Managing the needs of female patients

Atlanta-Optometrists can play key roles in women’s health, especially in macular degeneration and obesity. Include a conversation about cosmetic use in discussions with female patients as well.

The OD’s role in weight management

Body weight and obesity are the biggest public health concern in the United States as well as a number of other countries. Unfortunately, this subject has become highly stigmatized, and people who are overweight are being discriminated against and ostracized, says Kimberly Reed, OD, FAAO, associate professor at Nova Southeastern University College of Optometry.

Dr. Reed joined other female optometrists in a panel discussion about women’s health at SECO 2016.

“Treat your patients with kindness and compassion,” she says. “They’re not getting it anywhere else. If we are going to help the problem of obesity, the first thing we have to do is destigmatize it and start treating it as a disease rather than as a human flaw.”         

But what exactly is the role of an optometrist? Regardless of your comfort level in approaching what is clearly a sensitive subject, one thing any optometrist can do is support and refer, Dr. Reed says. Call, interview, and question nutritionists, dietitians, weight loss clinics or programs, and others to identify resources in your area.        

Related: How diet and nutrition affect disease

Use what you’ve learned to give patients as much targeted information as you can, such as a list of classes on healthy cooking and food choices. Remember to follow up at the next visit or by telephone, Dr. Reed says.                

In addition, review the literature for the latest findings on topics such as weight loss medication or surgical procedures so that you can give patients well-informed advice on discussing these management approaches with their primary care physicians.         

The optometrist can be more directly involved by providing nutritional support aimed at reducing inflammation, which has been identified as a risk factor for obesity. Dr. Reed recommends that patients take up to 2,000 to 3,000 mg/day of omega-3 EPA/DHA through dietary choices and supplements. Because brands of supplements may be made differently and have different ingredients-and because labeling may be false or misleading-do some research so that you can recommend products that contain adequate amounts of EPA and DHA per serving and are not contaminated with mercury or PCBs.          

Nutritional support for obese patients also should stress intake of lutein and zeaxanthin. These carotenoids are stored in body fat, Dr. Reed says, adding that this presents a particular problem for overweight patients.

“If it’s in your hips, it’s not in your macula,” she says, “so these patients need higher levels of these carotenoids because they’re not being distributed in a helpful way.”       

Recent: How alcohol consumption correlates with glaucoma

Increasing the levels of carotenoids is even more critical in patients who have undergone obesity or bariatric surgery, Dr. Reed says, because their levels of these nutrients are chronically low.         

Citing a correlation between magnesium deficiency and obesity, Dr. Reed also recommends that patients ingest more of this mineral through diet, oral supplementation, transdermal oils, or epsom salt baths.         

Doctors have been recommending for decades that overweight patients exercise more, but what’s new and possibly beneficial is high intensity interval training (HIIT), a workout of alternating high intensity effort and recovery periods. According to Dr. Reed, HIIT burns more calories and increases post-exercise fat burn more than steady state exercise and also improves various metabolic markers.       

Next: AMD: Women's greatest visual threat

AMD: Women’s greatest visual threat

Women’s greatest visual threat is age-related macular degeneration (AMD), says Pamela A. Lowe, OD, FAAO, in private practice in Niles, IL. She says that the prevalence of AMD exceeds that of glaucoma and diabetic retinopathy combined among Americans (male and female).

“Especially with women being two to one over our male patients, I think it’s very important to give them every opportunity to treat AMD early,” she says.       

However, early AMD is not adequately detected by current methods, and up to 78 percent of AMD patients have irreversible vision loss at their first diagnosis, she says.         

This level of unnecessary vision loss may be lessened by use of AREDS2 nutritional supplements in certain patients who have not progressed to advanced AMD as well as by behavioral modifications, Dr. Lowe says. But in her practice, Dr. Lowe has added evaluation of dark adaptation to her management strategies.          

The earliest changes in the sequence of events that could ultimately lead to vision loss happen at the microscopic level and can’t be seen with current technology until they become drusen. This early degeneration has several effects, including a localized deficiency of vitamin A that can be measured with dark adaptation, Dr. Lowe says.

Related: Managing glaucoma in women

“Impaired dark adaptation isn’t a risk factor for AMD,” she says. “It’s the earliest manifestation of the disease.”

For the past two years, Dr. Lowe has been using a dark adaptometer (AdaptDx, Maculogix) to screen patients. The instrument has two clinical protocols: a rapid test for quick assessment (≤6.5 minutes) and an extended test for benchmarking (≤20 minutes). If the retina can adapt in less than 6.5 minutes, then vision is normal and there is no localized vitamin A deficiency. In patients who have AMD, whether early, moderate, or advanced, adaptation will take longer. While the rapid test yields information quickly, Dr. Lowe generally runs the extended test, which can tell her not only if a patient has AMD but to what extent.          

