Dr. Joshua Dunaief
The telephone discussion features Dr. Joshua Dunaief, of the University of Pennsylvania’s Perelman School of Medicine, who specializes in the study of age-related macular degeneration.
The telephone discussion features Dr. Joshua Dunaief, of the University of Pennsylvania’s Perelman School of Medicine, who specializes in the study of age-related macular degeneration.
Vision Health During the Pandemic
April 29, 2020
1:00 p.m. EDT
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 the BrightFocus Foundation. Welcome to today’s BrightFocus Chat, “Vision Health During the Pandemic.” If this is your first time at a BrightFocus Chat, thank you, and welcome. Let me tell you about BrightFocus and what we’ll do today. BrightFocus funds some of the top researchers in the world. We support scientists who are trying to find cures for macular degeneration, glaucoma, and Alzheimer’s. We share the latest news from these scientists with families who are impacted by these diseases. We have a number of free publications and plenty of materials on our website, BrightFocus.org. Let me tell you about today’s guest, Dr. Joshua Dunaief of the University of Pennsylvania. We’ve been very fortunate to partner with Dr. Dunaief over the years on research projects involving root causes and possible treatments for macular degeneration. Dr. Dunaief is a frequent contributor to the BrightFocus website on articles about understanding and managing macular degeneration, and just recently, he wrote a great article for us about how to maintain your vision health during the pandemic, which is why we’re very fortunate to have the opportunity to have him with us today. So, without further ado, Dr. Dunaief, thank you very much for being back with BrightFocus.
DR. JOSHUA DUNAIEF: Hi, Michael. It’s always a pleasure to be with you here.
MICHAEL BUCKLEY: Let’s start off with just a few bigger-picture questions, then we’ll get a little more specific about vision health and some of our listener questions. Let’s start with the question that’s on everyone’s mind: When is this going to be over?
DR. JOSHUA DUNAIEF: We hoped sooner rather than later, but I think realistically we may have to get used to a new normal here, maybe for a year and a half until we have a vaccine or a medication, so I think we’re going to have to continue with some degree of social distancing and masks and just be as careful as we can during this period. But, you know, it’s also important to maintain connections with friends and family and do our activities as much as we can, while minimizing our risks, Michael.
MICHAEL BUCKLEY: Makes sense. For our listeners, today we will use “COVID” and “coronavirus” interchangeably. Dr. Dunaief, does COVID impact eyesight and eye health at all?
DR. JOSHUA DUNAIEF: Fortunately, not very much. It can cause a red eye—conjunctivitis—in not very many COVID patients, but a few COVID patients. That doesn’t impact the long-term eye health, but it can occur, which is not to say that anybody who has a red eye needs to be concerned that they have COVID. I mean, we have enough to worry about, and there are a lot of other causes of red eye. Most commonly, it would be a viral infection—not COVID, but some other type of virus. Usually, it would go away within a few days. If you do have a red eye and it kind of feels like you have something in your eye and it’s watering a lot, well, you may actually have something in your eye, in which case you could try to get it out by holding some water in the cup of your hand, put your face into it, and blink your eye, so you kind of wash that out of your eye. You can also hold your eyelashes—close your eye and hold your lashes with your finger—and then slowly roll your eye around, and that can help bring something that’s in your eye out. But if that doesn’t help and it’s affecting both eyes—both eyes are red and you feel like there’s something in it and they’re watering—you probably have a viral conjunctivitis. Again, probably not COVID. You just need to use some cool compresses, use a tincture of time, wait until that goes away. But you do want to try to keep from giving it to other people, so you don’t want to share towels or linens at a time when you have conjunctivitis. You do want to wash your hands—some of the same precautions that we’re using for COVID, except that, fortunately, viral conjunctivitis isn’t usually going to get transmitted by talking or sneezing the same kinds of things that COVID can get transmitted by.
MICHAEL BUCKLEY: I think one of the big picture challenges people face is that BrightFocus Chats and everything people read over the years talk about staying on top of your vision health, regular eye appointments, and regular treatments for AMD, but yet now in a social distancing, we know a lot of the medical appointments are getting canceled. How does somebody balance the risk of vision loss through AMD versus the risk of COVID? Should people keep their eye appointments or skip them? Do you have sort of a big-picture advice on that?
