Getting the Right Care for Your AMD
February 24, 2020
1:00 p.m. EST
Please note: This Chat may have been edited for clarity and brevity.
MICHAEL BUCKLEY: Hi, I’m Michael Buckley with the BrightFocus Foundation, and welcome to today’s BrightFocus Chat, “Getting the Right Care for Your AMD.” If today’s your first time with us, welcome. I’ll tell you a little bit about BrightFocus and what we’ll do today. The BrightFocus Foundation is a nonprofit, funding some of the top researchers in the world. We support scientists who are trying to find better treatments—and ultimately cures—for macular degeneration, glaucoma, and Alzheimer’s. And we share the latest news on research with families that are impacted by these diseases. We have a number of free materials on our website, BrightFocus.org. And today’s BrightFocus Chat is another way of sharing this information. Let me tell you about today’s Chat, “Getting the Right Care for Your AMD.” We’re really fortunate today to have Dr. Alan Glazier. He’s an award-winning optometrist in the state in Maryland—in the Washington suburbs—and today he’s going to tell us … kind of walk through different parts of the eye care world, different specialists, and also answer some question about the best way to receive eye care. So, Dr. Glazier, thank you very much for joining us today.
DR. ALAN GLAZIER: Thank you for having me. I’m honored to be asked to be on the show and am excited to share my knowledge.
MICHAEL BUCKLEY: You’re a first-time guest today. I was wondering if you could tell our audience a little bit about yourself and how or why you ended up doing what you do.
DR. ALAN GLAZIER: Sure, so I’m an optometrist, and I practice in the Rockville suburbs of Washington, D.C., and I have some leadership roles in the industry. I lecture, and I write articles. And, actually, my foray was … my first job was a specialist in AMD and low vision—so, very relevant to this talk. I went into optometry. I originally wanted to be a vascular surgeon, and when I found … my father was an optometrist, so when I found out how long it was going to take for me to get through the training … I was 27 at the time, it sounded like—I mean, I was 22 at the time—it sounded like forever. For the first time, probably, in my life, like a lot of us, I paid attention to my parents, and I when started looking at the parents and my father, I realized he was really happy with what he did, and in optometry, as a generally nonsurgical specialty, I could get out of school a lot younger and have a really … I figured if I could be half as happy as he was, I would have a great career. And that’s what made me pick optometry. It’s medical; we use medicine to treat eye diseases, and in some states, we can do surgeries. And yet, it didn’t have the lifestyle or the time in school commitment of a vascular surgeon.
MICHAEL BUCKLEY: Thank you. That’s very interesting. That’s what I want to do today, is walk through a handful of professions within the field or vision health, and I think it will help our audience understand the different roles that everyone plays and maybe help them know how to go about getting the best care possible. I was wondering if you could tell us about what an optometrist is and contrast that with an ophthalmologist.
DR. ALAN GLAZIER: Sure. It can be very confusing. We refer to them as the three O’s: ophthalmologists, optometrists, and opticians. Out of those three O’s, two of them are doctors or physicians—optometrists and ophthalmologists. Ophthalmologists first go to medical school for 4 years, and then they decide what … they have to match for what type of specialty they want to be in, and then they go for further training for that. So, they learn generally about the whole body, and then they spend between 2 and 5 years in their specialty training. If they choose the eyes, then they become an ophthalmologist, and in practice, ophthalmologists generally deal with diseases and surgeries of the eye. Some of them practice what we call primary care where they’re taking care of glasses and contact lenses, but generally, they’re working with the disease side of things. An optometrist goes … both professions go through 4 years of undergrad first. An optometrist goes to 4 years of optometry school, which is focused on the parts of the body that are related to the eye and the head and neck in great detail for 4 years, specifically eye care, and then they generally … a lot of them go to residences for another year or two, where they get additional specialty training. So, they do not go to a medical school; they go to an optometry school. And on graduating optometry school and passing their state licensure, they can practice in all 50 states now. They can prescribe medicines, and in a handful of states now, they have certain surgical abilities, as well, and opticians are generally tradesmen who sell and make eyewear, glasses, and lenses.
