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Translating Age-related Macular Degeneration Research into Practice

A survey conducted by Dr. Laura Downie and Associate Professor Peter Keller has identified potential areas to improve the primary optometric care provided to patients with early stages of age-related macular degeneration. Later this year, they intend to establish an innovative optometric clinical teaching centre in Victoria, which aims to address these areas of potential. Dr. Downie is conducting the project as part of her prestigious 2015 NHMRC Translating Research into Practice (TRIP) Fellowship. Hers is the first TRIP Fellowship to ever have been awarded to an optometrist.

The long-term risk of sight-threatening age-related eye disease can be strongly influenced by modifiable lifestyle factors, such as cigarette smoking and nutrition. Smoking has been causally linked to a range of ocular pathologies, including cataract1,2 and age-related macular degeneration (AMD),3,4 which are major causes of visual impairment worldwide.

While there is generally strong public awareness regarding the systemic morbidities associated with cigarette smoking, such as lung cancer, cardiovascular disease and stroke, the link between smoking and blinding eye disease is relatively less well recognised.5

Addressing a need for improved community awareness of this association, since 2007 the Australian government has supported advertising campaigns aimed at informing people about the incident risk of blindness from smoking. Enhanced awareness of the benefits of smoking cessation is considered valuable for altering smoking behaviours.6,7

…potential… to improve their routine engagement by questioning patients about smoking status and nutrition, as well as providing evidence-based clinical advice about modifiable risk factors

In addition to smoking cessation, dietary intervention is another avenue for potentially modifying the long-term risk of some eye diseases.8,9 People who consume a diet that is naturally rich in certain nutrients, in particular the xanthophyll carotenoids (lutein and zeaxanthin) and omega-3 essential fatty acids (EFAs), tend to have a decreased risk of developing late-stage age-related macular degeneation.10-13 Furthermore, some patients who show ocular fundus features that confer a higher risk of progression to late age-related macular degeneration may benefit from the
daily consumption of specific formulations of high-dose antioxidant vitamins and minerals.14,15

Importantly, such formulations may not be appropriate for all patients. For instance, caution should be exercised with regard to high-dose beta-carotene supplementation for current smokers or asbestos workers, due to documented links between high-dose anti-oxidant supplements and an increased risk of lung and stomach cancers.16

Optometrists as Counsel

As major providers of primary eye care to the Australian community, optometrists are well positioned, as part of a patient’s health care team, to provide counselling with regard to modifiable risk factors for eye disease.17-19

Such advice should ideally include a discussion about the importance of smoking cessation, as well as the relative benefits versus risks of nutritional interventions that are likely to affect ocular health. Recognising the important public health role that optometrists provide in these domains, a number of studies have been previously undertaken to gain insight into the patient care and advice provided by optometrists. These studies have analysed self-reported optometric practice behaviours in various demographics, including the United Kingdom (UK),20,21 United States,22 Canada23 and Australia.24 Overall, those findings suggest that there is scope for optometrists in these regions to be more pro-active in providing advice about smoking cessation to patients. A UK study that evaluated optometric practices in relation to diet and nutritional supplementation found that there was a need to improve awareness among UK optometrists about the research evidence underpinning the use of nutritional supplements for age-related macular degeneration.20

In 2013, Associate Professor Keller and I sought to examine the self-reported, routine clinical practice behaviours of Australian optometrists with respect to smoking, diet and nutritional supplementation. Our study also considered the potential influence of practitioner age, gender, practice location (major city versus regional), therapeutic-endorsement status and personal nutritional supplementation habits upon management practices in these areas. To date, this is the only study to have assessed these practice behaviours in optometrists outside the northern hemisphere. Findings from the study have been recently accepted for publication in the open-access refereed journal PLoS One.24

The electronic survey was distributed to the Optometry Australia membership. Less than half of respondents indicated routinely asking their patients about smoking status. Furthermore, younger optometrists were founds to be less likely to enquire about patients’ smoking behaviours; this trend did not however, extend to counselling about smoking cessation. Almost two-thirds of respondents specified that they counsel their patients about diet, with about 50 per cent of practitioners indicating that they routinely ask their patients about nutritional supplement intake. Female optometrists were significantly more likely to enquire about their patients’ behaviours relating to nutritional supplements than male practitioners. Optometrists who recommended nutritional supplementation to their patients most commonly did so for AMD (91.2 per cent) and dry eye disease (63.9 per cent).

