Insights into Macular Degeneration

Have you heard of age-related macular degeneration (AMD)?

In this podcast Denise Balch from Connex is joined by Dr. Alexa Hecht, optometrist at Richmond University Vision Care in Toronto, Ontario. Dr. Hecht can also be found on TikTok and Instagram at @dr.alexahecht. She is an outspoken advocate for education and public awareness about optometry.

AMD is a serious eye disease that results in the blurring of a patient’s central vision, which can lead to vision loss as the disease progresses. AMD can affect anyone, but there are factors that increase your risk. Using an ocular coherence tomography (OCT) scan, an optometrist can make an early diagnosis of AMD, but most benefit plans and provincial healthcare plans do not provide coverage for this important diagnostic tool.

Find out more about AMD and the gap in coverage by listening to this podcast. This is just one in our 2022 education series on how to care for your vision and the vision of employees.

--

This podcast is free and delivers valuable information for you and your clients about the role of optometrists, the importance of adequate vision care coverage, and healthy lifestyles in visual health. Look for more in this series on the modernization of vision care, Don’t Lose Sight, from the Canadian Association of Optometrists.

To speak with the CAO, contact info@opto.ca. Learn more about how vision care is changing from the Canadian Association of Optometrists at dontlosesight.ca. Plus look for more podcasts, blogs and posts on vision care, comprehensive eye examinations and best practices coming to you throughout 2022.

Brought to you by the Canadian Association of Optometrists in association with Connex Health Consulting.

Find out more information on upcoming podcasts and webinars at www.connexhc.com.

Transcript

Denise Balch: 0:00

Hi, my name is Denise Balch and I'd like to welcome you to today's podcast which is part of the podcast series from the Canadian Association of Optometrists. Today I'm joined by optometrist Doctor Alexa Hecht, and we're going to be speaking to her about her insights into macular degeneration. Doctor Hecht was born and raised in Winnipeg, Manitoba. She obtained her doctor of optometry with distinction from the University of Waterloo, and is currently practicing in Toronto, Ontario. She has clinical interests in dry eye disease, ocular aesthetics and myopia control. And Doctor Hecht is active on social media which is how we found her with messages about the importance of eye health including using social media such as TikTok and Instagram. She's passionate about helping drive the profession of optometry forward through education and public awareness. And she is also currently a transitions ambassador and an ambassador for the Ontario Association of Optometrists - Toronto south. So welcome today. I think it's okay to call you Alexa?

Doctor Alexa Hecht: 1:07

Yeah. Thank you so much for having me. I'm so happy to be here.

Denise Balch: 1:11

Well, it's a pleasure to have you and I really enjoyed your - I think it was TikTok - podcast on cosmetics and the impact on our eyes. So if anybody would like to learn more about that, then I think if I'm not sure how to - Yeah, it's on YouTube. On YouTube, okay, sorry. So YouTube, okay. And I guess Tik Tok, we always think about people dancing, don't we? So? She's not dancing.

Doctor Alexa Hecht: 1:40

Yeah, I think the platform has kind of progressed. So I'm on the educational side of TikTok. So you kind of have to get on that side, and maybe I'll come up on your on your page.

Denise Balch: 1:52

But your podcast on cosmetics and your eyes is on YouTube. You said,

Doctor Alexa Hecht: 1:59

under Ocushield's YouTube.

Denise Balch: 2:03

Okay, great. Yeah, no, it was very interesting. I really enjoyed it. So thank you very much again, Alexa, for being with us, I very much appreciate your time today. I have a few questions for you. When we talk about macular degeneration, and I know it's something that affects a lot of Canadians, but we don't necessarily know a lot about it from a benefits perspective as benefits professionals. So perhaps you can tell our audience a little bit about macular degeneration, what it is, and if there are different forms of the disease and what those are.

