Are ocular multivitamins (eye vitamins) recommended for proliferative age-related macular degeneration (AMD)?

Ocular Multivitamins for Proliferative Age-Related Macular Degeneration

The AREDS2 supplement formulation (vitamin C, vitamin E, zinc, copper, lutein, zeaxanthin) is strongly recommended for patients with proliferative (neovascular/wet) age-related macular degeneration (AMD) to slow disease progression and preserve vision. 1

Understanding AMD and Supplement Benefits

• AMD is a leading cause of severe vision impairment, with approximately 1.75 million people aged 40+ in the United States having either neovascular AMD or geographic atrophy in at least one eye 1
• Neovascular (wet/proliferative) AMD is characterized by abnormal blood vessel growth (choroidal neovascularization) and represents the more severe form with faster progression and greater vision loss 2
• The AREDS studies demonstrated that nutritional supplements can significantly reduce the risk of progression in AMD 1
• Patients with neovascular AMD report substantial decline in quality of life and increased need for assistance with activities of daily living as visual acuity worsens 1

AREDS2 Formulation Components and Evidence

• The recommended AREDS2 formulation includes: vitamin C, vitamin E, zinc, copper, lutein (10mg), and zeaxanthin (2mg) 1, 2
• This formulation has been shown to reduce the risk of progression to advanced AMD by approximately 25% 3, 4
• In the AREDS2 study, lutein and zeaxanthin were found to be appropriate carotenoid substitutes for beta-carotene, which is particularly important for former smokers due to increased lung cancer risk with beta-carotene supplementation 2, 4
• Moderate-certainty evidence suggests that antioxidant vitamin and mineral supplementation slows down progression to late AMD 4

Treatment Algorithm for AMD Management

1. For all patients with proliferative AMD:

   • Prescribe AREDS2 formulation supplements 1
   • Recommend smoking cessation, as smoking has been consistently identified as a risk factor for AMD progression 1

2. For patients with neovascular (wet) AMD:

   • Combine AREDS2 supplements with anti-VEGF therapy, which is the primary treatment for wet AMD 1, 2
   • Initiate anti-VEGF treatment as soon as diagnosis is made for optimal outcomes 1, 2

3. For patients with specific considerations:

   • For smokers or former smokers: Use AREDS2 formulation without beta-carotene 2, 4, 5
   • For patients with intermediate AMD or advanced AMD in one eye: AREDS2 supplements are particularly beneficial 1

Important Clinical Considerations

• Early treatment of wet AMD (within 2 years of diagnosis) has been shown to reduce legal blindness and visual impairment 1, 2
• If all patients at risk were given supplements, more than 300,000 could delay disease progression and associated vision loss 1
• Regular comprehensive eye examinations are crucial for early detection, as early symptoms may be subtle 1, 2
• The Amsler grid is a useful tool for patients to self-monitor for early signs of metamorphopsia (distorted vision) 2

Nutritional Recommendations Beyond Supplements

• Encourage adherence to a Mediterranean diet, characterized by high consumption of vegetables, whole grains, and nuts and low consumption of red meat, which has been associated with decreased risk of AMD progression 6
• Recommend foods rich in lutein and zeaxanthin (leafy greens, yellow/orange vegetables) and omega-3 fatty acids (fatty fish) 7, 3
• Advise limiting alcohol consumption, as high consumption is associated with higher risk of developing AMD 6

Potential Adverse Effects

• Gastrointestinal symptoms are the main reported adverse effects of zinc supplementation 4
• Beta-carotene supplementation increases the risk of lung cancer, particularly in former smokers, supporting the use of lutein/zeaxanthin instead 4, 5
• Most studies suggest there is little to no effect on mortality with multivitamin or lutein/zeaxanthin supplementation 4