VEGF medications—rarely, we even sometimes use surgery—but I would never encourage a patient to stop blood thinners for the sake of their macular degeneration.
MICHAEL BUCKLEY: That’s a good perspective. Kind of related to that, we have a caller from Indiana who has a question about statins, and I was wondering if you could just tell our audience what a statin is and why people take it. And again, is that helpful or hurtful for vision health?
DR. YASHA MODI: Absolutely. Statins is a class of medication to lower cholesterol, and there’s no evidence to support the use of statin therapy for specifically age-related macular degeneration. We are starting to realize, however, that there are patients who have various types of macular degeneration who do have problems with their cholesterol and may have a higher likelihood of developing kidney diseases or heart diseases, but those details are still very much in the preliminary research phases. So, in the current state of affairs, we don’t make an advisement on whether or not somebody should be on a statin based on their macular degeneration. That should be driven based on blood tests and indications to lower the cholesterol level from a medical perspective.
MICHAEL BUCKLEY: I got a couple of more questions I received about that connection between one health condition and another—glaucoma and cataracts. Do either of those help or hurt treatments for AMD or the likelihood of getting AMD? So, we were wondering…glaucoma and cataracts, and I guess cataract surgery would also be a part of that question.
DR. YASHA MODI: Glaucoma and macular degeneration. There are no strong associations connecting the two, but for many years doctors always worried if doing cataract surgery would potentially worsen somebody’s macular degeneration or cause them to progress to the wet form of macular degeneration. We now have some pretty strong evidence that doing cataract surgery does not alter your risk of progressing to more advanced forms of macular degeneration. In fact, cataract surgery may be one modifiable way to significantly improve the vision in select patients. So, at this point, if there’s a conversation between your retina specialist and your cataract surgeon and the decision is made to go ahead with cataract surgery, that’s frequently something where it can, one, improve your retina doctor’s view of the back, and two, potentially improve your vision.
MICHAEL BUCKLEY: Dr. Modi, as we kick off the new year, it’s cold in most parts of the country, so we have a couple of questions about weather. I’ll kind of combine them. One is a person wondering: Does weather—heat or cold—have impact on AMD? And then we have a question from New Hampshire, not surprisingly, asking about the glare from snow. So, I was wondering…the relation between weather and vision health.
DR. YASHA MODI: Yes, those are great questions, and this probably applies to individuals who don’t even have macular degeneration. There’s no worsening of macular degeneration from light conditions—dark or light—and no seasonal variation in which the disease progresses faster or slower. However, winter, as we all know…with people who live up in the Northeast or in the northern parts of the United States, the sunlight can be particularly oblique, meaning it doesn’t rise very high in the sky. If you take that and you put that on a wet road, then you can get a fair amount of glare where we otherwise don’t see that in the summertime. And so, there are a couple of ways…using sunglasses and trying to avoid certain times of driving, especially for those patients who have comorbid macular degeneration. That’s probably the best strategy, to use visors and sunglasses to really help with those very difficult driving conditions. But remember, we’re talking now about the most difficult driving conditions: glare and a wet road.
MICHAEL BUCKLEY: That’s good to know. Kind of related to that, we have a questioner from Maryland who’s kind of curious about other parts of the world where the weather might be different or the diet is different. How is the U.S. experience with AMD compared to other countries around the world?
DR. YASHA MODI: That’s a really great question. We certainly know there are some variations in who develops macular degeneration, and we’re not certain now as to whether or not that’s more genetically driven or environmentally driven. In fact, if we look at Asia, for instance, many patients have a different type of macular degeneration called “polypoidal choroidal vasculopathy,” which is a form of macular degeneration, but it’s a little bit different; it oftentimes may be a little bit more aggressive than the age-related macular degeneration that we see in the United States, but we’re starting to realize now that this type of macular degeneration we also see commonly in the United States. And there are also individuals where we think that UV exposure may be linked to changes in the macula, especially in the lens, causing cataract formation. But the demographics of individuals around the equator typically have not correlated well with patients who are at higher risk for developing macular degeneration.
MICHAEL BUCKLEY: Thank you. A couple of callers have been sending us questions about the duration of the injections that you talked about. Is that something that a person can get in perpetuity, or is there a certain number of years? Is there a point where this would stop?
DR. YASHA MODI: Yeah. We sort of lumped macular degeneration—and the wet form of macular degeneration, in this case—into one entity, but every patient is remarkably different. Some individuals may just get one, two, three injections, and that may be it—they may never need another injection ever again—but we know that that’s the minority of individuals, and the majority of individuals actually require a fair amount of therapy. We now have patients who have been receiving injections essentially since 2004 with continuous therapy, and a question that I get from some patients who’ve had a lot of injections is: Is there damage from repeat injections into the eye? And we now have patients who’ve done very, very well with 150 injections in the eye, so this is a very, very well-tolerated treatment. And we frequently know that patients who get the most number of injections on average—somewhere around seven to nine injections a year—are frequently the ones, on average, who end up doing the best in terms of preserving their long-term vision.
