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What’s Lifestyle Got to Do With Your Eyes?

Todd Lang OD



1. Brief review of ocular anatomy to include macula, retina and optic nerve.

2. Brief review of the pathogenesis of age-related macular degeneration, glaucoma, and retinopathy. Look at the link of cardiovascular diseases contributions to the disease progression in each of the common ocular diseases. 

3. Review current research relating to the importance of lifestyle to ocular and systemic disease management and prevention. Discuss research on the critical piece of personal physician health on the quality of care and outcomes for themselves and their patients. 


Todd Lang OD

Private Practice, Bayside Eye Center in Punta Gorda, Florida



  • October 26, 2018
    4:00 PM
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Rather have been we've come here Lord looking for you looking to understand you more and to to. To learn and to learn how we can can represent you better to be a brighter mirror to the world of who you are and as a lord I pray that we'll learn a little bit more about how to be better doctors. How to share this information with her patients and to have the energy and the clarity of mind to do so we pray in Jesus name on them so. So I'll tell you as she's handing those out. The slides do not follow chronologically I decided to reorganize them but the majority of the slides are in there except 2 in an anatomy slides that you'll see and which will be old hat for most of you. And so. Minute 4 were everybody to have one. Yeah so I. Feel discounted I would suggest the to page through and see where they are if you want to put notes by particular slide or just make notes as you as you go and. Use them together later works for you so but the meat of it's there so the able life of protein E.G. in association and age related macular degeneration the Melbourne collaborative cohort this large study demonstrates that the life of protein he too had a sadistic statistically significant association to A.M.D. and differed by smoking status so what I'm trying to help you see is is the genetics that in my study I believe is directs the cholesterol that we eat. OK And I think you'll understand a little bit more about that in a few more slide when we when we eat saturated fats the saturated fats we find in animal based proteins they have to go somewhere you know I used to think that our body just eliminated them but it's very clear that we don't. And so course the more we eat the more chance there is that some of that stand and we don't know what our genetic makeup is so we don't know for sure where it's going right and so so. Let's keep let's keep going here so here's another another study this was the American Journal of Human Genetics in 1908 so this is been known for a while but but look at this they show that the able polymorphism is significantly associated with the risk of A.M.D. and that the a is it expressed in lesions that characterize a and B. Here's the catch or a decreased risk of M.D. was associated with the e for a little while do you know what the for a little is associated with all Simers OK So so in some people the cholesterol goes to the brain and it's part of the pathogenesis of all Simers OK but if we have the E 2 OK and it doesn't necessarily go to the brain but it goes to the macula is the way that I under when I read this in the study this that's what I think is happening OK so. The reactive protein C. reactive protein in the incidence of macular degeneration 5 perspective case can cause control studies provide further evidence OK So look at this. After matching for age and controlling for smoking individuals with baseline it high sensitive C. reactive protein levels were with more than 3 milligrams per liter had a 50 percent increased risk and twofold risk of new vascular A.M.D. Now I looked this up below one is considered normal one to 3 is considered moderate risk for heart disease and about 3 is high risk OK so personal anecdote my mother had a high C. reactive protein I don't know if my dad told her or she done her own research but she didn't want to have a stroke like her mom so she goes to her doctor and her and her doctor says well you know you need to stop directing the choir at church take a rest at home and so she did what the doctor said it went up after that she decided to go to a plant based diet it went to low normal OK so that's what happened with my mom and we're going to see more studies here today that that support that so take a look at the what's in bold there food as medicine and diet impacts the risk for and progression of age related macular degeneration but we have few clues as to why we found that wild type mice fed a high glycaemic diet this was the 1st time I've ever seen that. Insulin resistance you're going to see here is involved in A.M.D. as well so but it says we found the wild type Fed mice that a high glycaemic diet similar in composition of the Western diet developed a disease state that resembles dry A.M.D. dropping down to the down below changing the diet to a low glycemic diet even late in life or rest of the development of A.M.D. offering a dietary intervention for A.M.D.. So in conclusion our study reinforces the importance of consuming low glycine diets. Edited by a Galv here at Duke University pretty good qualifications there this was last year that they identified this. Protein be in cholesterol containing Dru's and then basal deposits of human eyes with age related macular. So. In this study we learned that. It will be an A and protein finding cholesterol and they will be in the sub R.P. deposits links A.R.M. with important molecules and mechanisms in atherosclerosis initiation and progression so after a sclerosis hardening of the arteries OK so the source of Lipitor and mechanisms of depositions are unknown but analysis of the brooks membrane choroid Lippitt composition have implicated both local