Optometry

Smoking is a significant exogenous risk factor for various ocular conditions, such as age-related macular degeneration, cataracts and diabetic eye disease. As the patient’s main source of information about smoking and eye health, the optometrist is uniquely positioned to deliver a message of intervention.

Over the past 2 decades, aggressive anti-tobacco initiatives have resulted in a significant drop in cigarette smoking in the United States. However, according to a 2010 report from the Centers for Disease Control and Prevention, the rate of decrease has plateaued within the past 5 years.

Ophthalmic findings such as dry AMD, pictured here, can serve as a springboard to a discussion of smoking cessation. Image: Ball WL

As the principal overseer of the patient’s ocular health, the primary care optometrist has a unique opportunity to identify and explain the ocular manifestations of cigarette smoking.

“It’s compelling to be the person to identify the probable connection – and there is a high-probability connection – between smoking and AMD, or smoking and cataracts,” J. James Thimons, OD, of Ophthalmic Consultants of Connecticut and a Primary Care Optometry News Editorial Board member, said in an interview. “I think the bigger issue is, once you identify macular changes in a patient who smokes, how do you begin the process of moving them toward cessation?”

A clear connection

The relationships between cigarette smoking and conditions such as heart disease, stroke and lung cancer have long been established and understood by clinicians and the general public. More recently, the effects of smoking on ocular conditions such as AMD and cataracts have become more widely publicized.

“There have been well-defined, multicenter trials that have been published globally, which establish the link between smoking and cataracts, smoking and AMD,” Dr. Thimons said. “We can all agree it’s a problem.”

A study found that subjects with more than 40 pack years of cigarette smoking had a 2.75 times greater risk of wet AMD, pictured here. Image: Ball WL

Dr. Thimons cited a study that found that subjects with more than 40 pack years of cigarette smoking had a 2.75 times greater risk of wet AMD. Khan et al. also found that stopping smoking appears to reduce the risk of developing AMD.

Dr. Thimons said excessive drinking is also implicated in AMD, a risk exacerbated by the fact that smoking and excessive drinking frequently coexist.

“The alcohol usually causes the diet to be poor, and the cigarettes cause the vascular supply to decrease,” he said.

Smoking is also strongly associated with diabetes and diabetic eye disease, according to W. Lee Ball Jr., OD, FAAO, immediate past chair of the Pharmacy, Podiatry, Optometry and Dental work group for the National Diabetes Education Program.

“Smoking and diabetes absolutely do not mix,” Dr. Ball told PCON in an interview. “Diabetes affects the blood vessels, both large and small, preventing proper blood flow to every part of the body. Nicotine helps raise the level of LDL cholesterol. Over time, this will increase the degree to which the linings of the interior walls of blood vessels become coated with plaque.”

Starting the conversation

As a patient’s primary eye care provider, optometrists have the opportunity to drive home this message about smoking and eye health, and to encourage cessation.

According to a study published in the American Journal of Public Health by Folsom and Grimm, patients who received a brief smoking intervention message from their physicians reported “significantly more attempts to quit and/or cut down” than those whose doctors did not discuss it.

In initiating this conversation, PCON Editorial Board member Jeffrey Anshel, OD, FAAO, advises a frank but nonjudgmental approach. Oftentimes, he said, ophthalmic findings such as dry eye or macular changes can serve as a useful springboard to this discussion.

“Patients can be sensitive about smoking, so you want to be tactful about it,” Dr. Anshel told PCON. “If a patient presents with dry eye or macular degeneration, that’s a great chance to say, ‘You know, one of the main risk factors for this is smoking, so if you smoke, we need to know that, and we need to be able to help you to quit.’”

Dr. Thimons said he often frames discussions about smoking and ocular health in terms of the eye’s resilience and regenerative capabilities.

“There’s good data showing that 10 years out, and certainly at 20 years out, the effects of smoking have been completely eliminated from the behavior of the tissue,” he said. “So when I explain this to patients and, more powerfully, when I show them their macular degeneration, I say, ‘If you quit now, there’s a very good chance you can reverse this and bring it to a halt. It’s your choice.’”

According to Dr. Ball, an optometrist can introduce the topic of smoking cessation to patients before even talking to them.