DR. JOSHUA DUNAIEF: “Balance” is really the right word here. So, it’s going to depend on your risk of COVID, and that is going to depend on how many cases there are in your area at any given time. And it’s also going to depend on your risk factors. Many people know that the risk factors for severe outcomes with COVID are increasing age, high blood pressure, diabetes, and other chronic diseases, so people who have those are at higher risk and need to be even more careful. But then, we need to be able to see, and if you have an urgent eye issue that could impact your ability to see, you have to balance that against the risk of getting COVID. So, examples of urgent eye issues would be … well, for example, somebody who has macular degeneration and is getting injections for wet macular degeneration. Studies have shown that those injections helped to preserve the current vision and sometimes improve it, and patients who stopped getting the injections are likely to have a decrease in their vision, so it is important for these patients to talk to their ophthalmologists or their offices and figure out what is the best frequency to be getting those injections at this time or on an ongoing basis. That may change, Michael; it may change depending on the patient’s condition, and it may change depending on the condition of COVID in the area at that given time.
For patients without AMD, the risk factors for vision loss that I’d be concerned about are a sudden change in vision. That’s something to definitely call an ophthalmologist about—things like new floaters and flashing lights or part of the vision is blocked. If you’re not sure if you maybe had a change in vision, it is important to cover one eye at a time and check each eye individually, because with both eyes working together, the good eye can take over, for the most part, and you might not even notice that one eye isn’t seeing very well. One thing that would be concerning for people with a history of macular degeneration is distortion in the central vision. If, for example, you’re looking at a door frame and the door frame looks curved instead of straight, that could be concerning. Or if you’re looking at a page of text and some of the lines of text look wavy, or you’re looking at a graph—like an Amsler grid that we give to patients to check their vision—and the lines look wavy, that can be an indication that wet macular degeneration is acting up and the patients really need to call their eye doctor and probably get an injection within a few weeks if they’re having symptoms like that.
Another really concerning thing would be eye pain. Some eye pain can be a sign of an infection in the eye or inflammation in the eye that could potentially be permanently damaging. One thing that can cause eye pain that is not quite as concerning is a sty. So, if you have a little bump on your eyelid—it’s like a red, localized bump—that may go away on its own, and you can encourage it to go away by using some warm compresses. If the area of redness enlarges and the whole eyelid becomes red, then that’s more concerning, and an infection may be spreading. And, Michael, these are the kind of things that can be determined sometimes by telemedicine. Telemedicine is when you call your doctor and the doctor—the ophthalmologist—arranges for you to talk either on the computer with a camera in it or on the phone and you send them pictures of your eye. For some conditions, the ophthalmologist can figure out what’s going on based on the history that you tell them, your symptoms, and a picture of your eye, and that could save you a trip to the doctor’s office.
MICHAEL BUCKLEY: Dr. Dunaief, it’s a great point you mentioned about telemedicine. I think that’s new for a lot of people. It’s not how we’ve interacted with our health care professionals. Any tips for people on how to make something that is probably unfamiliar and new go better?
DR. JOSHUA DUNAIEF: It is very different for patients to do this, for doctors to be doing it. I think many of us are doing telecommunications, video communications, more Zoom chats, and iPhone, FaceTime chats, and lots of other chats that my kids know a lot more about than I do, but it enables us to stay connected to some degree as best we can with people, and that is very important. And it’s the same for a doctor’s visit. A telemedicine visit can be more informative than just a phone call if the doctor can actually see you and you can see the doctor. The doctor can see what your eye looks like, at least on the surface. To prepare for this, it can be on Zoom or whatever software the doctor’s office wants to use; they’ll make it easy for you to use it. The office would give you instructions about how to use it, and then it’s just like having, otherwise, how you prepare for an in-person doctor’s visit. You’d want to have a list of your symptoms so you can explain what’s been happening. You want to have your medical and eye history so you can tell that to the doctor; your medications that you’re on; the allergies that you have; and then you’ll be ready to give the doctor the information that they’ll need. If you have any medical records, if you’re not currently a patient with that doctor, it’s helpful to have medical records or even images of your eye from doctors that you’ve seen in the past, and you can request those records be sent to you electronically, often, by doctors’ offices.
MICHAEL BUCKLEY: In this sort of new area of telemedicine, are the things that we’ve grown accustomed to at an in-person appointments—such as the HIPAA privacy protections and insurance coverage and copays—do those stay the same in a telemedicine appointment?