Potential to Improve Engagement

The findings from our study indicate that the practice behaviours of Australian optometrists, in areas relating to the advice provided to patients about modifiable risk factors for eye disease, are similar to those of optometrists in other parts of the world. Interestingly, we did not find any clear predictors (in terms of practitioner age, gender, practice location, etc.) of practice behaviours for either questioning
or counselling about smoking or diet. Our results also suggest that, overall, there is potential for Australian optometrists to improve their routine engagement by questioning patients about smoking status and nutrition, as well as providing evidence-based clinical advice about modifiable risk factors for eye disease, in particular age-related macular degeneration.

Preventing Progression Most Valuable Approach

Age-related macular degeneration is the leading cause of blindness in Australia.25 At present, preventing progression to late stage age-related macular degeneration is the most valuable approach to reducing vision loss, and the associated individual and community burden of age-related macular degeneration. Given that many Australian optometrists are not routinely asking their patients about smoking behaviours and/or diet,24 there is a need, as a profession, to improve upon these evidence-practice gaps in the delivery of primary eye care. Through the award of a prestigious 2015 NHMRC Translating Research Into Practice (TRIP) Fellowship, I will be undertaking a two-year project, in association with A/Prof Keller as my TRIP mentor, which seeks to improve the translation of research evidence by optometrists relating to modifiable risk factors for age-related macular degeneration. This is the first TRIP Fellowship that has been ever awarded to an optometrist.

Over 2015 and 2016, the TRIP project will directly engage Victorian optometrists to participate in an innovative age-related macular degeneration optometric clinical teaching centre to be established within the University of Melbourne Eyecare clinic. This teaching and clinical service will be known as the UMeyecare AMD Clinical Teaching and Demonstration Service (CTDS). The expected outcomes of this project will include: (i) improved identification by optometrists of modifiable age-related macular degeneration risk factors, (ii) enhanced optometric adoption of standardised age-related macular degeneration grading scales for more consistent disease staging, (iii) increased understanding of the value and interpretation of clinical diagnostics for age-related macular degeneration, and (iv) improved overall management of patients with earlier stages of age-related macular degeneration, including counselling with regard to modifiable risk factors.

A website for the project will soon be available and further details about the project will be made available to Victorian optometrists over the coming months. Practitioner participation in the program is expected to attract continuing professional development (CPD) points.

For further information, please contact Dr. Laura Downie, ldownie@unimelb.edu.au at the University of Melbourne.

Dr. Laura Downie BOptom, PhD(Melb), PGCertOcTher, FAAO, FACO, DipMus(Prac), AMusA is a lecturer and NHMRC TRIP Fellow. Dr. Downie is an academic with the Department of Optometry & Vision Sciences at the Faculty of Medicine, Dentistry & Health Sciences, the University of Melbourne.


1. Christen WG, Manson JE, Seddon JM, et al. A prospective study of cigarette smoking and risk of cataract in men. JAMA 1992;268(8):989-93.

2. Hankinson SE, Willett WC, Colditz GA, et al. A prospective study of cigarette smoking and risk of cataract surgery in women. JAMA 1992;268(8):994-8.

3. Klein R, Klein BE, Linton KL, DeMets DL. The Beaver Dam Eye Study: the relation of age-related maculopathy to smoking. Am J Epidemiol 1993;137(2):190-200.

4. Seddon JM, Willett WC, Speizer FE, Hankinson SE. A prospective study of cigarette smoking and age-related macular degeneration in women. JAMA 1996;276(14):1141-6.