cells and plasma so they're collecting locally and there in the blood in the circulation in the vicinity placing a Boby in the principal lesions of area is significant because this is this molecule has a well documented role in disease initiation and progression of cardiovascular disease you know I had had a hunch about this back in 2013 when I really got involved with Chip I went to have lunch with a retina specialist and he kind of went blurry eyed on me I'm not sure if he's even read. This research but I believe that that that lifestyle can have a very positive effect. And here's one study that kind of shows this even back to 2007 exercises in one study was found effectively reduced plasma small dense L.D.L. particles via a lowering of the a protein B. what we just said was found in macular degeneration Well here we go here's a study on on. Exercise at the University of Wisconsin we've all probably heard of the beaver dam study and you know this one it in particular says that it helps women well. I think another study needs be done because I think it's it will work just as well in women I have no idea why the why it just worked for women there but I'm believing that that will find evidence that it works for men too so why did I. Look at this study that has the end of the on one end of feeling is is a potent Baze Oh constrictor that it's primary purpose is to help homeostasis or to prevent bascule or dysregulation most of the disease that we have in wet macular degeneration in diabetic retinopathy or are the ones that we see most commonly but that's really vascular dysregulation right new blood vessels forming in the vicinity of the macula. Are are there and I believe that's why end at the alien in the feelin is found in the higher quantities when wet macular degeneration at present so. Forth we've been talking about and I forgot this was all right. And so. So let's keep going here. So here's the. Normal retina which we all know here's our R R P E in the grooves in deposits so that's where I think there's San Diego be a polite protein be or a. Protein is being identified so course we know that it can be dry or it can be wet and. They believe that inflammation Lippa deposit deposition and eugenic factors of the that's that's active there is is is causing the various problems course we've all seen this on our O C T's if we haven't a C.T. and. Horse of E.M.T. this girl looks a little bit like a rose and I don't know why but. And but fortunately we can see her clearly but of course this is what happens to the vision so this. Moving on to. This is really really important for up cometary understand what's happening with diabetes so you see 22000000 people have been diagnosed in the in the U.S. 8000000 have it but don't know it but this is the one that's scary that means that one out of every 3 adults that come in your office one out of 3 either have. For all or one. That said information OK Now let me tell you this right now one out of every 4 healthcare dollars is on on taking care of diabetes so when the. When the at current research says that somewhere in the ballpark of 70 percent of those will become full diabetic if something doesn't change sometime in the next problem and 15 years that means it will. All of the year just on diabetes when that happens if something doesn't change the lifestyle that. We were talking about that earlier today so so 7th deafness optometrists we can play a huge role in but I think we have to have a different mindset when we take care of our patients I now ask for blood from all of the almost all vices fact that they might have died in the way that I doubt. You know. This really. Is the insulin resistance is a part of the pathogenesis. Shocking shocking to me I you know it's it's. We have a lot of opportunity to make a difference in our patients it's so important I mean God can use all of the physicians in our to nomination right here in our own country yes we need to pray with our patients we do once we make a difference with our patients and then then we have a chance to talk with them we were talking about earlier today about how many times we have to hear something before we act when I did some of the early creational seminars that that. Early on I remember being frustrated that I didn't observe people changing their you know applying the things that I was teaching them. God eventually put it in my heart that really I'm just planting seeds and so. We have to we we have to be planting seeds in our practices and as we're talking about these various. Systemic problems here hypertension hyper limit the metabolic syndrome. I had 4 of those the top 4. In 2009 I was obese. I don't think I had any of the other problems I was pre-diabetic. And so so. All right so here's a diabetic retina when we look at that you know you can see a few haemorrhages here and here it's probably one or 2 of them there but it doesn't look that bad it's fairly close to the macula But you know there's no Erma there's no cotton wool spots. But then we do the auto for us and we see it's actually pretty beat up and so that's the thing that occurs to me as it. In regards to insulin resistance it's kind of like the silent thief of life you know we call glaucoma the silent thief of sight well insulin resistance to me is the silent thief of life because I don't I'm sure that is because physicians don't have the time to talk to their patients about it but I have quite a few that are pre-diabetic and there isn't any discussions going on. In the primary care practice so I'm finding myself having these discussions with with them to to try and take care of that reimbursements are going down you know we have to figure out a way to kick to share this message in a more efficient way. And. In a way that will equip them and part of that is praying with them. So here's here's where the vessels are located as it relates to diabetic retinopathy and and they all pretty much know that as well so