“I have smoking cessation materials available in the patient waiting area and exam room,” Dr. Ball said. “Posters, pamphlets and tear sheets are available from the American Optometric Association order department (www.aoa.org) and from www.smokefree.gov.”

Dr. Ball said he also uses these resources as part of his discussion with patients on smoking cessation. He begins by asking patients if they smoke and if they want to quit. If the patient answers “yes,” he directs them to call 1-800-Quit-Now or visit the website.

“These tax dollar-supported resources are available to everyone who wishes to use them,” he said. “As primary eye and vision care providers, optometrists are well-positioned to help deliver this important message. It takes less than 30 seconds to have this conversation.”

Visual aids

An even more powerful means of conveying the ocular risks of smoking is through the use of images, both diagnostic and educational. Dr. Anshel said he uses tools that demonstrate eye disease to show a patient how their vision would be compromised by various eye conditions.

“This tool has five or six circles that patients look through, that illustrate what their vision would be like if they had cataract, AMD and various other diseases linked to smoking,” he said. “I hold that in front of someone’s eye and say, ‘How would you like to see like this?’”

Dr. Thimons said showing the patient a retinal photograph or other diagnostic image of their own eyes also has a powerful impact on motivating smoking cessation.

“We work with a clinic that specializes in smoking cessation,” he said, “And I’ve been advised by the clinic that the highest rate of smoking discontinuation is secondary to the referral of a patient who has had a retinal photograph taken and has visualized the damage.”

Dr. Thimons said he shows patients ocular anomalies, such as early drusen, in their photographs and explains the connections to smoking and the consequences.

“I can’t show you what your lungs look like and I can’t show you your kidneys, but I can show you what your eye looks like, and I can tell you that this will produce blindness,” he said. “That has a very profound effect.”

A collaborative effort

Once an optometrist has successfully made the case for smoking cessation and the patient has expressed a desire to quit, it is important to be ready to provide support right away, Dr. Anshel said.

“Smoking is an addiction, and patients are going to be tempted and need support – someone needs to be there to hold their hand and guide them through this process,” he said. “You have to have someone to refer them to. It’s something you need to do before the patient is in the chair.”

Dr. Anshel said he refers patients to a psychologist he has worked with in the past and is comfortable with.

Dr. Thimons said he has worked with a variety of specialists and providers, including the smoking cessation clinic and a pulmonologist. His first step, however, is usually to send the patient back to his or her internist or general practitioner.

“I want to keep that relationship open. I’ll send the internist a copy of the retinal photograph on a CD, with a letter,” he said. “I say, ‘This is your patient’s current status, and I’m recommending smoking cessation therapy. I’m referring them back to you for consultation and implementation.’”

Dr. Thimons said he has found that circumventing a patient’s general practitioner is ultimately problematic in the long run.

“I find that when you disconnect the internist, it doesn’t work as well. The internist or GP needs to be on board, or the issue could get lost in the shuffle,” he said. “It’s better to bang the drum with an equal volume on all levels, so everyone’s telling the patient the same thing.” – by Jennifer Byrne

References:

• Folsom AR, Grimm RH. Stop smoking advice by physicians: A feasible approach? Am J Pub Health. 1987;77(7)849-850.
• Khan JC, Thurlby DA, Shahid H, et al. Smoking and age-related macular degeneration: The number of pack years of cigarette smoking is a major determinant of risk for both geographic atrophy and choroidal neovascularization. Br J Ophthalmol. 2006;90:75-80. doi:10.1136/bjo.2005.073643.

• Jeffrey Anshel, OD, FAAO, is the founder of Corporate Vision Consulting in Encinitas, Calif., and a PCON Editorial Board member. He can be reached at 842 Arden Drive, Encinitas, CA 92024; (760) 944-1200; eyexam@cox.net.
• W. Lee Ball Jr., OD, FAAO, is the immediate past chair of the Pharmacy, Podiatry, Optometry and Dental Work group for the National Diabetes Education Program. He can be reached at 212 N. Main St., Franklinton, NC 27525-1119; (617) 667-3391; fax: (617) 667-7092; wball@bidmc.harvard.edu.
• J. James Thimons, OD, is a PCON Editorial Board member who practices at Ophthalmic Consultants of Connecticut. He can be reached at 75 Kings Highway Cutoff, Fairfield, CT 06430; (203) 366-8000; (203) 330-4958; jthimons@sbcglobal.net.