Stuart Richer, OD, PhD

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At the Ocular Wellness and Nutrition Society,

 we teach our members how to build a firewall of immune protection for patients, eyecare providers, and their families. 

Humans have lived and survived severe acute respiratory syndrome (SARS, 2004), avian flu (2008), swine flu (2010), Middle East respiratory syndrome (MERS, 2012), Ebola (2014), Zika (2016), and Ebola part deux (2018). Now COVID-19 is the new challenge.

Chief Optometric Editor Ben Casella checks in on Week 2 of office closure

Each flu season, tens of thousands die, especially those with pre-existing health challenges (smoking, obesity, diabetes, cancer, and more.) Yet as of this writing, we have seen only 302 U.S. coronavirus deaths.

For the United States, there remains an “unknown denominator” because reliable testing kits were largely unavailable during the first 4 months of the COVID-19 outbreak. That is, a small percentage Americans, thus far, have been tested for the pathogen.

 Regardless of the potential for increased virulence, resistance and proliferation of this virus, following government recommendations for social distancing and hygiene will of course buy us time and “flatten the curve.” However, optimizing the immune system by reducing  fear and stress, and improving lifestyle while optimizing nutrition is more important than ever.

Companies offer CE, other resources amid coronavirus pandemic

Immune processes and adjustment behaviors powerfully regulate each other.

 Thus, it is plausible that healthy food, quality sleep, sunshine, exercise, music, meditation, pets, and supplementation result in improved immune performance. Conversely, stress has been shown to lower immune competence in patients with cancer.

What the COVID-19 relief package means for ODs

Meta-analytic reviews have summarized results from the large number of studies using the “stress/non-stress” paradigm, revealing consistent immune changes in the presence of psychological stressors.

 Overly stressed individuals exhibit poorer sleep, exercise less, and have poor dietary habits, as well as habitual drug and alcohol use, all of which depress immune competence.

Central activation of the sympathetic nervous system, even via non-adrenomedullary pathways such as sleep deprivation, has been shown to have a pivotal role in the regulation of inflammation and innate immunity in astronauts in hyper-stressed environments.

 We know that the brain controls immune responses. Stress also increases the need for vitamin C from the diet or supplements.


	Even in the polluted Chinese city of Wuhan and surrounding environment, it is reported that 81  percent of individuals who were infected had only mild disease: non-pneumonia and mild pneumonia.

 The good news is that Americans are likely already developing antibodies on their own without the aid of a vaccine.

 Functional foods and dietary supplements may enhance this natural immunity to overcome immune senescence.

ARBO loosens rules on online CE during COVID-19 pandemic

Improve immunity by reducing simple sugars from the diet, from soda, fruit juices, candy, and cake. Choose nutrient-dense plant food, vegetables and vegetable juices and vitamin C/bioflavonoid-containing fruits. Sugar feeds bacteria that grow, like strep, so avoid secondary infections. 


	The potential for co-infection is always present. The over-arching governor is the Earth in winter solstice tilting away from the sun with our immune system crashing. It is then that infectious disease erupts. Mass vitamin D nourishment is preferred, from vitamin D rich foods such as cold-water fish (like sardines or salmon) and mushrooms. However, fish alone in the absence of sunlight might not significantly raise vitamin D blood levels. Therefore, evaluate and optimize patients’ 25 OH vitamin D liver reserve status with a blood draw or finger blood spot test.

Eyecare practitioners urged to provide emergency care only amid COVD-19

Protective effects of vitamin D are strongest in individuals with profound vitamin D deficiency at baseline, although those with higher baseline 25(OH)D concentrations also experience benefit according to meta-analysis studies.

House-bound elderly patients of color, those living in northern latitudes or not exposed to natural sunlight, and at-risk patient such as smokers, the obese, and patients with pre-existing conditions such as diabetes and heart disease are the patients to be concerned about.

How ODs are addressing COVID-19 in their practices


	The hallmark sign of an infection is a cough, probably bronchial. The immune system will not kick in to produce T cells until about the sixth or seventh day of a bout with flu or cold. Zinc combats microbial infection by invigorating the thymus gland to produce naÃ¯ve T white blood cells that will become competent memory T-cells that produce antibodies against incoming microbes.

Taking a zinc acetate lozenge at the first sign of a cold or cough may shorten a bout of the common cold by three days and longer.

 These lozenges should not be taken daily, only during illness.

Deep breathing the mist of a hot shower or from a nebulizer  are helpful. Sore throats are addressed by gargling with saltwater (alkaline) to battle streptococcus (acid forming bacteria), using anesthetics for comfort (such as Chloraseptic spray). Stress increases the need for vitamin C, while common medications such as steroids, aspirin, and diuretics deplete vitamin C.

Elderberry syrup, an option for children, may shorten a bout with a cold by one to one and a half days. Echinacea dosing is 10 g and is mildly helpful. Beta glucan is superior to elderberry syrup. Licorice root may quell SARS-type viruses, but it is not for daily use due to blood pressure raising effects.

COVID-19 and contact lens wear: What ODs and patients need to know


	As a general principles, in addition to minimizing junk food and promoting nutrient dense food, ODs may prescribe a high-potency, broad spectrum daily multivitamin. Optimal immunity requires A, C, D, E, B2, B6, folic acid, iron, selenium and zinc.