MICHAEL BUCKLEY: That’s good to know. We have a couple of questions, Dr. Modi, about stem cells. People hear and you read about stem cell treatments for diseases. Is that’s something that is applicable for AMD? Is there research going on in stem cells, or are there approved stem cell treatments in this field?
DR. YASHA MODI: There’s certainly stem cell therapy going on for the dry form of macular degeneration, and at the moment, this is all experimental and in early phases of development. So, it’s really important for patients to realize that these are very well-structured studies that are designed for—number one—safety in mind. And I’d like to say that around the United States, unfortunately, there are what we call quote-unquote “stem cell clinics,” where patients are actually paying out of pocket to receive stem cell therapy, and this is a completely unjustified treatment where patients have lost vision. So, just remember: When you’re enrolling in a clinical trial, you should never have an out-of-pocket fee; you should never pay for stem cell therapy. These are early trials in a select number of academic institutions around the United States that are doing this in a safe and controlled fashion. So, we get very excited when we hear the words “stem cells,” and we want to jump into the clinical trials, but we have to realize that sometimes in the unknown, there can be some downsides to this. So, as we embark on stem cell therapy, we have to do this in a very safe and controlled fashion.
MICHAEL BUCKLEY: That’s a great point. I know clinical trials is a big topic unto itself. Dr. Modi, a couple of minutes ago you mentioned how the more patients can adhere to these treatments, the better off they are. It can sound like a lot. Do you have advice for patients and caregivers on how they can continue adherence for years on end?
DR. YASHA MODI: Well, I think a big part of this is expectations. What I mean by that is, if you come into the clinic expecting your injection and then going home, that expectation is going to allow you some degree of clarity in terms of knowing what you’re in for that day. And so, a lot of times all of the treatments that are currently ongoing…for instance, the approval of brolucizumab was designed to try and extend the intervals between treatments. So, we certainly realize there’s a huge burden of disease of getting injections every 4, 6, even 8 weeks, and the goal of these treatments is to try and extend patients out even further—10 and 12 weeks—and there are some studies that are ongoing, looking at even doing implants in the eye to really try and increase that interval where the medication—the anti-VEGF medication—gets slowly released over several months, and that can decrease the burden of these repeated injections. So, we understand as retina specialists and as vision scientists that there is a huge burden of disease, and that’s what we’re currently working on to try and lower.
MICHAEL BUCKLEY: When you talk about the conversations and the expectations between patients and their families and clinicians, just sort of a big picture question: How can someone make a visit to an eye doctor go as well as possible? Do you any tips for, I guess, both the physician and the patient side of the coin? What makes it go the best?
DR. YASHA MODI: Well, let’s start from the case of macular degeneration, okay? We’ll use that as the example. Many times, you’re going to be going to your general ophthalmologist or one of the optometrists in the area that will make a diagnosis or see something unusual and then refer you to a retina specialist. And in that window of time, having a little bit of understanding about what it is that they were talking about, writing down a set of questions so that we don’t forget it when the retina doctor is speaking to you, can oftentimes result in a very productive visit. And, at any point, if there are any questions or any concerns—about the treatment, about the diagnosis, about the prognosis—these are all things where it’s really important to communicate those uncertainties to your retina provider so that you can have a meaningful conversation and get the clarity that you’re hoping for.
MICHAEL BUCKLEY: That’s great. Dr. Modi, as we conclude today, you’ve given us a lot of fantastic points, and you’ve been very helpful and easy to follow. Because you’re a sixth-generation ophthalmologist, I wanted to ask you to sort of conclude with some sort of big-picture advice, like maybe what have you learned or observed in your career? Is there a common piece of advice you give to your patients, or is there a myth that you’d like to correct? You know, as we start the year 2020, a very auspicious year for vision health, is there something that we as individuals or a country can do better? A lot of different questions there. You can just pick one or some sort of big-picture thoughts.
DR. YASHA MODI: What have I learned in my career? I think that’s a tough question, and I’ll say that as much as doctors think they know, there’s always more to learn. I think we’re constantly learning more and more about disease states, and that, hopefully, can translate to significantly improved patient outcomes.
Part of this, I’d also like to say, is it’s a dialog that we have between the patients and doctors. Every patient interaction is a little bit different, and the way in which we treat patients can oftentimes be shaped through that mechanism. And so, if I had to provide a piece of advice to patients, I’d say always try to do your best to be informed about what’s going on with your eyes. What is the treatment plan that has been enacted, and then what’s the goal? What’s the 6-month goal? What’s the 1-year goal? What’s the 5-year goal? And those are things that can add some clarity to what you’re going through and also make it a little easier to follow what the retina doctor is seeing in clinic.
MICHAEL BUCKLEY: That’s great advice about the patients themselves having goals and clearly articulating that, so that’s wonderful. Dr. Modi, on behalf of today’s listeners and the BrightFocus Foundation, I want to thank you for joining us, and we’d love to have you back on a future BrightFocus Chat.
DR. YASHA MODI: Well, thank you for having me, and it was a pleasure being here.
MICHAEL BUCKLEY: Alright, thank you everybody, and we will reconvene February 26th. Thanks.