Doctor Alexa Hecht: 2:37

yeah, for sure. So macular degeneration is the leading cause of vision loss in people over the age of 55. So basically, the back of our eye, it's called our retina. And a part of that is called our macula. And that's where macular degeneration occurs. And this part of our retina is actually responsible for your central vision. So your sharpest point of vision, and detailed vision is is where this occurs. So basically, what happens with this disease is it causes loss of your central vision, due to deposits and destruction in that area of the retina. So your peripheral vision is still intact. It's that central vision that gets affected. So for example, if you're looking at a clock, kind of in later stages of the disease, you might be able to see the numbers around the clock, but not necessarily the hands moving around the clock. So it can make it harder for people to do activities like reading, driving, recognizing faces. And then in more advanced stages, you can unfortunately have complete loss of your central vision. There are two types of the disease. So there's dry and wet AMD - AMD is an abbreviation for macular degeneration. So with dry AMD, this is the more common form so about 90% of patients dealing with this disease have dry form. And this usually progresses a little bit slower over several years. So you might in the early stages, not have any symptoms, maybe some mild blurriness or trouble in low lighting conditions. And then throughout this, as as it progresses in the dry form, you might have issues with seeing wavy lines in your vision or colors may seem less bright. And then in the wet form- this is definitely less common but definitely more severe. So you actually have leakage of fluid in your eye and new blood vessels that grow and this can cause significant vision loss. And it's important to know that at any stage in the dry form, it can progress to wet form.

Denise Balch: 4:57

It's interesting that there's the two different forms. So you mentioned a little bit about, you know, the people that are at highest risk for AMD. Can you tell us a little bit more about that?

Doctor Alexa Hecht: 5:11

Yeah. So, um, smoking is actually the number one risk factor. Current Smokers are exposed to a two to three times higher risk of AMD than non smokers. Some other risk factors include age, family history, genetics actually plays a more significant role than previously thought diet high in saturated fats or being overweight or obese. Having hypertension is also a risk factor. And then sun exposure. They're not exactly sure, you know, which are the main risks associated with it. But smoking is definitely number one. And then it's important to also know that nearly 2.5 million Canadians are affected by this disease. So that's quite a number. Yeah. So by age 60, one in nine Canadians will have vision loss from AMD. And this number is continuing to climb just because we do have an aging population. So we're seeing it more commonly.

Denise Balch: 6:12

So if we look at a workplace situation, and if, you know, one in nine over 60, a lot of people are still working at that age. And they would have had if they're already suffering vision loss, they would have had the disease for some years before before then, correct?

Unknown: 6:33

Yeah. So usually, like I said, at early stages, you're not experiencing severe vision loss, or even any symptoms at all.

Denise Balch: 6:44

Right. So really, during your working years, you may have the disease, but you may not be aware of it.

Doctor Alexa Hecht: 6:52

Exactly. Yes. That's why early detection

Denise Balch: 6:55

So perhaps you could tell me, Alexa, how does is so important. an optometrist detect and monitor AMD in their patients? Because what you've just said is that, you know, detecting the disease early is very important. So how do you do that as an optometrist, if patients aren't actually themselves experiencing any symptoms that they recognize?

Doctor Alexa Hecht: 7:18

Yeah, so usually, AMD is detected through just your average comprehensive, dilated, fundus exam. So when you go to your optometrist, you get dilated, we're able to see the back of the eye, the retina, and especially that macular region with our special slit lamp we use, so our microscope and our lens. But another really useful tool we now have access to, or a lot of optometrists have access to, is the OCT, which is short for optical coherence tomography. And what this actually does is it allows us to get a cross section of the retina and all its different layers, more specifically, the macular region, and allows us to pick up more detail and even detect macular degeneration. Really early, like I said, before patients even come in complaining of anything. So that's a really useful technique or tool we have now in our toolbox.

Denise Balch: 8:17

With that tool being so valuable, the OCT, how often do patients who are maybe at risk or in the early stages of AMD need to be examined through the kind of specialized testing that you've described?

Doctor Alexa Hecht: 8:32

Yeah, so I always recommend getting a baseline OCT, if there are any risk factors for development of AMD. So you know, if you come to me and you're a smoker, or you have a family history, I'm going to recommend you get that test. And then depending on what we find, it varies from case to case how often we're going to do that testing. So OCT findings may detect and diagnose early stages of the disease, even when there are no clinical symptoms. So that's why this testing is so important. You know, like I said, it does vary from case to case maybe every six months we're doing the test if you are more prone. Or if we do see some small little, what we call drusen in the macula, we might monitor you more closely. But it's also important to know that OCT has been shown to play a critical role in monitoring progression of early AMD. So we're able to detect those small changes that can lead to significant, you know, challenges or significant vision loss down the road.

