OFFICE OF RESEARCH ON
WOMEN'S HEALTH
(ORWH)
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PODCAST 4
EYE DISEASES AND WOMEN
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Recorded July 30, 2007
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DR. VIVIAN W. PINN
Director, ORWH
DR. JANINE SMITH
Deputy
Clinical Director
National
Eye Institute
This transcript produced from audio
downloaded from http://orwh.od.nih.gov/.
P-R-O-C-E-E-D-I-N-G-S
COMMENTATOR: From the National Institutes of Health in
DR. PINN: Welcome to another episode of Pinn Point on
Women's Health. Each month on this
broadcast, we're taking a look at latest developments in the areas of women's
health and medical research that affects our lives.
Today, I'm happy to welcome Dr.
Janine Smith who will talk to us about vision and eye health in women. But
first some hot flashes from the world of women's health research coming up in
just 60 seconds when we continue with Pinn Point on Women's Health.
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DR. PINN: Welcome back to Pinn Point on Women's
Health. As promised, I want to take a
look at some of the hot flashes in the news recently regarding women's health research
and women's health.
Well, let me first start with
something that's very important and that has to do with heart disease in women
and heart attacks in women. I think we are all well aware now that heart disease
is the leading cause of death for women in the United States, but a recent
report from the American Heart Association indicated that many women 55 years
and younger who have heart attacks don't recognize the warning signs.
Now maybe part of this is related to
the fact that probably many of us physicians don't recognize all the warning
signs in women because they may be different.
Women
younger than 55 constitute a very small percentage, however, of those who are
in the hospital with heart disease/heart attacks, only about five percent. But part of the issue is for women as well as
their physicians to recognize what are the symptoms of having a heart attack so
that women can be aware and make sure their physicians or those who see them in
the hospitals are aware and a heart attack is not missed.
This particular report indicated
that women still appear to have typical pain often. Maybe about 90 percent of women in the study
had typical attack symptoms of chest pain.
However, there were other symptoms that women experienced having heart
attacks especially younger women under age 55 like pain in the jaw or shoulder,
sweating, nausea, shortness of breath, indigestion or heart burn which we
typically hear is how women present or just feeling weak or feeling tired.
So with this, if you have any of
these symptoms or have any suspicions that you may be having a heart attack, it
is better to be safe, go to the emergency room, be checked out and if you then
are not having a heart attack, at least you have circumvented the possibility
of having worst effects because your heart attack was not picked up early.
But moving on to another issue,
we've talked about the HPV vaccine and we've talked about ways to prevent
cervical cancer. But, of course, we all know that we cannot eliminate the
importance of women getting pap smears.
There has been a recent report from the Agency for Health Care Research
and Quality that indicates that about one-fourth of uninsured
So don’t forget to get your pap
smears. Make sure that you see your physicians about getting your pap smears.
But moving onto another area, and
while I think this is a hot flash, it's something that's a fairly common flash
related to women and that is gallstone disease.
We know that gallstones are one of the most common problems for women
and women between the ages of 20 and 60 years are three times more likely to
develop gallstones than men.
The
Here are some types to help lower
the risk of gallstones. Have a healthy
body weight. Avoid crash diets or very
low intake of calories. Don't go down to
less than 800 calories a day or you may find yourself having one of those
gallbladder attacks. Exercise regularly
and choose a low-fat, high-fiber diet that emphasizes fresh fruits, vegetables
and whole grains and haven't we heard that before. Almost all of these are just things that we
generally know we should do to protect our health.
If you want more information on
gallstone disease, visit the
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provided at no cost and compensation is provided. For more info, call 866-999-5053 or log on to
clinicaltrials.gov. The National
Institutes of Health is a nonprofit government agency, part of the U.S.
Department of Health and Human Services.
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DR. PINN: Welcome back to Pinn Point on Women's
Health. Our guest today is Dr. Janine
Smith who is Deputy Clinical Director of the National Eye Institute here at the
National Institutes of Health. She is on
the clinical faculty at the Wilmer Eye Institute at Johns Hopkins and is also
on the board of directors of the Sjögren's Syndrome Foundation, Inc. and in a
moment you'll understand why that's important as we talk about vision and
vision impairment in women.
Dr. Smith, thank you for joining us
today and why don't we start with you telling us a little bit about why women
should be focusing on preserving their vision and giving us some beginning
statements relating to women and their eyes.
