Are Antioxidants Overprescribed in Ophthalmology?

The indiscriminate and over use of antioxidants is something that worries me. Any patient with a retinal lesion of any sort will most of the time come with a prescription for antioxidants/micronutrient supplements of one brand or the other already prescribed by another ophthalmologist, another retina specialist, or even by optometrists. There is clear evidence to show that at least in smokers they may cause potential harm, and some evidence to show that they may induce harm in others, or if not directly harmful may reduce the effectiveness of statins or even increase insulin resistance.

Why then do we indiscriminately prescribe these? Is it because of the pharmaceutical marketing machine, or is it that patients often feel short-changed if they come away from a consultation without a prescription of some 'medicine' What do you think? In a short poll on the Eye Surgeries Worldwide Facebook page, 20 of the 27 ophthalmologists who voted, thought that antioxidants were overprescribed in ophthalmology.

So where do we go from here.

Most dietary recommendations are from the western literature, and are in fact largely based on AREDS and AREDS2 studies done by the National Eye Institute in the USA, where dietary habits are very different from those in other parts of the world. The recommendation is to add foods which provide lutein and zeaxanthin, vitamin C, vitamin E and zinc, to fortify eye health. A typical article in the western literature about the influence of diet on eye health will recommend green leafy vegetables, with kale, spinach, broccoli, collards and turnip greens being highly recommended. Eggs are also a good source.Oranges, grapefruit, tangerines and lemons are high in Vitamin C, together with tomatoes, strawberries, peaches and red peppers. Fish like salmon, tuna, sardines and halibut are recommended as they are rich in omega-3 fatty acids. Nuts, sweet potatoes and fortified cereals contain vitamin E which helps protect cells from free radicals. Legumes such as black-eyed peas, kidney beans, lima beans and peanuts are recommended for their zinc content, which helps the delivery of Vitamin A to the retina, which in turn is needed for melanin production.

Many of these recommended food items are familiar to the Indian palette, whilst some are unfamiliar. Even the large variation of food habits across different parts of India, more green vegetables and legumes are consumed in the average Indian diet, with fish being popular in the coastal states. So maybe the Indian diet already provides these nutrients in adequate quantities? The answer is we really do not know, because it is not only the components of the diet, but also the process of preparation which influences the final availability of these nutrients. For example, how do deep frying foods effect the micro-nutrients which are desirable for eye health?

There is a need to study typical Indian diets to see how much of these desirable nutrients are available, so that evidence based dietary advice which is in keeping with usual food habits can be given to maximise natural availability of needed nutrients for the vast majority of our patients with only a targeted small proportion being asked to take supplements as pills.

This of course applies to a lot of medical research and recommendations based on their basis. Studies conducted in one population do not always translate to other populations, due to genetic, environmental, dietary variations, which also lead to variation in disease patterns themselves. I firmly believe, that at least in the Indian scenario, doctors should only prescribe the ‘mission critical’ medications. Adding a lot of others based on ‘soft evidence’ runs the risk, that the patient is unable to prioritise, the essential from the desirable, and may end up taking the ‘soft’ things prescribed and ignoring the more essential medications. Or maybe we should at least split our prescriptions into ‘essential’ and ‘desirable’ sections, so patients know where priorities lie. I am a minimalist myself, and is rare for me to have more than two or a maximum of three items on a prescription.

The obvious candidates in ophthalmology are the overuse of antioxidants or AREDs type preparation, which as I have pointed out above are not risk free and the indiscriminate use of antibiotics, which encourages the emergence of resistant strains. Remember, whilst all sorts of novel ant-cancer drugs and biologic agents are in the pharmacologic development pipe-stream, new antibiotics are scarcely on the horizon, which makes the emergence of resistance even more worrying. Also, less prescription, means less healthcare costs which can only be a good thing in an economically constrained healthcare environment.

I would strongly suggest restraint in prescribing combined with more robust local studies to delineate the effects of dietary, genetic and disease patter factors, which will help us apply knowledge from studies done in other populations to our population in a sensible manner.

Please let me have your views on this subject, as it is important to understand the motivations and reasons behind prescribing patterns. I am sure everyone has good reasons and beliefs for their own prescription habits, enunciating these will help us all to understand, why these things are done, which would be a first step to start addressing it.

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