DR. JOSHUA DUNAIEF: These things are evolving very rapidly, but the HIPAA protections are still in place, patient privacy is protected, and insurance will often cover telemedicine, especially now in this COVID era. Insurance companies realize the importance of the telemedicine, and these visits—virtual visits—are often covered by insurance.
MICHAEL BUCKLEY: I want to turn to a few listener questions. I have a listener that’s wondering about the regular vision health—tests for new prescription for glasses or contacts. Based off what you said before, is that something that they should assume that they would postpone or their doctor’s office would want to postpone? What about, I guess, your annual well visit to an eye care professional?
DR. JOSHUA DUNAIEF: Again, it’s a matter of balancing risks of COVID and risks to your eye from not going for that visit. I mean if your vision is good, you’re able to cover one eye at a time and read well and there’s nothing blocking any part of your visual field, your eyes are comfortable, you don’t have any history of macular degeneration or diabetes or glaucoma, then you can probably put off those regular visits. I know a lot of people go in to get their glasses adjusted. If you’re seeing well, then you don’t need to get a new pair of glasses. Some people think that maybe the glasses need to be changed on some regular basis, but if you’re able to see well, some people don’t need to change their glasses prescription for many years. Sometimes glasses get scratched and you want to get a new pair, but if everything is in focus, what you could do is just call your ophthalmologist or optometrist and ask to have a copy of the prescription sent to you, and then you could just order a new pair with the same prescription that you had before.
Same thing with contact lenses. If your eyes are comfortable, not red, and you’re seeing well, and you want to replace your contact lenses, you could call the ophthalmologist or optometrist and get the prescription and replace them. It is important to replace contact lenses as scheduled. If you use the same pair for too long, then material can build up on them, and that puts you at risk for a potentially vision-threatening infection, so you have to really continue to use the contact lenses as you were before—not longer than you were supposed to, never sleep in them, make sure the cleaning is done properly with the right cleaning solutions at the right frequency—because if you don’t do that, you can put your eye at severe risk for a bad infection in the eye.
MICHAEL BUCKLEY: I appreciate that point. Staying on contact lenses for a moment, you know, we read during the COVID times we’re told to try to not touch our face or touch our eyes. What about contact lenses or eye drops? How does somebody balance potentially conflicting advice about not touching their face and eyes but yet using eye drops or contacts?
DR. JOSHUA DUNAIEF: If you’re in your home and you’ve not been out in public—you haven’t gone shopping for food or something like that, you’ve been home for a few days—it’s really a minimal risk for getting COVID in there. If you do go out to shop for food, for example, you want to make sure that you wash your hands very thoroughly for at least 20 seconds—really scrub the front and back and between your fingers and your fingertips and your wrists—before you are going to touch your face, including something like putting in eye drops or putting in contact lenses.
MICHAEL BUCKLEY: Good advice. Another question we got was related to glasses. How do you not get your glasses fogged up when wearing a mask?
DR. JOSHUA DUNAIEF: Yeah, that’s a tough one. The reason they fog up is when you breathe out, a lot of air with moisture can be pushed up your face toward your eyes, toward your glasses, and then that moisture just sits on your glasses and fogs them. One way you can do it is to exhale through your mouth instead of your nose and direct that stream of air differently, or you can change the way the mask is fitting so that you let the air escape more from the bottom than from the top, but yeah, that can be a tough one.
MICHAEL BUCKLEY: It’s a challenge none of us ever thought about before a few weeks ago. I was kind of curious about your own practice or just ophthalmology, in general, when people do—under the conditions you talked about—need to see their eye doctor in person, how have the physical setup and the nature of a visit changed during the pandemic?
DR. JOSHUA DUNAIEF: Quite a lot, Michael. The American Academy of Ophthalmology has recommended some weeks ago that only really urgent cases be seen and routine care be deferred. Now they’re loosening that up a bit as the curve has been flattened, at least in some locations, and when it gets to the point where the number of cases is controlled, then we’re starting to see recommendations to expand the number of patients who can be seen. We may be able to see patients, for example, getting cataract surgery again in the coming weeks in some places. The offices are taking great precautions now to minimize risk. So, how are they doing that? They’re keeping people separated physically, at least 6 feet apart. The health care professionals are going to be wearing masks. Patients are probably going to be wearing masks, also, or at least recommended that they wear masks. Probably, accompanying family members or friends who come in with the patient will be encouraged not to come into the office unless it’s absolutely necessary to help the patient with mobility, and so forth, because we just want to keep the number of people in the office as low as possible and spaced apart as possible. Cleaning procedures—I mean, obviously, the offices were always cleaned carefully, but that’s been redoubled now, so that there’s a lot more disinfection going on in every corner of the offices.