DR. SMITH: Thank you for inviting me. It's very
important for women to be concerned about their eye health because many
diseases can be prevented. There are
some eye diseases that are inherently more prevalent in women and many people
don't know that. In addition, women tend to live longer than men and so since
many eye diseases are age-related, there are larger numbers of older women with
these age-related eye diseases. And thirdly,
there are aspects about women and care-seeking behavior or access to care that
may result in a higher rate of certain eye disease or access to certain
treatments in women as compared to men.
DR. PINN: Let's just start with getting some basic
facts. As a woman who is young or approaching menopause, what are some of the
eye conditions that I should be more concerned about?
DR. SMITH: The most common causes of visual impairment
are cataract, age-related macular degeneration and glaucoma. While those are
more common in older women, they can occur in younger women, even at the age of
20 to 40. It's very important for women
to have their eyes examined regularly to pick up early signs of these serious
eye diseases.
The second aspect is that many
diseases of the rest of the body can manifest in the eye. For example, diabetes can result in abnormal
blood vessels in the retina which can bleed into the eye, a condition called
diabetic retinopathy. In fact, that may
be the first sign of diabetes. So if a
woman presents to an eye care provider and is picked up with early signs of
diabetic retinopathy, she can then be seen by her primary care provider and
have appropriate testing to evaluate her blood sugar levels. Early treatment of diabetes can result in
less severe organ damage to the eye, the kidney, the brain, the heart and the
rest of the body.
DR. PINN: When you say women should regular eye exams,
how often are you talking about?
DR. SMITH: Women under the age of 40 can have eye exams
every two to three years if they have no underlying risk factors and are not in
a high-risk group. African Americans,
Native Americans and others have higher risks for glaucoma and diabetic
retinopathy and should be seen more frequently.
In addition, women need to know
their family, medical and eye history.
If you have a history of glaucoma in a first degree relative, for
example, you have a seven times increased risk of having glaucoma yourself and
glaucoma is a painless condition. In
glaucoma, the peripheral vision is affected first and often people will not
recognize this until the visual loss progresses to the center of the visual
field. At that point, the vision cannot
be regained. It's, therefore, very important for women and everyone to have
an eye pressure check as part of their eye exam.
DR. PINN: Why don't you explain a little bit about what
glaucoma really means? So many women are
afraid to go get checked and they're concerned that they might have glaucoma or
they might have a cataract. So maybe
this would be a good time to just explain what those are.
DR. SMITH: A cataract is a very common condition and it
is an aging condition. It is not necessarily a disease. The lens inside of the eye focuses light onto
the retina and makes a clear image for us.
As we get older, proteins change their structure in the eye and other
chemical reactions occur in the lens that result in it becoming yellowed or
opaque. That is a cataract. It's not a growth. It's not a tumor. It's not something that is uncommon as we get
older. It's an expected aging change.
Cataracts can be removed surgically
quite easily. While all surgery has risk, cataract surgery is one of the safest
surgeries that can be performed and one of the most common and can result in
significant improvement in quality of life when done appropriately and with
appropriate informed consent.
And contrast to cataract, glaucoma
is a disease. It is not an expected
aging change. It is more common in
African Americans and is, in fact, the leading cause of blindness in African
Americans.
Glaucoma is a condition in which the
optic nerve is damaged. The nerve in the
back of the eye that sends the message that vision is going from the retina to
the brain is damaged due to poor circulation, through abnormal blood vessels,
going to the optic nerve or through elevated eye pressure damaging the optic
nerve.
We're learning more and more through
our research about critical aspects of the pathogenesis of glaucoma so that we
can control that. However, many studies
that have already been performed have demonstrated that early reduction in eye
pressure with eye drops can result in decreased risk of progression to vision
loss in glaucoma. In fact, you can
prevent the vision loss aspect of glaucoma by lowering the eye pressure if you
catch it early in the disease.
DR. PINN: So the message comes back from research and
from just common clinical knowledge that it is important to have those regular
eye exams across the life span of women to protect our vision.
Let me ask you about dry eye. We hear about dry eye. I know that I hear about that from women who
are approaching menopause. I hear about
it from younger women. We hear about it
from more mature women. Tell us. What should we know about dry eye? What does it mean and what may it be associated
it or just what should we know about dry eye and what is research saying about
it?
