Smoking is a significant exogenous risk factor for various ocular
conditions, such as age-related macular degeneration, cataracts and diabetic
eye disease. As the patients main source of information about smoking and
eye health, the optometrist is uniquely positioned to deliver a message of
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 patients ocular health, the
primary care optometrist has a unique opportunity to identify and explain the
ocular manifestations of cigarette smoking.
Its 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 its a
|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
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
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
Starting the conversation
As a patients primary eye care provider, optometrists have the
opportunity to drive home this message about smoking and eye health, and to
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.
This 58-year-old patient complained of
reduced vision 5 years earlier. He had a history of smoking one pack per day
for 24 years. Early retinal pigment epithelium changes were evident as well as
thinning on the ocular coherence tomography image. The patient was counseled
regarding smoking cessation therapy and successfully completed the program with
no regression. Nutritional therapy was prescribed without beta carotene.
Retinal findings have been stable, but cataract formation has progressed in the
5 years of follow-up.
Images: Thimons JJ
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, thats 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 eyes resilience and regenerative capabilities.
Theres 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, theres a very good chance you can reverse this and
bring it to a halt. Its 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
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.
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 someones eye and say, How would you like to see like
Dr. Thimons said showing the patient a retinal photograph or other
diagnostic image of their own eyes also has a powerful impact on motivating
We work with a clinic that specializes in smoking cessation,
he said, And Ive 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
I cant show you what your lungs look like and I cant
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
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. Its something you need to do before the patient is in the
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. Ill send the
internist a copy of the retinal photograph on a CD, with a letter, he
said. I say, This is your patients current status, and
Im recommending smoking cessation therapy. Im referring them back
to you for consultation and implementation.
Dr. Thimons said he has found that circumventing a patients
general practitioner is ultimately problematic in the long run.
I find that when you disconnect the internist, it doesnt
work as well. The internist or GP needs to be on board, or the issue could get
lost in the shuffle, he said. Its better to bang the drum
with an equal volume on all levels, so everyones telling the patient the
same thing. by Jennifer Byrne
- 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.
- 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;
- 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;
- 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;