MICHAEL BUCKLEY: Just out of curiosity, are there more optometrists or ophthalmologists in the U.S.?
DR. ALAN GLAZIER: There are a lot more optometrists—so, around 70 to 80 percent of all the eye care in our country is provided by optometrists. The number is debatable, but there is somewhere between, we believe, 37,000 and 45,000 optometrists in the U.S., and there are somewhere in the neighborhood of 7,000 to 9,000 ophthalmologists.
MICHAEL BUCKLEY: Thanks. If someone were getting what I call routine care for visual acuity through glasses or contacts, what might make them consider going to an ophthalmologist?
DR. ALAN GLAZIER: Well, access to care is a big issue. Sometimes there will be more availability for ophthalmology, but, generally, there is more availability for optometrists. Generally, ophthalmology, again, is referred as secondary care; however, they do provide general eye exams. And some of them—well, not most of them—have opticals in their offices, and very few of them fit contact lenses; they often delegate that to a technician or an optometrist that they have working for them. And then optometrists, of course, in their independent private practices generally fit and prescribe glasses and contacts and do general eye care, as well. Does that answer your question?
MICHAEL BUCKLEY: Yes. Thank you. It does. So, as you walk through that world of optometrists and opticians and ophthalmologists, we hear people mention retina specialists. Where do they fit in that array of occupations?
DR. ALAN GLAZIER: Within the ophthalmology specialty, there are specialists for different parts of the eye, and then, the retina is an area where … when a condition occurs that reduces the vision and it is continuing to reduce the vision and needs to be treated, generally, both optometrists and general ophthalmologists will refer to a retina specialist who handles just that part of the eye. For macular degeneration, both ophthalmologists and optometrists are capable of following it and making recommendations to try and stop it from progressing, but when it gets to the point where the doctor’s concerned it’s progressing, then often they’ll refer patients to the retina specialist to apply their special training and help save the eye.
MICHAEL BUCKLEY: Is that where those injections that we talk about a lot on the Chat, is that where they come—at the retina specialist?
DR. ALAN GLAZIER: Yes, the most common injections that are given for macular degeneration are for the wet form or in eyes where the dry form is converting to the wet form, and they give these anti-VEGF shots into the eye. And it went into the area around the eye where they … it absorbs into the eye and treats the disease, and that is generally given by a retina specialist, yes.
MICHAEL BUCKLEY: I think a lot of us are familiar with physical therapy for various injuries or occupational therapy. How does that work for vision? What type of therapy and rehab services would somebody be able to access?
DR. ALAN GLAZIER: So, in relation to macular degeneration, is that what we’re talking about?
MICHAEL BUCKLEY: Yes.
DR. ALAN GLAZIER: In macular degeneration, if there is vision loss and it’s impacting your life negatively, if you can’t do the things that you used to love to do anymore, there are specialists called low vision specialists. These are generally optometrists with special training in prescribing powers of lenses and special devices for the particular type of visual loss you suffer; not every type of vision loss for macular degeneration would be the same. And depending on what that is and what your needs are, they can prescribe generally magnifiers or telescopic light devices, and now, they use a lot of screens, a lot of iPads by enlarging in print to help people read, and there are specialists whose whole careers is dedicated to help with these, use these, and prescribe these assistive devices.
MICHAEL BUCKLEY: That’s great. And in your practice, do you refer people to low vision therapists? Or how does one end up receiving that type of care?
DR. ALAN GLAZIER: General doctors will often refer to a low vision specialist. I started out as a low vision specialist, so I still perform it as part of my practice. I don’t have a ton of people in the age range that need it from me, but when they do, I know what to do. But, yeah, generally, if you’re suffering from macular degeneration, your doctor tells you there’s nothing else they can do and they haven’t offered, you can ask to be referred to a low vision specialist.