DR. SMITH: Great question. Dry eye is a very common condition and
somewhat of a misnomer in that there are two major types of dry eye. In the first type of dry eye, the eye does
not make enough volume of tears and the surface of the eye dries out. In the second type, the quality of the tears
is disturbed by disease of the surface of the eye. The tears evaporate from the surface of the
eye and secondarily, dry out the surface.
In the second case, the person may
actually be tearing. So it's somewhat
confusing. But dry eye is an extremely
common condition and can be seen in younger women as well as older women. Age is a primarily risk factor. Hormonal changes that occur around the time
of menopause and in other conditions like premature ovarian insufficiency or
other conditions in which estrogen levels are changing in relationship
specifically to androgen levels, there can be ocular surface dryness and symptoms
of irritation.
The symptoms of dry eye are a sandy
or gritty sensation, feeling like something is in the eye, increase light
sensitivity or just overall irritation and burning and stinging. It's important to note that there are some
diseases in which dry eye is a common feature and for which women are
especially at higher risk.
Sjögren's Syndrome is an example I
would like to share with you. The ratio
of women to men affected by this condition is nine to one and dry eye is one of
the features of this disorder.
DR. PINN: Tell us what Sjögren's Syndrome is. We now know it can affect the eye and we may
have what's referred to as dry eye. But
what is Sjögren's Syndrome?
DR. SMITH: Sjögren's Syndrome is one of the autoimmune
diseases in which the body's immune system directs an immune response against a
part of the self, an abnormal immune response that it should reserve for
microorganisms or infections or other processes. So the white blood cells of the immune system
attack certain parts of the body including the lacrimal gland which produces
tears and the salivary glands which produce saliva.
In addition, there are
autoantibodies produced by the white blood cells that affect the rest of the
body. There are other conditions that
can go along with this dry eye and dry mouth including arthritis, breathing
problems, kidney problems, etc.
DR. PINN: What have we learned about Sjögren's in terms
of treatment, prognosis for women who may have Sjögren's or may be diagnosed
with Sjögren's if they go for a check-up because of their dry eye and they're
told that they might have this diagnosis?
What should women know about this?
DR. SMITH: Before five years ago, there were really no
specific treatments, FDA -approved treatments, for dry eye. That's incredible considering how common this
condition is, dry eye. But because of
basic science research, there is expanded understanding of the pathogenesis of
Sjögren's Syndrome and dry eye in general at the tissue level.
The pathogenesis of dry eye has been
found to consist of inflammation on the surface of the eye. Laboratory research was very important in us
gaining this understanding that inflammatory process is mediated through a
specific type of cells.
As a result of this recognition,
there has been a development of a topical medication called Cyclosporin which
is an immunomodulatory drug and decreases the white blood cells activity and
decreases inflammation of the surface of the eye.
Prior to this understanding,
medications, or shall I say, palliative measures such as lubricating the eye
were only focused upon wetting the eye.
With this understanding from basic science research and clinical trials,
we now have a treatment that is specifically focused on the pathogenesis of the
disease and this has helped Sjögren's patients and other dry eye patients
significantly.
DR. PINN: And that's exciting because I know at the
time that this office was established, we heard from a lot of women with
Sjögren's who had dry eye for which we did not have answers and so called
"wetting the eye" was about all there was. So this shows that research can help us solve
some of the questions that women and their physicians have about their health
and make a difference. So that's
exciting.
But let me roll to another area and
that's one that you've mentioned before, one that I know so many women as they
mature or reach their elderly years begin to be concerned about loss of vision
and that is related to macular degeneration, something else we think about as
being more common in women. What can you
tell us about macular degeneration and what have we learned about macular
degeneration over the past few years?
DR. SMITH: Macular degeneration is an age-related
condition. You may hear it referred to
as AMD. It is leading cause of blindness
in white Americans and is characterized by development of deposits, yellowish
deposits, called drusen in the back of the eye.
They kind of look like yellow polka dots. They are focused in the center part of
retina, the part that subserves your best seeing vision. That's the macula.
As a result of the accumulation of
these yellow products, there's an increased risk for hemorrhage into the eye,
into that area, and for damage to the overlying retina. There are two major forms of AMD, the wet
form in which the hemorrhage occurs and the dry form. Both of them can lead to loss of central
vision.