 But it also requires prebiotics, probiotics and symbiotics for an optimal microbiome, as the gut lining represents 70 to 80 percent of the immune system.

Zinc is the gate keeper of immune function and Zn mono-methionine optimizes T-cell immunity.

 The body will not produce adequate T-cells for long-term immunity without zinc; 10 mg for children; 30 mg for adults.

 Advise patients not to take more or the body will excessively bind up zinc.

Polyphenols such as quercetin and resveratrol have robust anti-viral properties.

Choose foods or supplements that build the master intracellular antioxidant in all living cells: glutathione (GSH). This can be accomplished with a half a cup daily of avocado, pinto beans or asparagus, or prescribing 500 mg of reduced glutathione (Figure 1). Note that vitamin C is a master GSH booster. It is suggested that at-risk groups take 500 mg of vitamin C q4 to 6 hours.

Coronavirus: A quick summary for optometrists


	For elderly individuals or those with pre-existing medical conditions, who are at high risk, evidence confirms vitamin C’s effectiveness when used in excess of recommended allowances.

Patients with acute viral infections show a depletion of vitamin C and increasing free radicals and cellular dysfunction.

 The immune system of such patients should be treated with vitamin C, oral or intravenous (IV), for neutralizing free radicals throughout the body and inside cells, maintaining physiological functions, and enhancing natural healing.

An international team of physicians affiliated with the institute have organized three ongoing clinical trials in China and published the intravenous protocols  of the Japanese College of Intravenous Therapy (IVC) 12.5 g to 25 g (12,500 mg to 25,000 mg) for acute viral infections. 23-25 IVC is usually administered once or twice a day for two to five continuous days, at a dose of 12 grams to 24 grams per day, with or without general antiviral treatments.

ODs should use this information to begin further research on modulating immunity and form their opinions based on existing and unfolding knowledge

 Consider the underrated significance of vitamin K2 in eye care

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	5. Thornton LM, Andersen BL. Psychoneuroimmunology examined: The role of subjective stress. Cellscience. 2006 Apr 30;2(4):66-91.
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	7. Segerstrom SC, Miller GE. Psychological stress and the human immune system: A meta-analytic study of 30 years of inquiry. Psychol Bull. 2004 Jul;130(4):601-30.
	8. Frippiat JP, Crucian BE, de Quervain DJ, Grimm D, Montano N, Praun S, Roozendaal B, Schelling G, Thiel M, Ullrich O, ChoukÃ¨r A. Towards human exploration of space: The THESEUS review series on immunology research priorities. NPJ Microgravity. 2016 Dec 1;2:16040.
	9. Carr AC ,  Maggini S. Vitamin C and Immune Function. Nutrients. 2017 Nov 3;9(11). pii: E1211.
	10. Wang Y, Wang Y, Chen Y, Qin Q. Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures. J Med Virol. 2020 Mar 5. doi: 10.1002/jmv.25748.
	11. Sardi B. Covid-19 Coronavirus Vaccine Could Kill 8-16 Times More Senior Americans Compared to No Vaccine at All. Available at: https://www.lewrockwell.com/2020/03/no_author/covid-19-coronavirus-vaccine-could-kill-8-16-times-more-senior-americans-compared-to-no-vaccine-at-all/. Accessed 3/20/20.
	12. Martineau AR, Jolliffe DA, Greenberg L, Aloia JF, Bergman P, Dubnov-Raz G, Esposito S, Ganmaa D, Ginde AA, Goodall EC, Grant CC, Janssens W, Jensen ME, Kerley CP, Laaksi I, Manaseki-Holland S, Mauger D, Murdoch DR, Neale R, Rees JR, Simpson Jr S, Stelmach I, Trilok Kumar GT, Urashima M, Camargo Jr CA, Griffiths CJ, Hooper RL. Vitamin D supplementation to prevent acute respiratory infections: individual participant data meta-analysis. Available at: https://njl-admin.nihr.ac.uk/document/download/2021908. Accessed 3/30/20.
	13. HemilÃ¤ H, Petrus EJ, Fitzgerald JT, Prasad A. Zinc acetate lozenges for treating the common cold: an individual patient data meta-analysis. Br J Clin Pharmacol. 2016 Nov;82(5):1393-1398.
	14. Penn State Milton S. Hershey Medical Center. Drugs that Deplete: Vitamin C (Ascorbic Acid). Available at: http://pennstatehershey.adam.com/content.aspx?productId=107&pid=33&gid=000723. Accessed 3/30/20.
	15. Fukuchi K, Okudaira N, Adachi K, Odai-Ide R, Watanabe S, Ohno H, Yamamoto M, Kanamoto T, Terakubo S, Nakashima H, Uesawa Y, Kagaya H, Sakagami H. Antiviral and Antitumor Activity of Licorice Root Extracts. In Vivo. 2016 11-12;30(6):777-785.
	16. Maggini S, Pierre A, Calder PC. Immune Function and Micronutrient Requirements Change over the Life Course. Nutrients. 2018 Oct 17;10(10). pii: E1531.
	17. Vighi G, Marcucci F, Sensi L, Di Cara G, Frati F. Allergy and the gastrointestinal system. Clin Exp Immunol. 2008 Sep;153 Suppl 1:3-6.
	18. Wessels I, Maywald M, Rink L. Zinc as a Gatekeeper of Immune Function. Nutrients. 2017 Nov 25;9(12). pii: E1286. doi: 10.3390/nu9121286.
	19. Guillin OM, Vindry C, Ohlmann T, Chavatte L. Selenium, Selenoproteins and Viral Infection. Nutrients. 2019 Sep 4;11(9). pii: E2101.
	20. Li Y, Yao J, Han C, Yang J, Chaudhry MT, Wang S, Liu H, Yin Y. Quercetin, Inflammation and Immunity. Nutrients. 2016 Mar 15;8(3):167.
	21. Saul AW, Yanagisawa A. Hospital-based Intravenous Vitamin C Treatment for Coronavirus and Related Illnesses. Available at: https://orthomolecular.activehosted.com/index.php?action=social&chash=02522a2b2726fb0a03bb19f2d8d9524d.138. Accessed 3/30/20.  
	22. Saul AW. Nutritional Treatment of Coronavirus. Available at:
	http://orthomolecular.org/resources/omns/v16n06.shtml. Accessed 3/30/20.
	23. Saul AW. Vitamin C Protects Against Coronavirus. Available at: http://orthomolecular.org/resources/omns/v16n04.shtml. Accessed 3/30/20/
	24. Wu D, Lewis ED, Pae M, Meydani SN. Nutritional Modulation of Immune Function: Analysis of Evidence, Mechanisms, and Clinical Relevance. Front Immunol. 2019 Jan 15;9:3160.
	25. Wang Y, Wang Y, Chen Y, Qin Q. Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures. J Med Virol. 2020 Mar 5. doi: 10.1002/jmv.25748.