MICHAEL BUCKLEY: Well, great. And you’re in the Washington suburb area; I was wondering, for people who live in rural areas where it might be a little harder to access medical care, do you have any suggestions for folks that are in rural areas?
DR. ALAN GLAZIER: Sure, sure. Well, if there’s not access to optometry or ophthalmology in those areas easily, I recommend you put a call into the Lions Club, a regional Lions Club, and other organizations that do vision screenings periodically in the area. The screenings can help do a very basic look and see how urgent a visit might be so that you can minimize your need to travel unless absolutely necessary. You could also, as far as it relates to macular degeneration, you can download online or have a doctor provide you with a simple tool called an Amsler grid, which is a grid on a piece of paper, and use that daily to monitor your eye for changes, and should you see a change on that grid, immediately you’ll know it’s urgent and you need to get to the doctor.
MICHAEL BUCKLEY: Great. Dr. Glazier, I’d like to stay on the rural area topic for a minute. I am trying to think of ways to balance … let’s say you lived in New Hampshire or Maine. You can probably get to Boston a couple of times a year with some help, but yet, your day-to-day life and medical care is generally restricted to closer to town. Is there a way that patients can balance the kind of more frequent care in a rural area with some providers in the big city? I was wondering, how does that work?
DR. ALAN GLAZIER: I’m not sure I have the answer to that. I think that’s a challenge that exists in our country. Of course, we need more providers in rural areas, and until that happens, traveling is the only way I can think of. I can say one thing—that if you are used to visiting an ophthalmologist and you’ve never considered going to an optometrist, I strongly recommend you visit one, because there are more of them in rural areas than in ophthalmology. And they are more than capable of monitoring the progression, so just maybe expand your options in terms of which provider you’re willing to see if you’re in that situation.
MICHAEL BUCKLEY: So, since the pandemic started, have you branched into telehealth or telemed appointments?
DR. ALAN GLAZIER: It’s a great question, I tried telehealth in the beginning, and I found it was good for urgent care and it was good for the situation we were in, and I think ultimately as the technology evolves, it will be great. The problem is you can’t ask—well, that’s not the right terminology—I wouldn’t want as a health care provider to provide my specialty to my patients if there was any decrease in the quality of care that I am able to provide in the office, because that would be selling them short. And the technology for these telehealth visits, as far as eye care goes, isn’t all there yet. So, yes, it was urgent at a time where we were isolated, and it worked for that, and at some point, we will not have to reduce the standard of care by using it, but until then, it’s going to have a very limited role in, at least, ophthalmology and optometry, I believe.
MICHAEL BUCKLEY: I appreciate your candor on that, because it’s definitely an area of medicine that we’ve all been thrown into without a lot of preparation over the last year. And related to that, you’ll hear people use the phase, “a comprehensive eye exam.” How would you define that? Because I think it’s something people hear of but don’t necessarily know what that entails.
DR. ALAN GLAZIER: Both optometry and ophthalmology have national associations. For optometry, it’s the American Optometric Association, and in ophthalmology, I believe it’s the American Ophthalmology Association. Anyhow, each association creates guidelines on what determines the … what tests are included in a comprehensive eye examination, and I believe they’re very similar, if not exact. And that includes a visual acuity test, an observation of the eye using certain types of equipment. It includes a glaucoma test and other tests that are … and dilation of the eye and examination of the retina, which are deemed important to collect enough information to determine whether or not you can say that an eye is healthy or not.
MICHAEL BUCKLEY: Thank you. That’s good to know. And sort of just stepping back, big picture, what do you think makes an eye doctor visit go as well as it can for the patient and for the provider?