Denise Balch: 9:42

Yeah, no. So that early detection and monitoring is really critically important.

Doctor Alexa Hecht: 9:49

Yeah, for sure. And then, you know, if someone's at higher risk of progressing, then we might do that OCT every three to four months. So it totally is dependent on the patient.

Denise Balch: 10:00

Which is a perfect segue into reimbursement and how the tests are reimbursed because typically under an employee benefits group benefits contract, there are parameters that the insurer looks for for reimbursing different eligible expenses. So it sounds like for something like an OCT, it's really hard to put your finger on exactly what that reimbursable timeline should be, because it's going to vary by individual. Would that be correct?

Doctor Alexa Hecht: 10:35

Yeah, exactly. So most benefit plans don't cover an OCT, you know, every year, even every two years. Yeah, you might get some coverage. So, you know, a portion of the testing might be covered every two years, but a lot of patients are paying out of pocket for these additional tests. And a lot of patients, you know, just don't have the funds to allocate to these additional tests that us as optometrists want our patients to be able to get. So it's not actually typically covered by provinces. I'm in Ontario, and I know that it is not publicly funded here, and as well as in a lot of other provinces. So it is a struggle, and, you know, I want what's best for my patients. So it's hard.

Denise Balch: 11:29

Yeah, no, absolutely, I can appreciate that. And I think, too, it's not just a question of people, you know, not being able to afford the test, but they probably - I mean, they don't understand the medical science behind, you know, why those tests are so important. And it's not really something that, you know, as an optometrist, you're going to be able to educate, you know, the whole of the population, one patient at a time, like, that's a tough thing to do. And some people, they're not even seeing their optometrist regularly. So they wouldn't even have the chance to have that, you know, test explain to them and why it's so important. So, yeah, it's, that's it's really unfortunate that individuals don't have access to this test. Even if they have a group benefit plan, they're quite often not able to receive reimbursement.

Doctor Alexa Hecht: 12:20

Right. Yeah, most plans just cover your basic eye examination, usually every two years. And then, you know, the examinations that are covered by OHIP, or the government, you know, it doesn't include additional testing, like imaging and OCT, so...

Denise Balch: 12:38

Right. And would that extend to even once somebody is diagnosed, I think there's some gaps there that I've heard about to even - you'd think that once you had a diagnosis that these tests to continue to monitor the progress of the disease would be reimbursed. But I don't think that's always true. Is it?

Doctor Alexa Hecht: 12:58

Yeah, no, at least in Ontario, if someone is diagnosed, I mean, it depends if they're being managed, or monitored by an ophthalmologist. So, that's kind of separate. And they're able to do those tests and get reimbursement from them. But as an optometrist who is more than qualified to monitor at least early stages and intermediate stages of the disease, kind of those stages that don't require more advanced treatment methods, then I'm definitely wanting that OCT image done, and it can be costly, and it's expensive, especially if I'm seeing this patient every four months.

Denise Balch: 13:41

So when, in the benefits world, you know, expensive is kind of relative. Right? So what is expensive to you, like, what does an OTC - I know it varies by region of the country and by where the optometrist is located, even within one province - but roughly what does that go for?

Doctor Alexa Hecht: 14:02

I would say, yes, it totally varies. I would say anywhere from 60 to 160, maybe just for that scan.

Denise Balch: 14:14

So it's not something that's going to sort of break the benefits budget. So now that's good news. So let's take - we've sort of got our patient here, and they've been diagnosed now with AMD. So you've just referred to some treatments, but nothing specific, so maybe I can ask you to describe what the treatments are for AMD and maybe how they've developed over time as well.