Articles

Have a plan to combat immune senescence in your senior patients at risk for the disease

How to build a lifestyle and nutritional firewall against viruses like COVID-19

The question of how to maintain quality healthcare standards while forging ahead into new discoveries and developments is baffling to many clinicians. Optometry’s success in the coming years will depend on the ability of ODs to overcome challenges like economic competitiveness and utilize and grow alongside technological advances that are changing the way business is conducted, like artificial intelligence. Diving into the approximately 5,500 publications of peer reviewed materials exchanged on the National Library of Medicine every day is a great place to start if ODs can come up with the energy and time expenditures to do so. AI is here to help.

Optometry’s success in the coming years will depend on the ability of optometrists to overcome challenges like economic competitiveness and utilize and grow alongside technological advances that are changing the way business is conducted.

There are now 20 million medical publications, freely accessible as abstracts and full publications within the National Library of Medicine (NLM). Some two million publications are added each year for clinicians to reference in examination rooms, at home, or anywhere they’d like on smart devices. NLM sends more than 10 terabytes of data to nearly five million users and receives more than 100 terabytes of data, representing approximately 5,500 publications of exchanged, peer reviewed, reading material every day.

Related: How artificial intelligence is changing the future of optometry

There is incredible research waiting to be discovered and applied within this data, and few ODs rolling their sleeves up to unearth it.

The reasons why? Stressful modern practice demands, educational debt, and competing family priorities lead to 

In 1975, an average physician visit was 60 minutes long, and a follow-up visit was 30. Today, an average office visit is 12 minutes long, and return visits are seven.

Modern healthcare specifically demands the treatment of increasingly diverse and aging populations, which creates the “perfect storm” for 

, especially when it comes to primary-care doctors and their associated teams of practitioners.

The question of how to maintain quality healthcare standards while forging ahead into new discoveries and developments is baffling.

Related: Nutrition in the future of primary-care optometry

With so much ground to cover in the areas of environmental medicine, public health, exercise physiology, 

, epigenetics, geriatric medicine, anti-aging medicine and neuroscience, ODs may start to wonder:

– Will pharmaceutical companies embrace new discoveries?

– Will governments support efforts if it means fewer customers and jobs?

Related: Innovative mobile technology targets low vision

In his book Deep Medicine, Eric Topol, MD, presents this idea: the physician of today is living in a world of insufficient presence, insufficient time, insufficient data, and “shallow medicine.”

In his classic book, The Biology of Belief, neuroscientist Bruce H. Lipton, PhD, claims that one third of all healing is due to patient belief, not drug or 

Whether you subscribe to this belief or not, all practicing clinicians should realize that there is no substitute for face-to-face time with our patients, regardless of the increasing prevalence of AI.

The US has world-class health care for individual segments of medicine such as emergency medicine, neurosurgery and, indeed, ophthalmology with all of its sub-specializations.

Related: Artificial intelligence might be the future of practice management

However, five iterations of universal United States Department of Agriculture (USDA) dietary recommendations have failed to take into account the tide of cellular insulin insensitivity, non-alcoholic fatty liver disease, and the growing diabetes epidemic that currently plagues our most vulnerable citizens.

According to the Centers for Disease Control, more than 100 million U.S. adults are living with diabetes or prediabetes.

 Our own experience as patients and optometric physicians suggest a broken “disease management system,” inconsistent with scientific data available through NLM. We know that genetics plays a role in chronic disease such as age-related macular degeneration (AMD), but the story does not end there, even if the way we tell it does. Epigenetics plays a much larger role.