systemic cardiovascular diseases like arterial hypertension coronary heart disease or diabetes as well as obesity are all associated with structural vascular changes in the retina so when we look when we look at the retina and you know. We probably all are are are. Documenting what the Ab ratio is. Looking at. The arterials and the dilated bands and. Since I got my opto map I'm really starting to be able to see. Early signs of arteriosclerosis and it gives me an opportunity to have the lifestyle conversation with the patients OK You see you see how how it's darker and thicker here got a white line there it almost disappears right here I believe that's flocking in the in the vessel and if you don't agree with me on that one I think you'll agree with me here. Copper wiring OK. Definitely this is got to be a advance off home a patient and. Of course we have a significant Jarome here and P.V.T. So this is a 50 something white female that I've been seeing for probably 15 years she put on probably 30 or 40 pounds in the last 5 years. And this is one that I'm going to make certain she gets a diabetic work up probably have see how dilated that Vaness she's also looks like she she could be at risk of developing C.R.V. Oh. And depending on which artery you pick her A.V. ratio could be anywhere from one 4th to even though certain things is there it could be a it could be one worker more or lower I mean and so that one that that person is at risk so let's talk about glaucoma. You know one when I was in school the definition for glaucoma was high pressure in the eye causing damage to the optic nerve with the resulting visual feel loss right now it's a multi not high pressure multi factor world disease of the optic nerve with loss of visual field loss right so why is that well it's because we know that we have lots of glaucoma patients that have damage to their nerve in their pressure isn't above normal right course we know about the diarrheal curve and so we wonder about that. To take a look at this. Insulin resistance there it is again is believed to contribute to. The Homa so. In the bowl there that nitric oxide is important in a quiz outflow regulation than has been reported to increase outflow this means insulin resistance may cause elevation in leading to ocular hypertension and this is by the way from the journal Current walk home a practice put out last year. This means insulin resistance may cause elevation in I'll be leading to ocular hypertension and P O A G and insulin based therapy may have a role in play in lowering I'll peek through unhandsome and a quick shower flow and drop to the bottom evidence existed insulin resistance resistance can lead to impaired retinal Daniel and cell function and trigger a pop Whosis and cell that OK so before today did you think that insulin resistance was the cause for retinal gangling Selda No I'd. I didn't know that. So this is a current patient of mine she's a 73 year old white female. She has vision of a 2020 Try vision her her I'll piece were 15 and 18 and she wasn't on in significant. System of meds so I'm treating her for walk home I've got her on the town across. And this was a that I did on her in 2015 and you can see that that that matches this is more abnormal then then the right eye this right side the left side in the left side the right eye in this in this diagram and. What I'm surprised at is that the E.R.D. was did not show more asymmetry. And what was even more surprising was that when we took it in 2017 it looked like it improved now do any of you have in your office OK so you do OK how long you had your 2 years OK So the reason this happened is is. It's very sensitive to the refractive lenses that you used to do the test and a refraction a new refraction was done. Since the 1st one and that's the only only reason that this could have improved but with that said we can still see that the left eye is the one that is abnormal and I want you to look at the visual field so the right eye says that it's outside normal and the left side says it's normal it's got a few more spots there but no clusters and the statistical probability says no progression detected so I find this really interesting that O.C.T.A. looks terrible Right OK but yet we've got reasonably good function with both the G. and the visual field so. 14 months ago I added Transcranial Doppler to my practice and one know what Transcranial Doppler is OK Transcranial Doppler is an ultrasound of course and basically what it's doing is testing the blood vessels around circle of Willis. Including the authentic artery and the studies that that. This company did. I.Q. 80 determined that their study showed that when when there was an abnormal. Well let me back up and tell you how it works the the Doppler essentially is measuring the velocity of the blood passing through the vessels and they've identified what what velocities are in you know on either side of the bell curve etc. And so. They were able in their research developing the technology to determine. What finding could identify patients at risk for glaucoma is progression OK This technology is amazing and it it tests well you can see you can't read it but there's a number of of vessels that are tested that can help us help primary care physicians neurologists to to modify blood thinning that kind of thing and for me it goes back to my philosophy is we know we can reverse heart disease Dr wrestles and Dr Dean Ornish and others have reversed heart disease Well if you can reverse the main blood vessels of the heart the macro vascular system of the heart we it should work for the microvascular system as well and so so I'm anxious to to see research in that regard and so am I going to change my treatment for this patient I'm going to make sure that my pressures are below 15 because she's really but in in this case it's about the circulation the way I see it and I believe that the circulation the poor circulation is what caused the