DR. ALAN GLAZIER: Well, I think this is a dance of two, and there’s onus on both sides. From the provider’s perspective, the provider needs to be a very good listener and a good caretaker—someone who went into this so that they could care for people. And when you combine, as a doctor in any field, I think, the skills of wanting to first and foremost take care of the patient—and not just the condition in the chair, but the actual person—listen to their needs and then act on them in the patient’s best interest, you have a good doctor. Doctors display their diplomas and their academic credentials all over their offices all the time, but all patients know at the end of the eye exam—or any exam, for that matter—is if their needs were met, and if their needs are met, they felt that they had a good experience generally. From the patient’s standpoint, there’s certain information that doctor needs to have to do their job to the best of their ability. And that includes everything from providing the proper information for their insurance through answering their questions clearly and directly and communicating with the doctor why they’re there. The more information the doctor has, the better that exam will go, and often patients are like, “Why do they need to know this?” or “Why do they need to know that?” Don’t worry about that. That’s because we are trained to put that information together to provide that care that we so want to provide for you. So, that’s the dance between the patient and the doctor, and there’s probably a lot more to it.
MICHAEL BUCKLEY: That’s very well said; I appreciate that. So, across the span of the appointments that you have, are there common questions or even common misperceptions that you feel like you need to address or dispel across your patient population?
DR. ALAN GLAZIER: Yeah, very much so. I’ve been in practice for 28 years now, and we get very similar questions over the course of our day generally, and occasionally there’s a red herring or something that hasn’t been asked of us before. But, generally, that’s an exception, not the rule, so we’re very familiar with answering questions like that. I can’t remember the last time I got stumped, but we get similar questions about diseases, and people want to know what’s going on; we want to be able to answer that.
MICHAEL BUCKLEY: Is there a key message, the key thing you want your patients to know across the age and the health span of who you see? Is there a common message that you’d like to impart to your patients?
DR. ALAN GLAZIER: There’s probably a lot of them, but most important, though being a limited call here, is if you see something change in your vision, don’t wait for it to go away. Don’t wait for it to change or get better. Most of the problems in the human eye that occur and are caught within a short amount of time from 24 to 48 hours can be treated successfully, especially since 2007 when these anti-VEGF medicines came on the market. So, if you have any questions about anything you see, set up a doctor’s appointment. If you have floaters in your eye—things that float around—don’t just watch them for a couple of days and wait for them to go away. You might be getting a retinal tear, which might be leading to a retinal detachment. The sooner that gets to the retina specialist, the better off you’ll be. With the eyes, it’s interesting, because the eyes are the only way that a doctor of any kind can look into the human body without penetrating it or cutting it open, and when we do, we see active, working blood vessels that are a mirror to how the blood vessels inside your body mirror of your whole health. So, the eye exams are very important, even a primary care physician will tell you, “Have you had an eye exam?” because they are very important for not only picking up eye diseases but also many systemic diseases, as well. Those are some points that I’d like people to consider: When you have an eye problem, get it checked right away. Don’t wait. It may make the difference between saving your vision and not.
MICHAEL BUCKLEY: Fantastic points, and I have heard the expression over the years, “Time lost is vision loss,” and I think that that’s a great message you try to impart to your patients, because I think a lot of us believe in wishful thinking, and all … maybe time’s going to heal all wounds, and I think we know, particularly in vision care, that’s not a wise approach. [voices overlapping] Do you have patients ask you … Go ahead, Dr. Glazier.
DR. ALAN GLAZIER: Sure. Most of the treatments that would restore your vision or save it are painless. So, there’s really no reason not to get it checked; I’m sorry; I just wanted to add that.
MICHAEL BUCKLEY: Great point. Particularly in the macular degeneration, we get a lot of questions here about vitamin supplements. I was wondering if you could tell us what you recommend—and others—for people that have forms of AMD?