Related: AI may be the answer for early disease detection

Furthermore, there is no single magic diagnostic test, pharmaceutical, or nutrient for progressive retinopathy/choroidopathy. Lifestyle, which encompasses a broad range of ancient nutrients and minimization or modulation of modern stressors, is the task at hand as exemplified by my own life’s work and more recently by ophthalmologist Chris Knobbe, MD.

My challenge as a residency coordinator is to cover the medically essential information first, then the chronic ocular disease aspect of the teaching program. That is, I must emphasize to new optometrists their responsibilities to detect, diagnose, and manage (i.e., appropriately refer) life- and vision-threatening diseases.

The most prevalent challenges include an aging population and the resulting high clinical traffic in medical emergencies, chronic oculo-vascular disease, and eye cancers. All contemporary optometric institutions embrace this approach. This is no small task for even seasoned practitioners. Several “must know” conditions for residents are listed in 

Related: Year in review of optometric advancements

Employment of ODs is projected to grow 10 percent from 2018 to 2028, faster than the average for all occupations.

 Science in all medical disciplines has revealed that patients and their physicians must begin treatments early to prevent cell loss. Nutritional supplements play a role earlier, while pharmaceutical drugs are best used later.

Related: AI testing is almost here, and it doesn’t care if ODs are ready

Is it not time to move independently of ophthalmology in providing preventative eye care? All primary-care medicines are facing the same realities. 

It is not a matter of science in 2020, but the adoption of bold new strategies that will best shape the future. AI can make health care human again, allowing optometrists to embrace our rooted tradition of face-to-face encounters as we get on with the business of preserving vision. 

The soon-to-be-released feature-length documentary, “Open Your Eyes” delivers the resounding message that the eye holds the secrets to health. It explores how America became so sick and how optometrists can now see almost 300 diseases in the eye. 

Kerry Gelb, OD, travels throughout North America and Europe and explores in contrast the Centenarians in Costa Rica, who for the most part have no disease and live beyond 100 years without the major cause of blindness seen in the US. Interviews with medical experts, PhDs, researchers, and journalists convey the emerging importance of eye doctors, how they have a major impact on disease prevention, and why they should stand at the forefront of health and wellness.

More by Dr. Richer: Go beyond fish oil with astaxanthin in krill oil

1. Topol E. Deep Medicine. 1st Edition. Hatchett Books, New York, NY. 2019.
	2. Lipton BH. The Biology of Belief, Unleashing the Power of Consciousness, Matter and Miracles. 10th Edition. Hay House, Inc. Carlsbad, CA. 2016.
	3. Lustig, R. Video: Sugar the Bitter Truth, https://youtu.be/ dBnniua6-oM. Accessed 1/29/20.
	4. Lustig, R. Sugar the Bitter Truth. Plume, Penguin Group. New York, NY. 2014.
	5. Richer S. Is there a prevention and treatment strategy for age related macular degeneration? J Am Optom Assoc. 1993;64(12):838-50.
	6. Centers for Disease Control. National Diabetes Statistics Report, 2017. Available at: https://www.cdc.gov/diabetes/ pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed 1/29/30.
	7. Richer S, Gelb K, Jaffe R. Windows into Wellness: Eight Biomarkers You Should Know. Rev Optom. 2018 Sept 15, 2018, pages 30-33..
	8. Knobbe C. Ancestral Dietary Strategy to Prevent and Treat Macular Degeneration. 1st edition. Cure AMD Foundation. Boulder, CO. 2016.
	9. Richer S, Poteet J, Ruskin D, Summerton S, Hitchmoth D. Wellness Essentials for Clinical Practice, 2nd Edition. Suppl Rev Optom. 15 October 2018.
	10. Richer S, Poteet J, Ruskin D, Summerton S, Hitchmoth D. Wellness Essentials for Clinical Practice. 3nd Edition. Suppl Rev Optom. 15 October 2019.
	11. Bureau of Labor Statistics. Occupational Outlook Handbook: Optometrists. Available at: https://www.bls.gov/ ooh/healthcare/optometrists.htm. Accessed 1/29/20.
	12. Chester W, Engfehr K, Gelb, K. Open your Eyes. https:// www.imdb.com/title/tt11487298/?ref_=nm_knf_i2. Accessed 1/29/20.

Optometry’s success in the future will depend on the ability of ODs to overcome new challenges.

Prevention, artificial intelligence, and the future of optometry

Astaxanthin is the oceanic carotenoid that makes flamingos pink and salmon red. Astaxanthin is found in krill, the small crustaceans eaten by Antarctic whales.

, contains astaxanthin, lecithin, and marine omega-3 fatty acids. Similar to more widely studied fish oil, KO also contains the long-chain fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). These “good” fats are essential for basic eye and brain function.

However, KO also contains the phospholipid phosphatidyl ethanolamine (lecithin). The phospholipid bound nature of fatty acids found in KO improves omega-3 fatty acid absorption and bioavailability. This type of natural oil that contains astaxanthin is useful in our modern environment of 

Related: Consider the underrated significance of vitamin K2 in eye care

At least 4 mg to 6 mg astaxanthin are important for eye health. This is the amount found in one and a half servings of Sockeye salmon or three servings of Coho salmon, the other prime sources of DHA and EPA. Fortunately for our natural resources, astaxanthin is now commercially prepared in abundance from the haematococcus pluvalis algae under controlled aquiculture conditions of light and temperature.

