Stuart Richer, OD, PhD, FAAO, is director of ocular preventive medicine at James Lovell Federal Health Care Facility in Chicago. He is also associate professor of family and preventative medicine at Chicago Medical School and assistant clinical professor
Paul Chous, OD, MA, and his scientific team, as published in a recent British Journal of Ophthalmology clinical scientific study, have just raised the bar for public service, professional practice, and fiscal responsibility.
Paul Chous, OD, MA, and his scientific team, as published in a recent British Journal of Ophthalmology clinical scientific study, have just raised the bar for public service, professional practice, and fiscal responsibility.1
The clinical results of this placebo-controlled, randomized, double-masked, peer-reviewed DiVFuSS study (Diabetes Visual Function Supplement Study) should be embraced by optometrists and inspire ocular disease faculty at our growing list of colleges and schools of optometry to do much more for the optometric patient with diabetes. And it’s non–invasive.
DiVFuSS should be required reading for every optometry student and ophthalmology resident, postgraduate optometry residents, and practicing OD regardless of their ability or practice location-this article is for doctors treating patients and healthcare agencies trying to save money.
DiVFuSS shows us that beyond blood sugar and blood pressure control, more can be done for the diabetic patient with retinal disease to improve both overall health and retinal function (vision), rather than blindly forwarding on all patients to the retinal specialist for invasive intraretinal treatments once damage has already occurred.
Such anti-VEGF and depot steroid treatments, for example, while an improvement over past retinal ablation therapy, fail to address the multisystem ocular and systemic pathophysiology that all too often result in loss of vision, nerve damage (neuropathy), and cardiovascular, nephron-vascular, and neuro-cognitive damage.2
The results of DiVFuSS demonstrate that treatment with an inexpensive nutritional supplement matrix normalizes most serum lipids (i.e., triglycerides and HDL: P values ranging from 0.01 to 0.0004), lowers inflammatory hsCRP (high sensitivity C reactive protein: P=0.01), and improves diabetic peripheral neuropathy (P=0.0024). Though not quite statistically significant (P< 0.07), six percent of subjects receiving the DiVFuSS formula were clinically upgraded from moderate to merely mild non-proliferative diabetic retinopathy.1
The preventive ocular medicine principles exhibited by the DiVFuSS principal investigator within his specialized private practice devoted to the care of patients with diabetes is not new. Most optometrists have already embraced pharmacological management of early and moderate glaucoma. This optometrist has adopted the approach with early and moderate AMD via macular pigment testing, objective retinal imaging, dark adaptation testing and repigmentation with dietary carotenoid/essential fatty acid supplementation.3-5
Optometrists now have an insurance reimbursable novel dark adaptation device called the Adapt Dx which has a 90 percent sensitivity and 90 percent specificity to diagnose “pre-drusen” retinal disease in only 6.5 minutes.6
As with glaucoma management, evaluation and treatment of early macular degeneration and/or diabetic retinopathy expands the primary care role of the optometrist.
More from Dr. Richer: Bad blue light, macular pigment, and prescriptive carotenoids
The broader implications of the British Journal of Ophthalmology DiVFuSS diabetes study is that using the principles of preventive ocular medicine can serve to maintain the overall health of the patient with diabetes while restoring bilateral visual function lost in the disease process.
DiVFuSS or studies like it, should underpin our approach to serve the burgeoning number of patients with diabetes and/or AMD that we encounter each and every day.
According to Dr. Chous: “We wish to underscore the fact that diabetes affects retinal function long before we see retinopathy, and that the DiVFuSS formula represents an additional strategy to disrupt the underlying pathobiology of diabetes without improving metabolic control.It represents a defensive strategy for patients with diabetes who don’t yet have retinal disease and an additional ‘insurance policy’ against sub-optimal glycemic control and disease duration-the two biggest risk factors for diabetic retinopathy and blindness.”
Use of nutritional supplementation, a powerful tool, may prove to be even more effective than written agreements with patients to follow up with their optometrists and ophthalmologists. The use of such contracts in one large study did not increase follow-up adherence to eye appointments in diabetic patients with ocular abnormalities.7 An over-the-counter nutritional recommendation may be just the answer for doctors, patients, and their wallets.8
Disclosure: Dr. Richer, second author of DiVFuSS, is president of the Ocular Nutrition Society and global scientific director of the Zeaxanthin Trade Association. ZeaVision LLC is the DiVFuSS grant sponsor (ClinicalTrials.gov Identifier: NCT01646047) and manufacturer of the nutritional supplement used in DiVFuSS.
More from Dr. Richer: Lutein and zeaxanthin: Beyond retinal health
1. Chous AP, Richer SP, Gerson JD, et al. The Diabetes Visual Function Supplement Study (DiVFuSS). Br J Ophthalmol. 18 June 2015.
2. Somvanshi PR , Venkatesh KV., A conceptual review on systems biology in health and diseases: from biological networks to modern therapeutics. Syst Synth Biol. 2014 Mar;8(1):99-116.
3. Richer SP, Stiles W, Statkute L, et al. Double-masked placebo-controlled, randomized trial of lutein and antioxidant supplementation for the treatment of age related macular degeneration: the Veterans LAST study (Lutein Antioxidant Supplementation Trial). Optometry. 2004 Apr;75(4):216-30.
4. Richer SP, Stiles WR, Levin MR, et al. Randomized, double-blind, placebo-controlled study of zeaxanthin and visual function in patients with atrophic age-related macular degeneration: the Zeaxanthin and Visual Function Study (ZVF) FDA IND #78, 973. Optometry. 2011 Nov;82(11):687-680.
5. Richer SP, Cho J, Stiles WR, et al. Retinal spectral domain optical coherence tomography in early atrophic age-related macular degeneration (AMD) and a new metric for objective evaluation of the efficacy of ocular nutrition. Nutrients. 2012 Nov 27;4(12):1812-27.
6. Owsley C, Huisingh C, Clark ME, et al. Comparison of Visual Function in Older Eyes in the Earliest Stages of Age-related Macular Degeneration to Those in Normal Macular Health. Curr Eye Res. 2015 Aug 19:1-7.
7. Aleo CL, Murchison AP, Dai Y, et al. Improving eye care follow-up adherence in diabetic patients with ocular abnormalities: the effectiveness of patient contracts in a free, pharmacy-based eye screening. Public Health. 2015 Jul;129(7):996-9.
8. EyePromise. EyePromise DVS. Available at: http://www.eyepromise.com/doctors/products/eyepromise-dvs/. Accessed: 10/16/2015.