damage and it is scheming damage more than likely it's in the scheme of copy property so am I going to stop treating or No No Am I asking the encouraging these patients to exercise Yes I am so here's the medication that Brad talked about yesterday. That has the. Nitric oxide component to it and. You know in lifestyle medicine we have foods we have foods that produce nitric oxide and I I did see an article that said that that foods wouldn't work well if we get if we get these components the precursors to nitric oxide into the bloodstream if we've consumed it and we know that it actually increases night nitric oxide in the bloodstream then that travels to every part of the body does it not when we actually size we improve the circulation that every part of the body and so and we know that exercise actually produces nitric oxide and so and so. There's still going to be a need for this because not all of our patients will change their diet or or even eat the foods that are recommended a lot of them are not going to exercise and then we know that there's going to be a need for the medication for certain so the effects of physical exercise on ocular physiology this was Journal glaucoma $2016.00 physical exercise increased profusion pressure up to 190 percent from baseline and also increased coreutils what flow a 140 percent majority of patients show a better ocular physiologic function due to sports and sports are thus considered essential or proven preventing ocular diseases so I would plug in exercise there for sports. Several studies have shown that aerobic exercise training improves in that the only old dependent basal dilation in healthy older adults as well as patients with hypertension. So here's the example 12 weeks of moderate aerobic exercise training have been shown to reverse the age related loss in India. Valleys 0 dilator on Sion and previously said Terry men so does anyone know what moderate aerobic exercise how you know that you're getting it well that's that's another way to tell OK One of them is if you if you're able to whistle freely then it's milder Robey got your size. Whistle or saying and so so if you're just beyond that then you're probably moderate the one that I like to share with patients is the talk test it means that if you can talk freely like I am right now then you're probably not exercising to your best level if you have to take a breath every few words or so you have to take another breath then you know you're at moderate aerobic exercise and if you can't speak at all then you know you're vigorous you're at the bigger is level and by the way the harder you exercise the shorter amount of time you have to do it so for those of you who just want to get it over with. There's there are studies that show that So this was a I learned this actually probably 5 years ago. One of our well known speakers shared this from Harry Quigley it Don Hopkins. You can be lowered by exercise that raises the poles just 20 to 25 percent for 20 minutes a minimum of 4 times per week 20 to 25 percent I'm not sure actually is at the moderate level. I know I'm not I'm not. Out of breath at that point so. I want you the next several slides that we're going to go through I want you to remember. Genesis Chapter one Verse 29 and the verses in Daniel one because for me this proves what the Bible says OK these these. Slides coming up here so a look at them based hypo chlorate diet reduces pro-inflammatory status and improves metabolic features in overweight obese subjects the consumption of lagoons 4 servings per week within a hypo chlorate diet resulted in a specific reduction in pro-inflammatory markers such as the C.R.P. allowing people to to lose weight as well European Journal of Nutrition 2011. Here's a nother study. You know oxidative stress and scheming and. What's the other one. All of those are are considered to be part of of what's happening to the body when when we're consuming these saturated fats found primarily in animal based foods and causes the toxicity and. The fat starts to accumulate in the liver fatty liver disease is actually becoming quite quite common and skeletal muscle cells impairing insulin signalling and thus decreasing glucose uptake the saturated fat has been associated with oxidative stress mitochondrial dysfunction and still age insulin resistance and numerous metabolic and epidemiologic studies as well so in addition diets high in saturated fats are associated with a predominantly gram negative life was soccer I had rich Mark microbial pattern which also leads insulin resistance and inflammation. So bottom line a plant based diet has been shown to reduce visceral fat and improve markers of oxidative stress more than a conventional diet and individuals with type 2 diabetes. And that was last year last year so this is more of the same here researchers concluded that a plant based diet and for interventions are effective in lowering plasma cholesterol concentrations this one is just came out just within the last month or 2 and you know the American Heart Association Association has what they say is the ideal diet for heart disease and so they compared that to to. The beginner whole food plant based and so. The vague and diet significantly reduces stomach inflammation as evidenced by the high sense of C. U. C. reactive protein test in patients with cardio core coronary artery artery disease on guideline directed medical therapy while on American Heart Association diet did not so it's miraculous I mean it's proving again and again and again that a whole food plant based is so so here I am 2009 it's about the time I was on that panel with my 1st creation health series and. I'm 201000 pounds I'm obese at a B.M.I. of 33 here's my here's my A one C. and I a triglycerides of 319 so you know I'm a heart attack waiting to happen and. I had to take a nap. Pretty much every day. My wife bought me a nice comfy couch and so I you know I I inherited this ability to