Astaxanthin has a chemical structure that fully spans cellular membranes with potent antioxidant and anti-inflammatory properties. By peroxyl scavenging measures, it is a far stronger antioxidant than zeaxanthin, canthaxanthin, lutein, B-carotene, and alpha-tocopherol. Astaxanthin crosses both the blood-retinal and blood-brain barriers.

Astaxanthin is also an important component of mitochondrial membranes, improving cellular energetics in a variety of diseases.

 There are now more than 60 human clinical trials for a variety of health benefits, including the eye. Ranges of 4 to 12 mg doses have been used in research studies.

Research from Asia suggests that astaxanthin can reduce eye fatigue, alleviate eyestrain and assist eyes to resist and recover from screen time. It does this by improving accommodative speed, accommodative amplitude, near point of focus and depth perception.

One study showed a 21.7 percent increase in accommodation amplitude after only four weeks of astaxanthin ingestion (AstaReal) at 5 mg/day (p<0.01).

Mechanistically, astaxanthin also promotes improved circulation and nourishment of anterior and posterior segment eye tissue, as well as improvement in mitochondrial function, while alleviating oxidative stress.

Specifically, astaxanthin increases ciliary muscle recovery and endurance, improves capillary blood flow and other rheology parameters, and inhibits inflammation via the NF-kB pathway.

Millennials as well as older computer users often suffer from 

. One study showed that at 6 mg per day, in 22 patients ages ranging from 45 years to 65 years, those with 

 experienced a 15 percent subjective improvement in lacrimation, a 19 percent improvement in redness and a 46 percent improvement in pain at 1 month.

It appears this is accomplished in part by increasing aquaporin 5 (water transporter) expression that plays a role in tear production as well as saliva and pulmonary physiology.

Related: Understand diabetes and nutrition

, astaxanthin has been shown to localize to the ciliary body, increase antioxidant capacity of aqueous humor, reduce pro-inflammatory factors in the trabecular meshwork, and increase ocular blood flow, apparently without lowering IOP.

In uveitis animal models (rats and mice), research has shown a reduction in the NF-KB mediated inflammatory response and reduced lipopolysaccharide-induced accumulation of protein, NO, TNF-Î±, andPGE2.

 Thus this marine carotenoid could play an importance role in uveitis as well as glaucoma.

 is a common procedure in the U.S. Pre-operative patients taking 6 mg per day of astaxanthin exhibited significantly lower aqueous flare intensity three days after surgery compared to controls, suggesting reduced post-surgical inflammation (p<0.01).

Finally, age-related macular degeneration pathophysiology results in reduced retinal pigment epithelium mitochondria number and size, increased mitochondrial DNA lesions, and reduced mitochondrial DNA repair capacity.

Plus, astaxanthin complements both lutein and zeaxanthin.

More by Dr. Richer: Consider the whole patient when treating glaucoma

1. Andraka JM, Sharma N, Marchalant Y. Can krill oil be of use for counteracting neuroinflammatory processes induced by high fat diet and aging? Neurosci Res. 2019 Aug 22. pii: S0168-0102(19)30312-8.
	2. Yu T, Dohl J, Chen Y, Gasier HG, Deuster PA. Astaxanthin but not quercetin preserves mitochondrial integrity and function, ameliorates oxidative stress, and reduces heat-induced skeletal muscle injury. J Cell Physiol. 2019 Aug;234(8):13292-13302.
	3. Nagaki Y, Hayasaka S, Yamada T, Hayasaka Y, Sanada M, Uonomi T. Effects of astaxanthin on accommodation, critical flicker fusion, and pattern visual evoked potential in visual display terminal workers. J Trad Med. 2002 Oct;19(5):170-173.
	4. Kajita et al. J Clinical Therapeutics Med. 2009;25(8):37-49.
	5. Kuraji M, Matsuno T, Saloh T. Astaxanthin affects oxidative stress and hyposalivation in aging mice. J Clin Biochem Nutr. 2016 Sep;59(2):79-85.
	6. Nagaki et al. J Clinical Therapeutics Med. 2005;21(5):537-
	542.
	7. Suzuki Y, Ohgami K, Shiratori K, Jin XH, Ilieva I, Koyama Y, Yazawa K, Yoshida K, Kase S, Ohno S. Suppressive effects of astaxanthin against rat endotoxin-induced uveitis by inhibiting the NF-kappaB signaling pathway. Exp Eye Res. 2006 Feb;82(2):275-81.
	8. Hashimoto H, Arai K, Hayashi S, Okamoto H Takahashi J5, Chikuda M2 . The effect of astaxanthin on vascular endothelial growth factor (VEGF) levels and peroxidation reactions in the aqueous humor. J Clin Biochem Nutr. 2016 Jul;59(1):10-5.
	9. Feher J, Kovacs I, Artico M, Cavallotti C, Papale A, Balacco Gabrieli C. Mitochondrial alterations of retinal pigment epithelium in age-related macular degeneration. Neurobiol Aging. 2006 Jul;27(7):983-93.
	10. Lin H, Xu H, Liang FQ, Liang H, Gupta P, Havey AN, Boulton ME, Godley BF. Mitochondrial DNA damage and repair in RPE associated with aging and age-related
	macular degeneration. Invest Ophthalmol Vis Sci. 2011 Jun 1;52(6):3521-9.