5. Handa S, Woo JH, Wagle AM, et al. Awareness of blindness and other smoking-related diseases and its impact on motivation for smoking cessation in eye patients. Eye (Lond) 2011;25(9):1170-6.

6. Carroll T, Rock B. Generating Quitline calls during Australia’s National Tobacco Campaign: effects of television advertisement execution and programme placement. Tob Control 2003;12:ii40-ii4.

7. Kennedy RD, Spafford MM, Behm I, et al. Positive impact of Australian ‘blindness’ tobacco warning labels: findings from the ITC four country survey. Clin Exp Optom 2012;95(6):590-8.

8. Downie LE, Keller PR. Nutrition and age-related macular degeneration: research evidence in practice. Optom Vis Sci 2014;91(8):821-31.

9. Evans JR, Lawrenson JG. Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration. Cochrane Database Syst Rev 2012;11:CD000254.

10. The Age Related Eye Disease Study Research Group, SanGiovanni JP, Chew EY, et al. The relationship of dietary carotenoid and vitamin A, E, and C intake with age-related macular degeneration in a case-control study: AREDS Report No. 22. Arch Ophthalmol 2007;125(9):1225-32.

11. Seddon JM, Ajani UA, Sperduto RD, et al. Dietary carotenoids, vitamins A, C, and E, and advanced age-related macular degeneration. Eye Disease Case-Control Study Group. JAMA 1994;272(18):1413-20.

12. Augood C, Chakravarthy U, Young I, et al. Oily fish consumption, dietary docosahexaenoic acid and eicosapentaenoic acid intakes, and associations with neovascular age-related macular degeneration. Am J Clin Nutr 2008;88(2):398-406.

13. Merle BMJ, Delyfer M-N, Korobelnik J-F, et al. High concentrations of plasma n3 fatty acids are associated with decreased risk for late age-related macular degeneration. J Nutr 2013;143:505-11.

14. The Age Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene,
and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Arch Ophthalmol 2001;119(10):1417-36.

15. The Age Related Eye Disease Study 2 Research Group. Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial. JAMA 2013;309(19):2005-15.

16. Druesne-Pecollo N, Latino-Martel P, Norat T, et al. Beta-carotene supplementation and cancer risk: a systematic review and metaanalysis of randomized controlled trials. Int J Cancer 2010;127:172-84.

17. Cockburn DM. Is it any of our business if our patients smoke? Clin Exp Optom 2005;88:2-4.

18. Loo DLS, Ng DHL, Tang W, Au Eong KG. Raising awareness of blindness as another smoking-related condition: a public health role for optometrists? Clin Exp Optom 2009;92:42-4.

19. Sheck LHN, Field AP, McRobbie H, Wilson GA. Raising awareness of blindness as another smoking-related condition: a public health role for optometrists? Clin Exp Optom 2009;92:75-7.

20. Lawrenson JG, Evans JR. Advice about diet and smoking for people with or at risk of age-related macular degeneration: a cross-sectional survey of eye care professionals in the UK. BMC Public Health 2013;13:564.

21. Thompson C, Harrison RA, Wilkinson SC, et al. Attitudes of community optometrists to smoking cessation: an untapped opportunity overlooked? Ophthal Physiol Opt 2007;27:389-93.

22. Caban-Martinez AJ, Davila EP, Lam BL, et al. Age-Related Macular Degeneration and Smoking Cessation Advice by Eye Care Providers: A Pilot Study. Prev Chron Dis 2011;8(6):A147.

23. Brûlé J, Abboud C, Deschambault E. Smoking cessation counselling practices among Québec optometrists: evaluating beliefs, practices, barriers and needs. Clin Exp Optom 2012;95:599-605.

24. Downie LE, Keller PR. The self-reported clinical practice behaviors of Australian optometrists as related to smoking, diet and nutritional supplementation. PLOS One 2015. Accepted 14 March 2015.

25. Deloitte Access Economics – Macular Disease Foundation. ‘Eyes on the future – A clear outlook on age-related macular degeneration’. 2011.


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