from my dad actually I could go up and sleep for 15 or 20 minutes and go back to work and. It was a long time before my staff ever learned about that. And so I wasn't getting much exercise at that time and remember I was rehabbing hamstring abortion and or repair for that so here I am in 2018 I'm out about 170 My B.M.I. is improved my triglycerides are down in the low hundreds and I don't need naps anymore I enjoy exercising I I I enjoy light feeling in my stomach. And. I want you to I want to go back to what I shared with you as to how I got into this with. Starting with reading my Bible I'm convinced that that even though I have known Jesus all my life I've known who he is I know I've had a relationship with him but my relationship with him went to a different level after reading my Bible through and have I had ups and downs since then absolutely but I know that that in order for me to be able to make the right decisions on a daily basis I have to have the relationship with him 1st and the concern that I have for all of my friends baby boomers and and even some of their children who have left the church my concern is this because I've experienced it myself is that when I was not able to conform to. All of the. The things that that were supposed to do a 7th heaven as Christians if I failed at that I felt guilty now that the devil made me feel guilty we know that that that happens right OK But the thing that I with all my heart believe is that we have to understand that it's Jesus that he quits us to make the right decisions and so our 1st fight our 1st fight is to cry out to Jesus to give me the strength to do what it is he wants me to do. And that includes every single choice because every single choice that we make can if we don't make the right one it can confuse us we heard about that earlier you follow me and so and so that's the if I don't if I don't have the relationship 1st then and then nothing none of it none of the rest of it matters it but if I if I have the relationship then all the the rest of it happens automatically because it's who I know that changes the way the who I am and what I do and so so. That's part of what I've learned on my journey within the last few years is as well but I believe that that. Our lifestyle is part of what helps us keep our minds clear now we've learned that exercise is important bride disease now right do we agree on that is there enough science there to to to believe that it's real well there's another psychiatry as I believe is out of Harvard he wrote a book called spark his last name is Roddy R R A T E Y and his his book is basically of about brain health. And he shares a story in there about exercise and the story that I'm remembering is a high school in Chicago a suburb of Chicago I believe it's Naperville are neighbors bill and. They had kids underprivileged kids of weren't doing well in their their test scores were really bad and they put them on an exercise program and their test scores grew 20 percent just from from adding exercise to their curriculum Well we also know that exercise is part of. Stress management and you do some some research. Regular exercise is really important for people who are depressed it's equal to medication equal to counseling if they'll just do it regularly and what happens for me personally is that I know my mind is clear I know that I deal with my stress better and. And I believe that it's part of what we should be doing in order to be our best selves because we you know have any of you all ever done any endurance exercise so you all know about endorphins though have you all ever exercise enough to feel endorphins I don't see too many and nods I see a few It's amazing it's amazing what one God has has put into our bodies that happens when we exercise and if you can if you can do it it will it will do amazing things for you it gives you a sense of wellbeing that you can't get any other way you can. Bad knees swimming would probably be your best swimming laps. Biking it depending on what type of knee problem you have. Jogging Have you tried biking so so accidents with with bikers is and it's about time to wrap this up. With cars is kind of a scary thing. I've not had an accident from a from a car but I had 2 pit bulls run out in front of me and this that happened and I believe they were Damon possessed because that was the 2 weeks before that one of those creation hell seminars. And A So I got to go back to the same surgeon that fixed my hamstring to put my shoulder back together and and but and I thought about selling my bike at that point but. You know what it's too important exercise is too important and so I just try to be more careful. Stationary bike is fine as long as you get that 30 minutes most days of the week of moderate aerobic exercise that the United States prevention services task force says that that is good for 80 percent of the health benefit you'll get from any I mean for even someone who may be rides you know 150 miles a week on the bike and so so. It's that's the way it works so. Brad should I wrap this up for the recording Let's pray. Father in heaven we thank you for the opportunity to share today for the information that you provided and were I just pray for each person here and that you will impress them for what it is that that there are to do more you have a special relationship for each one of us you have a special plans for each one of us Lord help us to to seek you every day and to know and to understand exactly what it is you will have us to do in our practices and and in the circles that we reengage Thank you Lord for this privilege to serve you in Jesus name. This media was brought to you by audio 1st a website dedicated to spreading God's word through free sermon audio and much more if you would like to know more about audio verse if you would like to listen to more sermons lead to visit W W W audio verse or.


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