This carotenoid helps with dry eye, glaucoma, AMD, eye fatigue, and more.

Go beyond fish oil with astaxanthin in krill oil 

It is difficult to take it all in, let alone summarize the information gained by attending an Association of Research in Vision and Ophthalmology (ARVO) annual scientific meeting.

In my opinion, every optometrist should attend at least one ARVO meeting in their professional careers, and the earlier the better. This year’s meeting in Vancouver saw a record-setting 11,000 attendees from more than 75 countries. Some of the presentations that ODs are involved with are literally out of this world.
	
	

Highlights of ARVO 2018's anterior segment posters 

A brief review of topic themes of papers, posters, and presentations is listed below.

Spaceflight-associated neuro-ocular syndrome


	Spaceflight-associated neuro-ocular syndrome (SANS) syndrome affects about 40 percent of astronauts on long-duration spaceflights as assessed by one or more findings:
	
	• Optic disc edema
	• Hyperopic shifts
	• Globe flattening
	• Cotton-wool spots
	• Choroidal folds

Quantitative ocular coherence tomography (OCT)

-based metrics of optic nerve head morphology during long-duration spaceflight suggest that intracranial pressure (ICP) during spaceflight is not pathologically elevated. Yet optic nerve head changes, consistent with edema, developed in over half of their cohort of n=150 astronauts. The headward fluid shift associated with weightlessness induces optic disc edema independent of pathologically elevated ICP.

Researchers from Kentucky Colleges of Optometry and Osteopathic Medicine have an explanation of why astronauts develop pathologies more often in their right eyes after returning from long-duration spaceflights.

The researchers propose that a contributing factor is greater intraocular pressure (IOP) in the right eye versus the left eye when astronauts are in a nonstandard (head down) body position, as would be expected in an environment with low gravity.

IOP increased OD relative to OS during head down tilt with a 19 percent increase at a 45° head tilt, while no differences were seen in the supine position.

The researchers attribute this to anatomic variations in internal jugular vein distension and drainage, contributing to both the increased IOP and optic disc edema.


	Back on earth, traumatic brain injury (TBI) is a real and present danger for motorists and pedestrians as well as civilians of all ages engaged in sports and soldiers.

Patients with TBI, even mild TBI, often show impaired stereopsis not appreciated during a conventional eye exam. Measuring stereopsis in different positions of the visual field with virtual reality glasses seems to be an effective new tool for fast concussion assessment.

Looking through computer-tethered virtual reality glasses, German scientists displayed four balls with differing stereo offset presented in nine different positions of the visual field. The task was to evaluate third-degree fusion (stereopsis) in all gaze positions by selecting the closer ball using a gaming controller.

Virtual reality, tablet devices capture visual fields in unconventional ways 

This technology is being used to train athletes. Ocular healthy athletes improved their stereo vision over a six-week time frame in respect to disparity threshold, reaction time, gain, and percentage of correct answers.

Consumer 3-D head-mounted displays provide potential for improving visual functions such as contrast sensitivity, visual crowding, and visual attention.

Scientists at UC Berkeley School of Optometry and Baylor College of Medicine Department of Neuroscience further explored the potential of 3-D video games to improve stereopsis. Playing stereoscopic 3-D video games for short periods of time improves depth perception by 33.5 percent in healthy young adults.

Notably, their most recent experiments have shown these types of video games to have a special benefit for triggering the plasticity of stereo vision in patients with amblyopia.

 How to recognize and manage digital eye strain 

Distinguishing Alzheimer’s from other dementia with OCT


	While dichoptic tests such as stereopsis are being extended to those patients suspected of having a neurodegenerative disorder such as Alzheimer’s or Parkinson’s disease, there was much interest at ARVO 2019 in the potential of spectral-domain OCT (SDOCT) to be used for the objective diagnosis of neurodegenerative diseases.

Alzheimer’s disease (AD) is difficult to clinically distinguish from frontotemporal degeneration (FTD), an age-related dementia with distinct brain pathology.

Researchers from the University of Pennsylvania Scheie Eye Institute and the Department of Neurology evaluated SDOCTs of these two district neurodegenerations (n=15 AD and n=33 FTD patients). Differences in retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL) thicknesses were not seen.

However, outer retina thinning detected by SDOCT may distinguish FTD from AD. The researchers suggest that the thicker outer plexiform layer in FTD patients stems from bipolar and horizontal cell dendrite sprouting as the outer nuclear layer thins.


	Tear biomarkers have been identified for several ocular diseases as well as neurological diseases like migraine, Parkinson’s disease, and multiple sclerosis.

Now a group from the University Eye Clinic and Departments of Psychiatry & Neuropsychology at Maastricht University Medical Center, Netherlands, has evaluated the tear biomarker level of total-tau and amyloid-beta 42 (AÎ²42) in a cohort of n=25 patients with AD, mild cognitive impairment, or subjective cognitive impairment and n=9 age-matching healthy controls.

