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Coming Out of the Dark About AMD (Vision Source Exchange 2019)

Amanda Lee, OD

Dr. Amanda Lee has seen the light when it comes to the early detection of AMD.

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Shining light on the early detection of AMD

Host: Our next platinum performer is about to come up so please welcome to the stage Dr. Amanda Lee, Senior Director of Professional Relations for MacuLogix!

Dr.  Lee: Hello friends, I’m Amanda and  I’m a Vision Source doctor just like you. I’ve been practicing for the past 20 years and I think that you’d agree that we’ve seen a few changes over that period of time. It’s hard to keep up with all the changes, I get it! I want to share with you one of my most recent lessons. But before I do, I want to take a moment and look at that picture. It’s what I call a high-energy glamour shot:  proud business owner, beautiful office, bad-ass Vision Source doctor pose. I’m looking good, right? But I got to be honest with you.  You don’t see what’s below the surface. You see the high energy, but what you don’t see is low IQ. As Vision Source practitioners, we protect and optimize vision from all of these diseases, don’t we? I thought I was a pretty darn good doctor. Of course, my mother would have said, “There you go thinking again!” Yet, I have a confession to make: I really didn’t handle one disease very well. In fact, I treated it much like I did 20 years ago when I graduated. Here comes that low IQ part. Did you know that it’s the number one cause of blindness in the industrialized world? That it’s 3 to 5 times more prevalent than glaucoma? I didn’t! Because of AMD, I had to have a come-to-Jesus meeting with my bad-ass low-IQ doctor self. The truth is there was a lot about this disease I didn’t know or understand.

Biology of AMD

It reminds me of an old story: Immediately after I graduated optometry school, my dad pulled me aside and said: “You know what that Dr. in front of your name stands for, don’t you?” “Doctor,” I said. “Nope, it stands for derrr!” Now if that doesn’t reset your ego on graduation day! Back to AMD and my low IQ.  I’m going to share with you what I didn’t know so your dad, or worse your patients, don’t say derrr to you! The first thing I didn’t know is that there have been 15 years of histology studies published demonstrating how drusen forms and where it first appears in the retina. I didn’t know that it begins to deposit along the base membrane of the RPE cells and in the layers of Bruch’s membrane. I also didn’t know that its cholesterol; the same type of cholesterol that builds up in our arteries from arteriosclerosis. And I didn’t understand that like an oil slick this cholesterol blocks the transport of oxygen and nutrition from the choriocapillaris through Bruch’s membrane into the RPE cells. This creates oxidative stress and inflammation in the RPE cells. And you know that they support the rods and cones. But it also prevents vitamin A from crossing in enough quantities to regenerate rhodopsin in the visual cycle. And because there isn’t enough vitamin A it severely affects our ability to adapt to the dark. This is the functional breakdown in the macula. By the way this, cholesterol slick can’t be seen by any of our current imaging devices or even during a dilated fundus exam.

The first manifestation of AMD is dark adaptation

The other thing I didn’t know until I spoke to doctors Pam Lowe and Laurie Sorrenson, is that there is a technology, the AdaptDx, that could detect impaired dark adaptation. It tests the function of the macula. And folks, it’s already five years old. They taught me that the very first manifestation of AMD, the initial biomarker that we can detect, is impaired dark adaptation. It’s over 90% accurate! And finally, I learned that once enough of that cholesterol builds up and aggregates in one location, then it forms a druse; which hopefully I would pick up during my bad-ass dilated fundus exam. Visible drusen are just the tip of the iceberg. It’s all connected below the surface as that oil slick coating the back of the macula. And it could be present for years before I can see it! So you could say that there was a lot my low IQ self didn’t know about subclinical AMD.

You could say that when it came to AMD  I was in the dark. If I was in the dark then our patients were as well. These are four of our patients from our clinic and they all have impaired dark adaptation and AMD. I never thought that they would understand this disease as well as they do. And that’s really because they know someone with the disease who’s either gone blind or who’s already taking anti-VEGF injections. Yet they’re all on video saying how grateful they are that we found this disease at the earliest stage and took a proactive approach to treat it.  They had one thing in common: Their chief complaint was difficulty seeing at night. That makes sense, right? As that oxidative stress on those RPE cells is occurring, dark adaptation is becoming impaired. I think that you would agree it’s a common chief complaint that we all get. Yet we chalk it up to cataracts and even the patient may feel that it’s just normal aging changes. This is a new picture of our AMD patients:  they’re 59 years old with 20/20 vision, they have a healthy retina and they’re being pre-appointed for next year’s exam. Yet we don’t have a clue that they have this disease.

However, if we added one more functional test based on their night vision complaint, we’d quickly learn that they have impaired dark adaptation. And we can start managing and treating them for subclinical AMD. And there’s a lot we can do to be proactive; the same way we were proactive with other chronic progressive diseases. We can recommend a healthy Mediterranean diet. We can prescribe antioxidants because we now know that there’s oxidative stress on the RPE cells. Exercising moderately can have a significant impact on reducing our patients’ risk for CNV. And co-managing care with the primary care physician is critical to make sure that the cholesterol levels are under good control. Getting our patients to quit smoking is key to preventing the worst outcomes in AMD. And when we don’t find this disease early enough we leave our patients to diagnose themselves. And we know that the outcomes are devastating. The patient and their loved ones,  about half of that 78% are 20/200 or worse. You could literally say that our patients are in the dark. AMD puts an enormous burden on our health care system and GDP. Anti-VEGF treatment is the most expensive line item in our healthcare organizations today and many healthcare organizations are starting to pay close attention.

Vision Source can lead the way in early AMD diagnosis

Hello! It’s expensive and the outcomes suck. So what?  Where do we come in as Vision Source doctors? I’ll tell you where we come in: collectively we see roughly 16 million patients a year. Together we will be able to diagnose nearly 1.2 million patients with AMD. Remember, some of those patients would have walked out of your office without us knowing that they had the disease. And of those 1.2 million, we could save almost 160,000 people from going blind. With an AdaptDx we will make one hell of a Vision Source dent in blindness due to AMD. I think that you would agree: if we apply a very familiar standard of care model that we all use for glaucoma to AMD, you’ll notice this can be implemented into your practice very easily. Even John McCall can do it! And just like glaucoma, no one should go blind from AMD, not today. Now here comes the hard part, we recognize that you’re free to choose. But please understand we are not free from the consequences of our choices. There is a responsibility that comes with free will. If you choose to do nothing for our AMD patients, if that’s your conscious choice, then our AMD patients will continue to go blind. Yet I know that this Vision Source family is full of leaders, each and every single one of you. And as leaders, we sometimes have to make difficult choices. We have to transform ourselves and our practices so that we may deliver the gold standard of care for our AMD patients. And as transformational leaders, I know you’ll use that high IQ to choose to do the right thing and come out of the dark. Thank you to the Joyful Noise Choir for joining me on stage today. Please stop by our booth 1117. And before you do that stop by the Vision Source Foundation booth to purchase a raffle ticket. You might win an AdaptDx!

Thank you.