Because this was such a common
condition and an important cause of vision loss, there have been many studies
including the Age-Related Eye Disease Study funded by the National Eye
Institute and other NIH partners that looked at using zinc and antioxidants to
reduce the risk of AMD. In fact, this
study found that certain formulation of zinc and antioxidants along with other
vitamins was associated with a decreased risk of progression from moderate AMD
to severe AMD. Further, there have been
additional studies in the last few years that have introduced anti-bleeding
agents, so-called anti-VEG-F medications which can be actually injected into
the eye for the bleeding type, for the hemorrhagic type. Those medications can significantly improve
vision. In both of these areas, these
are important advances for women to know so that they don't have to be fearful
that if an early feature of AMD is found there is nothing that can be done
about it.
DR. PINN: I think that needs to be emphasized again
because for so many years as women were getting older and were told they were
developing macular degeneration. They
were also told there was nothing that could be done. So make that last statement again. Make it clear so that women will know that
there may be hope for them in terms of not losing their vision if they have
this diagnosis.
DR. SMITH: It's very important for all women to get
examined for age-related macular degeneration.
The early features of AMD can be recognized and there are now strategies
including specific formulations of zinc and antioxidants that can reduce the
risk of progression to the severe form and there are several treatments now
available for severe AMD. The diagnosis
does not necessarily lead to loss of vision.
DR. PINN: Thank you and I think that's worth
emphasizing and, again, it's always nice when we find from research that we can
offer hope of prevention of progression of diseases or conditions that just a
few years ago we had no hope of doing.
Now I understand from some of your
publications, Dr. Smith, that vision impairment and loss of visions occur more
often in women because women tend to live longer and we see this as a matter of
fact in women around the world. Would
you like to comment on vision issues as they relate to women around the globe?
DR. SMITH: That's a very interesting topic. Women around the world are at higher risk for
vision impairment and blindness than men and, as you mentioned, some of that is
due to women living longer. However,
that relationship holds true in industrialized nations as well. Around the world in other continents, for
example,
Let's use trachoma as an
example. Trachoma is an infectious cause
of blindness that is caused by a microorganism called chlamydia trachomatis and
can result in scarring of the eyelid, scarring of the cornea, the front part of
the eye, and loss of vision.
More women are affected than men
because women are often in closed environments in which trachoma is
transmitted. That is their enclosed
environments where they are carrying for children and cooking. A recently published study, Surgery for
Trachiasis Antibiotics to Prevent Recurrence, the Star Study, looked at a
single dose of an antibiotic called azithromycin given after the surgical
correction of a scarring of the eyelid.
This single dose of medication that is commonly available in the
DR. PINN: You are involved in research yourself, Dr.
Smith, and you're well aware of research that's being conducted at the NIH and
in other parts of the world related to women and eye diseases. What do you think are some of the most
exciting developments that we've not talked about so far?
DR. SMITH: There are many studies as you mentioned
looking at all aspects of women and eye disease. Expanded understanding and techniques
available to detect biologic markers in both the blood and in tissues will
really help us to understand what's going on in a specific organ.
For example, we have had a limited
ability to study samples from the eye because they are very small. With expanded techniques that can look at a
multitude of markers in small samples from tissue and from fluids, we're going
to be able to look at the pathogenesis of diseases in many organ systems right
at the tissue level when it's occurring.
DR. PINN: Are there some eye conditions that we've not
discussed that you think that women should know about?
DR. SMITH: I think it's very important for women to
recognize that they're also at risk for other eye diseases. Thyroid disease is much more common in women
than in men and can be associated with serious eye disease. Optic neuritis, inflammation of the optic
nerve in the back of the eye, which can be associated with multiple sclerosis,
is much more common in women than men.
And a condition called pseudotumorous
cerebri in which increased intercranial pressure, pressure around the brain
and the spine cord, can damage the optic nerve is also more common in women
than in men.
In summary, it's very important for
women to have their eyes examined for all of these conditions. It's also important for women to ensure that
their family members have their eyes examined for these conditions as
well. We know that women make many of
the health care provider choices in our families. Women are the ones who often choose the foods
for the diet we take. Women choose the
recreational activities often for their children and ensure that they wear eye
protection in sports and other activities.
So it's important that women be
recognized for that role and take advantage of that to protect eye health of
their families.