DR. ALAN GLAZIER: Sure, sure … so there’s a group of studies—the AREDS studies. In the latest AREDS studies, the recommendations are turned by companies into supplements to take, with some data to suggest that they may help. Now, I always tell people, they can’t hurt you. And the question is with all vitamin supplements, “How well are they absorbed by your intestinal tract, and what benefit do you really get out of them?” There was a study of vitamins in the 1970s where they dredged the New York City sewers, and they came up with hundreds of thousands of undigested pills. So, what you want to do if you’re going to take AREDS2 supplements, I’d definitely recommend you take them if you have AMD and your doctor recommended it. If you’re going to take them, make sure that you’re also getting the proper nutrition, because the things that are in those vitamins, you can also get from specific vegetables and fruits and even egg yolks. The lutein, the zeaxanthin—these are important things that help your macula, and we know that your body absorbs them and they go right to your macula to protect it when you eat foods. And some of the vitamins will, as well—they are supplements. And that word “supplement” is really important to understand because they’re supplemental; they are not supposed to … they’re not going to keep you from eating what you need to eat to protect your eyes, as well. So, make sure that you use them only as supplements to a healthy diet, and then you’re doing everything you can that we know to protect yourself: using your Amsler grid, taking your supplements, and eating a healthy diet with foods your doctor recommends.
MICHAEL BUCKLEY: Great, and that sounds like key ways to keep AMD from progressing. We have a question today, somebody wondering about cataract surgery. Does it help AMD? Does it worsen AMD? Is there a connection between cataract surgery and AMD?
DR. ALAN GLAZIER: A long time ago, there was a study that showed that cataract surgery can worsen AMD. Since then, there have been other studies that have countered that claim. The jury’s out on that. If you have any kind of macular issue or retinal issue, a responsible cataract surgeon will refer you to retinologist for a complete retina exam and give you the okay to go ahead with cataract surgery. And if you have those two doctors in the picture, it’s probably a safe bet that it’ll be safe to move ahead. At a certain point, though, the cataract—which is a reversible type of blindness—will need to come out because you won’t be able to see at all. So, while it’s okay to delay it, a lot of doctors will recommend if there are any retinal issues that you delay the cataract surgery as far out as possible until you either are threatened in losing your driver’s license or unable to do the things you love to do in your life. So, yes and no. There are no data that strongly show cataract surgery worsens any kind of retinal diseases, but there have been some studies that have shown different.
MICHAEL BUCKLEY: Well, thanks. I have a couple of questions for you, Dr. Glazier, related to the pandemic. At this recording, we’re about 2 weeks, 3 weeks shy of the 1-year mark. What have you seen in your patients? Are you seeing signs of loneliness or depression or are there pandemic-related concerns that you been finding these last 11 months?
DR. ALAN GLAZIER: Absolutely, absolutely. In that age group, first of all—across all age groups—we’ve all been impacted by this psychologically, and we all deal with that kind of stress differently. In that age group, it’s particularly worrisome people are kept from seeing their families and their grandchildren, and that is very stressful for a lot of them. They can’t go out to get the things they need to get, so they’re limited in what they’re able to do. Their families who used to bring them things won’t bring them stuff. It’s very hard, very hard on that population.
MICHAEL BUCKLEY: What do you recommend to them when you see signs of this in your patients?
DR. ALAN GLAZIER: Well, I try and find out if they’re able to use digital devices to communicate with their families, and I really don’t have many recommendations other than that at this point. We all have to be safe, and we all have to isolate, and hopefully they understand I don’t really have many recommendations for them other than that.
MICHAEL BUCKLEY: I think it’s great to at least have the conversation and get it out there that this is hard for everybody. And my other pandemic question was, we are all spending a lot of time looking at screens. Any tips on that? Or, what have you observed with your patients over our year of increased screen time?
DR. ALAN GLAZIER: That’s a great question, and it’s highly relevant to a young population, children, young children up to the age of adolescence; their eyes are still developing, and this screen usage can increase … and has been shown in a recent study the increase of myopia, which is nearsightedness. And myopia increase has been shown to later in life lead to increased risk of having macular degeneration and other eye problems. So, in the short term, the children’s prescriptions are going up, and in the long term, there might be a big burden on public health because there will be more age-related eye diseases when that generation is in their 60s and 70s. For people who are already adults, we see eye strain and sore eyes as a consequence, but we don’t see any kind of long-term impact on their eye health from screen time.