Although the sample size is small, their results suggest tear total-tau and AÎ²42 have reasonable discriminatory power for the AD state with is potential for utility as a clinical diagnostic marker.

ODs' role promising in detecting Alzheimer's disease 


	At ARVO 2019, several presentations focused on driving and fall risk. These two topics are of clinical importance to optometrists adapting to examining an increasingly aged population.

Driving is a complex task involving cognitive, motor, and vision measures such as novel tests of central motion sensitivity and contrast sensitivity (CSF) that are significantly associated with driving performance among older adults with and without visual impairment.

However, standard worldwide vision licensing tests are not strongly predictive of driving performance.

Australian researchers, including Joanne M. Wood, BSc, PhD, from the Queensland School of Optometry, are moving toward identifying unsafe older drivers using a comprehensive performance model, which is important in those with visual impairment.

Innovative mobile technology target low vision 

Is there a biomarker for predicting night vision difficulties during an eye examination? Our group at the James A. Lovell Federal Health Care Center found self-assessed global low luminance performance correlates with macular pigment optical density even in patients without retinal disease.

Researchers from Australia once again have given much thought to another concern of elderly beyond driving: fear of falling. This concern potentially contributes to activity restriction, physical deconditioning, psychological distress, and reduced quality of life. Not surprisingly, higher levels of anxiety about falling are commonly found among older patients with age-related macular degeneration (AMD) and associated with their central vision loss.

Yearly declines in CSF were linked to increased levels of their concern about falling. The researchers’ findings highlight the need for monitoring “fall risk concern” among older people with AMD, particularly those with progressive vision loss. Regular assessment of CSF could assist in identifying those at greatest risk of fall risk concern.

Considering scleral lenses for astigmatic patients 

Validation of a self-administered CSF test


	Another poster confirmed the utility of a new simple home (or office) CSF test known as the CamBlobs2.

Researchers from the School of Optometry at UniversitÃ© de MontrÃ©al  demonstrated that CSF measured with the CamBlobs2 chart agrees with the validated Mars chart in a group of multiple sclerosis patients with optic neuritis. Camblobs2 can be self-administered by patients at home as a self-monitoring tool.


	
	Fluorescence lifetime imaging ophthalmoscopy


	The retina contains components (fluorophores) which glow back after illumination with light. Researchers from Bern, Switzerland, as well as at the University of Utah/Moran Eye Center presented several posters on this new imaging modality.

Fluorescence lifetime imaging ophthalmoscopy (FLIO) images show how long these fluorophores glow (fluorescence lifetimes), providing vital information about the metabolism and health of the retina.

The Bern group analyzed 141 healthy eyes of subjects with a broad age range (21 to 91 years) to construct a normative data base. The Moran Eye Center group is likewise evaluating patients with various disease states. Longer fluorescence lifetimes measured in older subjects indicate a change in composition of the retina over time. As with autofluorescence imaging, human lens status must be considered when analyzing FLIO.

 How artificial intelligence can transform eye care 


	There were no less than 23 special topic presentations concerning artificial intelligence (AI), both novel applications and refinements (such as diabetic retinopathy). Some of the myriad and growing potential applications are nothing short of breathtaking.

See the specific AI topics:
	
	• LASIK and PRK


	• Collaborative management of cataracts


	• Predicting chronic kidney disease (CKD) from retinal images


	• Distinguishing cavernous hemangioma and neurilemmoma


	• Infectious keratitis with slit-lamp images


	• Diabetic retinopathy using SDOCT and SDOCTA


	• Automatic detection of diabetic retinopathy


	• Predicting myopic macular degeneration


	• Classification of subclinical keratoconus using Scheimpflug and SDOCT


	• Immune related factors of intraocular disease


	• Fully automated feature-based segmentation of diabetic retinopathy


	• SDOCT and novel deep learning algorithms in Singapore


	• Opacity suppression in teleretinal imaging


	• Optical Coherence Tomography and Artificial Intelligence for Glaucomatous Optic Neuropathy (OCTAGON) research group


	• Subjective refraction from wavefront aberrometry

1. Macias B, Laurie S , Lee S, Martin D, Sargsyan A, Marshall-Goebel K, Ebert D, Dulchavsky S, Hargens A, Stenger MB. Elevated intracranial pressure does not explain spaceflight-induced optic disc edema. 

. 2019;60(9):4809.
	2. Murthy N, Mutter MW, Bradley J, Watson LJ, Hickenbotham A, Kinzer E. Contribution of intraocular pressure disparity in head-down tilt to the development of Spaceflight-Associated Neuro-ocular Syndrome. 

. 2019;60(9):2260.
	3. Kara DD, Ring M, Mehringer W, Eskofier B, Hennig FF, Michelson G. Detection of mild traumatic brain injury by a virtual reality system. 

. 2019;60(9):2304.
	4. Michelson G, Kutzner B, Mehringer W, Paulus J, Ring M, Eskofier B. Dichoptic binocular vision training improved stereo vision in top athletes.

. 2019;60(9):1798.
	5. Bui J, Li B, Li B, Fung E, Antonucci M, Tran KD, Patel S, Chung STL, Levi DM, Li R. Stereoscopic 3D video games boost depth perception. 