Doctor Alexa Hecht: 14:47

Yeah, so this is super dependent on the stage and the type. But something to note, there's no cure for this condition. So that is something really important. In, you know, early detection and discovery of this disease. So for early AMD, we're just monitoring, there is no treatment, we're making sure that it's not progressing, and if it is progressing, we're ensuring it's doing so very slowly. If you have intermediate AMD in one or both eyes or if you have late AMD in one eye, then dietary supplements may be suggested to you by your optometrist in order to prevent you from progressing to late AMD. These vitamins are called AREDS or AREDS2 depending if you smoke or do not smoke. And then for what x to date of AMD treatment has changed within the last six years. So previously, they were doing things like laser photocoagulation and photodynamic therapies, which were more destructive, so they were actually killing parts of the retina. Now, they've moved on to more advanced treatments called anti-VEGF, so anti vascular endothelial growth factor injection. So these are actually - yes, it is a mouthful to say. But these are actually injections that are being injected into one's eyes. So I had the opportunity to actually shadow an ophthalmologist in my training, who, you know, had long lines of patients lined up to come and get their monthly eye injections. And it's a grueling process for these patients, you know. Think about the psychological effects on this patient who has to come every month and is, you know, knowing what they're going to have to go through. It's quick, but it's not a painless procedure. And they have found that with this treatment with the injections, it can improve vision, but the improvement is usually only maintained if these patients are coming back and getting these treatments as required. So usually around 69 injections per year, sometimes every month, like I said, and, you know, early diagnosis and treatment of wet AMD is crucial in order to preserve vision and the quality of life of these patients.

Denise Balch: 17:26

So from what you've told me so far, and told our listeners, what are the most- I guess there's two really important things that people should do. Number one, they should have a baseline OCT, and then go have the OCT as recommended thereafter by their optometrist. And the other is, like a lot of other things in health care, it's really important to maintain a healthy lifestyle, so eat well and don't smoke, and that can go a long way to either preventing or managing the early stages of AMD.

Doctor Alexa Hecht: 18:04

Yeah, so some tips I always tell patients, you know, you're going to hear this from every doctor, but regular physical activity is so important. Eating healthy foods, including leafy green vegetables, kale, spinach, fish, so eating also foods high in what we call lutein and zeaxanthin, which are macular pigments, so they're good for our macular health. Some of these foods include egg yolk, broccoli, spinach, grapes, kiwi, just to name a few, and then eating meals rich and healthy fat, so salmon, tuna, sardines, nuts, seeds. Basically eating the rainbow, I always say. Another important thing is sun protection. So wearing a good pair of sunglasses that block both UVA and UVB forms of light.

Denise Balch: 18:59

That's an incredible takeaway just right there, just what you said in the last minute or so for folks, and that's not just for eye health, too, but that's for your overall health. So I just wanted to go back to those anti-VEGF treatments again. Is there a narrow window of time when they're effective, or are those really just used in, as you said, the more advanced stages, and then they would continue on, or is there an endpoint to those types of injections?

Doctor Alexa Hecht: 19:32

Yeah, so when when we have detected that someone has progressed from dry to wet form. We do want to get that treatment going as soon as possible to either gain some vision back or preserve the vision that's still there. And then it's usually monitored by an ophthalmologist. Once they're receiving injections, how often those injections need to be continued, whether it's every month, every three months. And then once the fluid or the leakage of fluid has kind of settled, or there's no longer any there, then they might not require injections as often as they were getting them previously. So it might be, you know, just maintenance therapy or just watching to make sure that they don't need an injection right away.

Denise Balch: 20:27

And those injections are covered by public health plans, is that right?

Doctor Alexa Hecht: 20:32

Yes, for the most part, they are, again, case to case, but if you do have wet AMD and you require injections, those would be covered.

Denise Balch: 20:42

Okay, great. So I know you talked a little bit about it, but I'd like to go into a little bit more detail about what the impact is on individuals when they are diagnosed with AMD. Their ability to say function in and out of work. When we talk about vision, and any difficulties with vision, I always think of, you know, particularly people that have to drive for their occupation - bus drivers or, you know, fire persons or police people, you know, those kinds of professions, but obviously, there's a much wider range, but how does it affect individuals?