When a patient has a positive result, the next step is to look at the other characteristics of the retina with imaging tools, Dr. Lowe says. If drusen, pigmentary changes, and evidence of choroidal neovascularization are found, she follows the American Optometric Association’s AMD patient treatment protocol, adding dark adaptation to the list of tests. If there are no other characteristics of AMD, she follows the protocol for subclinical AMD patients, again adding dark adaption testing as well as counseling on diet, nutritional supplementation, exercise, UVA and UVB protection, and smoking cessation to the management options.         

She also uses genetic testing, especially with subclinical patients.

“I want to know how to target my high-risk patients,” she says. “I want to help them before they lose any vision and have to go to a retina specialist.”

Dr. Lowe recommends the Macula Risk PGx test (Arctic Dx), which evaluates a patient’s current AMD status, genetic predisposition, and nongenetic risk factors to determine the two, five, and 10-year risk of progression. The Vita Risk component of the test provides information to help the doctor choose an eye supplement formulation based on the patient’s genotype.        

The test analyzes 15 genetic markers across 12 AMD-associated genes. According to Dr. Lowe, the most important ones for optometrists to focus on are CFH (complement factor H) and ARMS2 (age-related maculopathy susceptibility 2).         

Patients who have two or more CFH risk alleles and zero ARMS 2 risk alleles do not benefit from taking AREDS eye vitamins. About 15 percent of the U.S. population has this profile, Dr. Lowe says, and taking these vitamins could make their AMD worse. Therefore, genetic testing is a critical factor in determining the proper supplement for each individual.

Next: Counseling on cosmetics          

Counseling on cosmetics

Exploring women’s health from a different perspective, Melanie Denton, OD, MBA, FAAO, who is in private practice in Salisbury, NC, offered advice on counseling patients about cosmetics.

“It’s really important when we work with female patients to have a conversation about their makeup,” Dr. Denton says. “I really don’t hesitate to bring it up.”

She is especially proactive with preteens and teens, although she might also tactfully offer a few tips to an adult who seemed to need a bit of advice.          

A few tips she shares include:

• Avoid eye cosmetics with glitter

• Introduce one new product at a time so that the cause of an allergic reaction could be identified

• Don’t mix and match products, such as using lip liner as eye liner

• Never tug on lashes with a curler or sharp object

• Remove cosmetics at bedtime

• Replace mascara and liquid eyeliner at least every three months

• Never try to extend the a container of mascara with saline solution

• Don’t share makeup with others          

She suggests having a tip sheet about makeup for girls who are at the age when they’re likely to begin wearing makeup. These girls might take your advice when they won’t listen to similar suggestions from their moms, Dr. Denton says. She has also trained her staff to offer advice because they might have more time with patients at the optical table or the front desk.          

If patients inquire about permanent makeup, also known as micropigmentation or tattooing, refer them to a reputable service, such as a licensed dermatologist, cosmetologist, aesthetician, or nurse.

 Next: Other beauty concerns         

Other beauty concerns

You also may be asked what can be done about dark circles under the eyes. Explain the contributing factors, such as lack of sleep, allergies, smoking, excessive caffeine or alcohol, dehydration, iron deficiency, and genetics, and suggest a few things that might help. Simple remedies include making cold compresses from tea bags, using white eyeliner or a night cream with vitamin K and retinol, and discontinuing use of glitter makeup.         

If a patient has used eyelash augmentation, you might find yourself treating someone who has gotten adhesive in the eye after self-application. False eyelashes also could mask signs of blepharitis, so make sure you move them out of the way during the examination, Dr. Denton says.          

Patients also may inquire about eyelash growth products. Whether or not you choose to sell such products in your office, the best choices among the over-the-counter products are those that list myristoyl pentapeptide-17 as an active ingredient; many products are simply mineral oils. Zoria Boost (Ocusoft), which Dr. Denton carries in her practice, is available only through eyecare professionals.         

Latisse Ophthalmic (bimatoprost ophthalmic 0.3%, Allergan), which requires a prescription, increases the thickness and darkness of lashes but may also have side effects such as darkened brown pigmentation in the iris. It must be used continuously to maintain eyelash improvement.        

Patients may also be interested in scleral whitening to treat red eyes. While Dr. Denton said she isn’t a fan of using over-the-counter topical drops containing vasoconstrictors for this reason, she says that it might be acceptable for special occasions such as a wedding, party, or photography session.