. 2019;60(9):1797.
	6. Kim BJ, Grossman M, Saludades A, Song D, Dunaief JL McGeehan B, Ying GS, Aleman TS, Irwin D. Optic retina thinning distinguishes fronto-temporal degeneration from Alzheimer’s disease. 

. 2019;60(9):2296.
	7. Giljs M, Nuijts, RM, Ramakers I, Verhey F, Webers CAB. Differences in tear protein biomarkers between patients with Alzheimer’s disease and controls. 

. 2019;60(9):1744.
	8. Wood JM, Black AA, Mallon J, Anstey K. Predictors of driving performance in older adults with and without visual impairment. 

. 2019;60(9):4259.
	9. Richer S, Davis R, Novil S, Devishi A, Nassiri S, Davey PG. Predicting night vision difficulties during an eye examination. (Night Vision & Carotenoids RCT; Hines VA IRB 1052607-1, Baseline Data). 

. 2019;60(9):1828.
	10. White U, Black AA, Wood JM, Delbaere K. Progressive central vision impairment and concern about falling: a longitudinal study.

. 2019;60(9):4262.
	11. Bachir V, Marinier JA, Wittich W, Tchakmakian L. Ganglion cell layer thickness on optical coherence tomography allows differentiation of MS patients without optic neuritis from age-matched controls. Invest Ophthalmol Vis Sci. 2019;60(9):2289.
	12. Dysli C, Dysli M, Wolf S, Zinkernagel MS. Influence of age and lens status on fluorescence lifetimes in FLIO.

. 2019;60(9):1579. 
	13. DebellemaniÃ¨re G, Crahay FX, Rampat R, Saad A, Gatinel D. A new nomogram for the Wavelight Refractive Suite based on Artificial Intelligence. 

. 2019;60(9):6431.
	14. Wu X, Chen L, Liu Z, Lai W, Zhang K, Lin D, Chen K, Yu T, Wu D, Li C, Chen C, Zhu Y, Lin H. A universal artificial intelligence platform for collaborative management of cataracts. Invest Ophthalmol Vis Sci. 2019;60(9):1477. Tien Y Wong, Dejiang Xu, Daniel Ting, Simon Nusinovici, Carol Cheung, 15. Wong TY, Xu D, Ting D, Nusinovici S, Cheung C, Shyong TE, Cheng CY, Lee ML, Hsu W, Sabanayagam C. Artificial intelligence deep learning system for predicting chronic kidney disease from retinal images. 

. 2019;60(9):1468.
	16. Solanki K. Artificial Intelligence Eye Screening Using Smartphones: The Good, the Bad and the Ugly. Paper presented at: Association for Research in Vision and Ophthalmology; Vancouver, April 28-May 2, 2019.
	17. Schmidt-Erfurth U. Artificial Intelligence approaches to enrich clinical trials populations. 

. 2019;60(9):993.
	18. C De Moraes CG. Artificial intelligence for glaucoma diagnosis. 

. 2019;60(9):1407.
	19. Bi S, Lin H, Zhang K, Yang H. Artificial intelligence: A framework that can distinguish cavernous hemangioma and neurilemmoma automatically.

. 2019;60(9):1471.
	20. Vupparaboina KK, Vedula SN, Aithu S, Bashar SB, Challa K, Loomba A, Taneja M, Channapayya S, Richhariya A. Artificial intelligence based detection of infectious keratitis using slit-lamp images. 

 2019;60(9):4236.
	21. Govindasamy N, Ratra D, Dalan D, Mochi TB, Roy AS. Artificial intelligence effectively combined OCT and OCTA indices to improve early detection of diabetic retinopathy (DR). Invest Ophthalmol Vis Sci. 2019;60(9):1434.
	22. Ceruso S, Bonaque-GonzÃ¡lez S, Pareja-RÃ­os A, Rodriguez-Ramos JM, Marichal-HernÃ¡ndez JG, Carmona-Ballester D, Oliva R. Artificial intelligence for the automatic detection of diabetic retinopathy with feedback from key areas. Invest Ophthalmol Vis Sci. 2019;60(9):1435.
	23. Tan TE, Ting DSW, Liu Y, Li S, Chen C, Nguyen Q, Wong CW, Hoang QV, Lee SY, Wong EYM, Yeo IYS, Wong YL, Cheng CY, Saw SM, Cheung GCM, Wong TY. Artificial intelligence using a deep learning system with transfer learning to predict refractive error and myopic macular degeneration from color fundus photographs. Invest Ophthalmol Vis Sci. 2019;60(9):1478.
	24. Shen M, Shi C, Chen S, Jiang J, Ye Y, Lu F. Classification of subclinical keratoconus based on the combination of Scheimpflug and Spectral-Domain OCT imaging data using artificial intelligence. Invest Ophthalmol Vis Sci. 2019;60(9):1481.
	25. Nezu N, Usui Y, Asakage M, Shimizu H, Ogawa M, Yamakawa N, Yanagida C, Tsubota K, Narimatsu A, Maruyama K, Saito A, Kuroda M, Goto H. Determining immune-related factors of intraocular diseases by artificial intelligence methods. 

Author | Stuart Richer, OD, PhD

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