MICHAEL BUCKLEY: At the outset, you talked about the new normal. In just your own projection of the future, what type of changes in an ophthalmology office do you think we’ll endure after? Which, if any, will endure after the coronavirus dies down?
DR. JOSHUA DUNAIEF: We’re going to see more physical barriers. There will be more plastic barriers, like for check-in. There may be more of a plastic or glass barrier between the patient and the front-desk personnel. You may see more plastic barriers going up on the equipment that the eye doctor uses to examine you. For example, the main piece of equipment that we use is called a slit lamp, which is the thing that you put your chin on and your forehead against a cushion strap. Now many of those are going to have a plastic shield between the patient’s face and the ophthalmologist’s face. That doesn’t interfere with the exam, but it does prevent any transfer of air or droplets between the ophthalmologist’s and the patient’s mouth or nose.
MICHAEL BUCKLEY: That’s good to know. We have a few questions that have come in about life at home, which is something we’re doing a lot of now. We have one caller wondering about any specific vitamins or food that is best for vision health during the pandemic?
DR. JOSHUA DUNAIEF: I am glad you asked that, Michael. People who have inflammation are at increased risk for complications of COVID, so the people who are at highest risk have diseases like diabetes and high blood pressure and just people who are older. What this all has in common—all of these conditions—is that they have inflammation. And what do I mean by that? Inflammation is the immune system being overactive and tending to attack our own bodies to some extent, and all these chronic conditions—heart disease, diabetes, macular degeneration, Alzheimer’s disease, arthritis—they all involve inflammation. As we get older, our immune systems tend to be more overactive against ourselves and causing this inflammation. My brother and I—my brother is an internist who studies the benefits of including a lot of plants in the diet—we’ve now studied his patients and come out with a couple of peer-reviewed publications showing that people who eat lots of fruits and vegetables can decrease their inflammation.
How do we know that? We can measure it with a blood test called C-reactive protein, or CRP. CRP’s important because people with higher CRP are known to have a higher risk of heart disease. This was shown over the past couple of decades by a doctor named Paul Ridker at Harvard. It’s also associated with increased risk for macular degeneration: Johanna Seddon at Harvard also showed that CRP in the blood is associated with increased risk for macular degeneration. We’ve shown that we can lower CRP in the blood by putting people on a diet that’s rich in fruits and vegetables, nuts, grains, and seeds—especially dark green leafy vegetables, like spinach, kale, collard greens, and bok choy—and one staple of this diet, Michael, is a smoothie. I’m sitting here right now with a smoothie on my desk at home. I’ll tell you, ironically, with this COVID thing, I’ve never felt healthier because I’ve been eating at home all the time—not eating out, not eating at the office—and so I can really control what I am eating, and that’s really what I recommend for patients with macular degeneration or just anyone who wants to reduce their COVID risk. Get that inflammation down. And so this smoothie—if you like, I can post the recipe on your website.
MICHAEL BUCKLEY: Yes, that’s great.
DR. JOSHUA DUNAIEF: It contains blueberries, cocoa powder, banana, flax seed, spinach, and soy milk. And you may say, “Oh, gross, spinach in a smoothie,” but there’s enough other stuff in there that it actually tastes pretty good. We actually just looked at some data. People who don’t change anything in their diet, other than have one of these smoothies once a day, can lower their C-reactive protein in 7 days.
MICHAEL BUCKLEY: That’s great.
DR. JOSHUA DUNAIEF: A really quick effect from a relatively painless thing—just having this smoothie for breakfast, or whenever you want throughout the day. The benefit of the smoothie is that these plants have a lot of antioxidants and phytonutrients that lower your inflammation, and the smoothie mixes it all up in a way that it’s very easy to digest and absorb all these healthy plant nutrients. Things like sugar—refined sugar—and lots of animal products increase your inflammation. Fish—like salmon once or twice a week—has healthy fish oils that reduce the risk of macular degeneration. So, if you’re going to have an animal product, I think fish is the preferred one.
MICHAEL BUCKLEY: We have another question about a different part of being at home. A lot of us want to try to read more. Any suggestions for magnifying tools or lighting changes, now that we are spending more time at home—whether that’s reading or different activities that are home-based? How can we enjoy those activities while also keeping good vision health?