MICHAEL BUCKLEY: Good to know. Well, we have a couple more questions from our audience before we conclude. We’ve got a caller from West Virginia that’s wondering, what can she do around the house to make her home a little safer for people with age-related vision loss? Or do you ever come across this question in your practice about what can you do to make your home a little safer?
DR. ALAN GLAZIER: From a safer standpoint, I know that with macular degeneration, you never really lose your side vision; you lose mostly your central vision. So, putting things near steps, putting things near railings or sharp table edges that you’re easily able to pick up with your side vision can alert you to what what’s around you and maybe keep you physically safe. I don’t really know much more about that. I know that in the early stages of macular degeneration, it can be very challenging because you’re still trying to understand your surroundings and get familiar with them. And with time, practice is also important. Make sure that you’re able to count your steps and the spaces around you. Get familiar with how far away things are so you can judge where you are. Make sure if you have … the doors that need to be shut, like refrigerator doors and things like that, that there are certain types of beeps on them if they are left open for too long, so that you can hear them and things like that.
MICHAEL BUCKLEY: Great. We’ve actually got a follow-up question about screen time. A caller is wondering, are there types of filters or settings that we could adjust to either get higher contrast or make things a little less strain on the eye when looking at a screen?
DR. ALAN GLAZIER: I’m sorry. Can you say that again?
MICHAEL BUCKLEY: We had a caller who wanted to follow up on the question about screen time. Are there filters or settings that could help reduce some eye strain?
DR. ALAN GLAZIER: There is some conversation out there about the blue light that screens emanate, and that for some people, it may be more sensitive to it than others. And by eliminating the blue light, they may feel better, and there’s some suggestion that the blue light exposure over many, many, many years can contribute to macular degeneration. So, blue light filters might be something to try.
MICHAEL BUCKLEY: Great, thank you. Dr. Glazier you have several decades in vision health; I was wondering, is there a big picture piece of advice you’d like to leave us with about how we can best take care of our vision health or anything related to that?
DR. ALAN GLAZIER: Sure, sure. Well, it’s very important to have good eye care. The eye doctor would want an annual eye exam, especially in people over the age of 50 and the regular communication with the doctor … communication with anything going on with your eyes that might be out of the ordinary. And also know that looking at things, using your eyes to see things, not harm them, the only thing you want to remember about that is that you want to protect your eye from the sun from wearing good sunglasses with UV protection.
MICHAEL BUCKLEY: I think we may have lost you for a second there.
DR. ALAN GLAZIER: I’m here. Can you hear me now?
MICHAEL BUCKLEY: Yes. You talked about good sunglasses, UV protection …
DR. ALAN GLAZIER: Yup, yup. UV protection, see your eye doctor annually, use your Amsler grid, and report anything that you’re suspicious that might be worrisome to you.
MICHAEL BUCKLEY: Great. Well, thank you. To our listeners, this concludes the discussion. So, Dr. Glazier, I really appreciate the chance for you spend time with the BrightFocus audience and give a lot of great points. I think it’ll help all of us get the best eye care that we can.
DR. ALAN GLAZIER: Great. Well, thank you. It was wonderful. And I’m great that I could add some value to everyone’s health care.
MICHAEL BUCKLEY: Fantastic. We hope to have you back soon. And to our audience, this concludes this BrightFocus Chat, and thank you so much for joining us. Bye-bye.
Useful Resources and Key Terms
BrightFocus Foundation: (800) 437-2423 or visit us at www.BrightFocus.org. Available resources include—
- BrightFocus Foundation Live Chats and Chat Archive
- Clinical Trials: Your Questions Answered
- Healthy Living and Macular Degeneration: Tips to Protect Your Sight
- How Low Vision Services Can Help You
- Macular Degeneration: Essential Facts
- Research funded by BrightFocus Foundation
- The Top Five Questions to Ask Your Eye Doctor
- Treatments for Age-Related Macular Degeneration
- Understanding Your Disease: Quick Facts About Age-Related Macular Degeneration (AMD)
Other resources mentioned during the Chat include—
- Amsler grid