DR. PINN: And I was told at a recent conference on
health that many of the men, younger men, who come into their physician, say
they're there because their wives brought them or sent them. So, yes, we do think it's important to
remember the caregiving roles of women and in a podcast coming soon, we're
going to talk about the effects of caregiving on women and their families
because giving care can also bring stress to the lives of women. But that's not what our topic is about today.
I think we've covered a number of
the top conditions that can affect the vision of women or visual impairment as
I guess is the appropriate way to phrase it and you've touched on a number of
issues related to research and how research is helping us to learn more about
prevention of blindness.
Are there any other issues that you
would like to bring forward that I haven't noted up about to ask you about, Dr.
Smith, that we should make sure women know about related to their eyes and
their eye care?
DR. SMITH: The last point I'd like to make is that
pregnancy can be associated with eye disease.
So if visual changes occur in pregnancy, it's very important for a woman
to report those to her obstetrician.
Often, we don't recognize that things happening in the eye are
reflecting the rest of the body. So we
don't tell our care providers. We wait
to talk to our eye care provider. It's
very important to share that information with the physician and I just wanted
to remind our listeners about that.
The other important points that I'd
like to summarize with is that many diseases that cause vision loss are
preventable and without being examined, there is no way the disease could be
prevented. The first step is to get in
the door to have your eyes examined.
DR. PINN: And the last word I'll ask you about is what
are some areas of research that have not yet given us answers but that we
should stay tuned for that may, in fact, help us learn more about some of these
conditions related to eye diseases in women.
Or maybe let me phrase it differently.
What are some of the remaining major questions related to vision in
women that research is addressing?
DR. SMITH: We know that blood flow is different in women
than in men and, as I mentioned, in glaucoma there is an aspect of compromise
of blood flow in oxygenation to the optic nerve. I think the area of vascular involvement in
many of these diseases has been under recognized.
The second area is the fact that
inflammation is involved in many eye diseases, even in age-related macular
degeneration and large amount of research is being focused upon inflammation as
a pathologic process. Hopefully, the
understanding from many studies can be applied to the eye and can be applied to
women and eye disease.
DR. PINN: Thank you so much, Dr. Smith. Coming up next, a few final thoughts for this
month when Pinn Point on Women's Health continues.
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DR. PINN: And now, a few final thoughts. We've heard today from Dr. Janine Smith who
is an expert based here at the NIH at the National Eye Institute who has talked
to us about some of the advances from research that can help us prevent or
better treat or have better outcomes for women as well as men, actually, who
may suffer from conditions that affect their eyes and that can possibly lead to
blindness. As we've heard, vision loss
meaning blindness occurs more often in women around the world and in this
country partially because women tend to live longer but also because of many of
the conditions like autoimmune diseases that are more apt to affect women than
men.
But the central message from this
discussion today is, for example, looking at macular degeneration, looking at
dry eye, just a few years ago, we did not have much hope. When you went to your physician and asked
about these conditions and got a diagnosis, there was not a lot of hope for
preventing their progression to blindness.
Today, you're hearing that research
is beginning to reveal some of the cures based on better understanding of what
brings about these conditions. But the
important thing is while research and the practice of medicine, be it your
physician, your nurse, whoever your health care provider is, may have better
information. If you don't seek that care
and if you don't pay attention to your own symptoms to bring them to the
attention of your health care provider, you may not benefit from these advances
we're learning. So as we move forward
looking at research on women's health and advances we have to continue to
recognize that we have a dual responsibility, that of those involved in
research to get the answers and those providing health care to make sure
they're aware of the answers and then our own personal responsibility and our
own role of preventing diseases that might affect us and making sure that we
seek attention from the health care community to help us prevent or help us
know better how to protect our own health.
I want to thank Dr. Smith again for
being with us and I want to thank you for listening to Pinn Point on Women's
Health. In a moment, the announcer will
tell you where to send your comments and suggestions for future episodes and at
this point, I should thank many of you who have, in fact, made comments and
sent in questions and raised concerns or given us comments about how we can
improve our podcast.
I'm Dr. Vivian Pinn, Director of the
Office of Research on Women's Health at the National Institutes of Health in
ANNOUNCER: You can e-mail your comments and suggestions
concerning this podcast to Marsha Love, at lovem@od.nih.gov. Pinn Point on Women's Health comes from the
Office of Research on Women's Health and is a production of the NIH Radio News
Service, News Media Branch, Office of Communications and Public Liaison at the
Office of the Director, National Institutes of Health,
(End of tape.)