DR. JOSHUA DUNAIEF: Good question. If you’re having trouble reading, it can help to increase the lighting. So, if you have a lamp that you can have nearby or maybe one that is on a swivel, or one of those flexible ones that you can bring nearer to the reading material and shine it on a reading material, that may make it easier for you. If you’re reading on a computer or a Kindle or an electronic device, you can change the settings. You can increase the size of the letters, the font. You can increase the brightness. You can reverse the contrast, which can make it easier, so that rather than reading black letters on a white background, you’re reading white letters on a black background; it’s easier on the eyes actually because you’re kind of shining less bright background light at your eyes. And magnifiers can help; you can get them on Amazon, for example. Some of them have built-in lights, so you hold the magnifier, you press a switch, the light goes on, and then you can really see the few words that you want to read with that hand-held magnifier. There are also magnifiers that’ll sit on a table or a desk, so you don’t have to hold it if you want to read something for a longer period of time.
MICHAEL BUCKLEY: Another question about being at home is, you know, we’ve all learned that a key part of healthy aging is that social interaction/social stimulation, in terms of keeping age-related diseases at bay. Any advice for people that are dealing with the isolation and the loneliness and the anxiety that comes from a quarantine period?
DR. JOSHUA DUNAIEF: It’s really important to stay connected by phone or by computer with Zoom or by FaceTime, so you can see people, too. I just bought something for my mom, which is a digital picture frame that I can email photos to. My brothers and her grandchildren can do this too, so she can get new photos to look at every day. It’s called a Skylight; I have nothing to do with this company other than I bought their product. I am sure … I’m getting that for her for Mother’s Day; I am sure she’s really going to love that.
MICHAEL BUCKLEY: I think it really is very important about the connectivity. Another question we got related to that was: People who go to vision rehabilitation services, is something like that continuing during COVID?
DR. JOSHUA DUNAIEF: Again, there’s the issue of the balance, so at times when there is more COVID around, that’s not an urgent issue in most cases. It’s something that can be put off for a while, but there’s probably some telemedicine happening with low vision specialists who are optometrists who are focused (no pun intended) on patients with visual impairment. They’re experts on all kinds of approaches to optimizing the vision that you have using computers or magnifiers or lights or special glasses. So, in a time when there is some COVID around, I think it would be hard to justify the risk of going in in person until the risks are reduced. Certainly in most places now, the risk would be too high for that—maybe not in some locations where there’s not much virus, but wherever there’s a fair amount of virus, you wouldn’t want to go in for that in person, but you might be able to do it by telemedicine.
MICHAEL BUCKLEY: Dr. Dunaief, I want to thank you so much for all your advice and assistance today. Just kind of a final concluding question: Is there sort of one bit of advice that you want to share with us to help us all stay as healthy and safe and as happy as we can be during this difficult time?
DR. JOSHUA DUNAIEF: Michael, I want to thank you and BrightFocus for giving me the opportunity to reach all these people at this time, especially when our mobility is limited. We do have a lot of concerns, things that changed in a lot of ways over the past few months. I really appreciate being able to talk to all these people, and I think the final thought I would leave you with today is cooperation. I think we really need to work together on this at every level. Patients need to talk to their doctors more on the phone, initially, rather than coming into the office right away. It’s very important to make that phone call and explain what the issue may be before deciding with the office staff or the doctor whether to come in. Don’t just show up. That’s just putting yourself and everyone else at risk. And just working together with family, with community, internationally, every political party. The enemy here is the virus. We need to keep our focus on that and make sure we’re all working together and cooperating to get this under control and eradicate it as soon as possible.
MICHAEL BUCKLEY: That’s great advice. I think you’re right; I think in times of stress and great challenge, it’s a real fork in the road to either come together and cooperate, or not. I really appreciate today how you outlined the intersection between COVID and vision health, and I think you made a lot of really good points because this is a time when people have a lot of questions and a lot of concerns, and I really appreciate your help guiding us through that. So, again, Dr. Dunaief, on behalf of BrightFocus, I just want to thank you for being so helpful to our community during this time.
DR. JOSHUA DUNAIEF: My pleasure. Thank you, Michael. Stay safe and healthy, everybody.
MICHAEL BUCKLEY: This concludes today’s BrightFocus Chat. We’ll talk to you May 27. Thanks.
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