Doctor Alexa Hecht: 21:19

Yeah, so I think like you mentioned, you know, it can affect definitely in those later stages. Being able to drive people, see people's faces. But I think it's also important to mention that, you know, these people are attending way more appointments. And so you're being taken out of work to attend these appointments, you usually need someone to accompany you if you're getting those injections. So I actually found a study that was presented at ARVO in 2022, and it looked at the physical, psychological and practical challenge those who are living with AMD in Canada face. So just

to list off a few stats: 21:57

up to 80% reported that sight loss from their AMD affected their ability to do at least one daily activity. So you know, even if that's reading for someone, think of not being able to read your newspaper, a book - I mean, I love to read, so that would definitely impact my mental health. 77% reported having anxiety that their condition would worsen. So like I said, at any point in dry form, it can progress to wet form. And that's super scary for someone dealing with that. Just knowing that it can get much worse than what it already is. 75% received injections and 1/3 of respondents missed at least one injection appointment in the past year with the main reason being they couldn't find someone to accompany them. So it's not only you that might be being bothered or taken out of work, you need to find someone to accompany you. With most diseases, you know, you need someone coming with you to treatments, and that's a burden too. And then, you know, those patients that, let's say, have hit a plateau, and there's not much else we can do, then we do refer a lot of these patients to low vision therapy. So they can learn how to use their remaining vision with different devices and magnifiers and how to live their daily life or do the activities they want to do, you know, just alter them. So I had the opportunity to work in a low vision clinic at the University of Waterloo. And it's amazing what these new technologies have brought into people's lives who are suffering with low vision.

Denise Balch: 23:47

Yeah, and that extends obviously to what we most of us do on a regular basis, which is looking at a computer screen or our smartphones or tablets. And I know that there are accessibility standards that are being implemented, which would help people I'm sure for low vision as well.

Doctor Alexa Hecht: 24:05

Exactly, yes.

Denise Balch: 24:07

So as we've been coming to the end of our time together today, what would you like plan sponsors - typically their employers, but sometimes they can be other groups that sponsor benefit plans - and insurance brokers, benefits advisors and insurers, what would you like them to know about AMD and benefits coverage that can prevent, detect and monitor AMD?

Doctor Alexa Hecht: 24:32

Yeah, so like I've probably already said a few times, getting that early OCT imaging is super important as a diagnostic tool in order to detect early AMD and to detect any changes along the way of those who have already been diagnosed with AMD. I know I always want to do what's best for my patients, and I do feel that having this diagnostic tool in a lot of cases allows me to better diagnose and manage conditions such as AMD. So that's kind of my take home message.

Denise Balch: 25:05

Yeah. Well, I want to thank you very much for being with us today. It was great to see your initial YouTube video on cosmetics. Some very - I was going to say eye opening, I guess I already have - but very eye opening and very interesting facts about cosmetics. You've provided some great information for us today on AMD. These recordings that we're doing for podcasts are really a critical part of the Don't Lose Sight campaign from the Canadian Association of Optometrists. And we're really concerned that, you know, the coverage that we have available today to people that are working is just not adequate to meet their vision care needs based on the technology that's available to detect and monitor some very serious eye diseases that can impact people's ability to see. So for those that are on the line today, and are interested in finding out more, and listening to our other podcasts and reading some of our blogs, we do have on the don't lose sight dot CA site, links to all of our prior releases. You can also email info at don't lose sight dot CA for one on one discussion with the CAO, and we'll also have, for those of you that know me, Benefits Breakfast Club meeting, our first in-person session since COVID on November 24. We'll be talking about diabetes. But of course, as Alexa I'm sure will say in response to this, diabetic retinopathy is a really big deal in the management of diabetes, and it's a significant comorbidity of diabetes for those whose diabetes isn't in good control. So that's on November 24. So you can find that on the on the Connex HC dot com website. And I don't know if you have any parting comments about diabetic retinopathy, Alexa, but that's probably something that you see pretty regularly in your practice.

Doctor Alexa Hecht: 27:18

Yeah, it's more common than you would think. And also the anti-VEGF injections that we talked about, that's actually a common treatment that's used for diabetic retinopathy when it's in more advanced stages, and it's affecting that central part of the vision, the macula, so yeah, both are terrible conditions, and we want to make sure we're doing what's best for our patients and managing it in a timely manner.

Denise Balch: 27:43

Yeah, that's great. So again, thank you very much, Doctor Hecht, for being with us. Very much appreciate your time today and the insights you've given us into macular degeneration. Thanks so much once again.

Doctor Alexa Hecht: 27:57

Thank you so much for having me, and if anyone wants to check me out on social media, it's just Doctor Dot Alexa Hecht on TikTok and Instagram.

Denise Balch: 28:06

Great, and the last name is HECHT. Yes. Great. Thanks so much.

Doctor Alexa Hecht: 28:11

Thank you.