Monday, October 22, 2007

Do You Ever Wonder?

Do you ever wonder what goes on between the scientists researching new ideas, or controversial concepts? I thought it might be of interest to readers to share an actual exchange between three of the scientists of a nutraceutical company (Biosyntrx) as they debate the understanding of a condition and the possible role of nutritional supplements in answer to a question frequently heard from patients.

One should not draw the conclusion from this exchange that any one of us has the final answer. But the exchange of ideas is challenging and exciting, and this is what makes it all worthwhile.

The participants in this exchange are Ellen Troyer, Executive Vice President and Chief Research Officer of Biosyntrx, Dr. Jeffrey Anshel, a nationally known optometric educator and member of Biosyntrx Scientific Advisory Board, and Spencer Thornton, M.D., president of Biosyntrx.

The background of this particular exchange is a question frequently asked of eye specialists that was directed to Dr. Anshel recently. “What causes the floaters that interfere with vision?”
To: Dr. Jeffrey Anshel
Date: Friday, 19 Oct 2007 06:25:15 -0700
Subject: RE: Nutritional Supplements
Dear Dr. Anshel:
Many patients have been asking me if nutritional supplements will help with vitreous floaters. Any news about this?
From: Dr. Jeffrey Anshel
Sent: Saturday, October 20, 2007 12:47 AM
To: Ellen Troyer
Subject: Fwd: Re: nutritional supplements

I was going to tell this doctor ”No”, but just thought I'd run it past you
first (can't think of anything new at the moment). Maybe you have some thoughts about it. JA
From: Ellen Troyer
Date: Sat, 20 Oct 2007 08:35:05 -0600
To: "'Dr. Jeffrey Anshel'"
Subject: RE: Re: nutritional supplements

The question is, are vitreous floaters cellular debris? When I had the YAG done to open holes in the film that had grown over the back of my IOLs, I had almost no floaters, which is apparently most always a complaint for a few days post YAG treatment. Kevin Waltz and I wondered if I had almost none because I was taking so many scavenging antioxidants. This is not proven science, so be careful using it as anything other than a possibility. Spencer will surely have some thoughts on this subject. ET
From: "Dr. Jeffrey Anshel"
Date: Sat, 20 Oct 2007 09:26:15 -0700
To: Ellen Troyer
Subject: RE: Re: nutritional supplements

Technically, yes it is cellular debris, but it's embryonic cellular debris, so most of it is there from birth! I don't see how it relates to anything related to YAG capsulectomy.
From: Spencer Thornton
Date: Sat, 20 Oct 2007 23:30:30 -0500
To: Jeffrey Anshel , Ellen Troyer
Subject: Re: Thoughts on floaters

I have to disagree with the statement that “technically, vitreous floaters are embryonic cellular debris”. There is one type of floater that is embryonic in origin, and that is the small protein clumps that are remnants of embryonic structures. These are referred to as “congenital” floaters. These may be seen at any age, and are more common in myopic young people.

The most common cause of floaters in adults is degeneration of the vitreous, which consists of 99% water and 1% solid elements. The solid portion consists of a network of collagen and hyaluronic acid, with the latter retaining water molecules. Other components include salts, sugars, and phagocytes. The phagocytic cells in the vitreous serve to remove unwanted debris.

Though vitreous is 99% water, it has a gel like consistency because of its 1% collagen and hyaluronic acid content. Degeneration of the collagen network causes the hyaluronic acid to release its bound water, thereby liquefying the gel. The collagen then breaks down into fibrils, which ultimately are the floaters that people see. This is the “acquired type”, more commonly seen in older patients, and may vary in size, shape and consistency, appearing as spots, threads or cobwebs.

The collagen fibers of the vitreous are held apart by electrical charges. With aging and free radical accumulation, these charges tend to weaken, and the fibers tend to clump together. Also, the gel may liquefy, leading cells and other organic clusters to float freely within the vitreous humour. Floaters are generally harmless, but sudden onset of recurring floaters may signify a posterior vitreous detachment (PVD) or other diseases of the eye. Floaters may also appear in macular degeneration, cystoid macular edema, and after surgery that disturbs the vitreous.

Normally, there is no treatment indicated. Vitrectomy has been used in treating more severe cases; however, the procedure is typically not warranted in those with lesser symptoms due to the potential for complications. Another treatment is laser vitreolysis. In this procedure a YAG Laser is focused onto the floater and in a quick burst vaporizes the structure. There is no consensus as to how completely effective this is. Because of the degenerative nature of acquired vitreous floaters it would seem reasonable to believe that antioxidant supplements may help reduce or neutralize free radicals present. ST

From: "Dr. Jeffrey Anshel"
Date: Sat, 20 Oct 2007 22:22:25 -0700
To: Spencer Thornton , Ellen Troyer
Subject: Re: Thoughts on floaters

Thanks Spence! I agree with most of what you say but my impression of "acquired" floaters in the HEALTHY eye (important point) is that they are just more visible congenital floaters. The way I explain it to patients is that their existing floaters are suspended in a more substantial gel-like vitreous which softens and liquifies with age. The SAME floaters now become more visible due to their movement.

We agree that most surgical interventions tend to worsen the problem. I've looked at the YAG "treatment" for them and have seen mixed results- some better, most worse (seems that the laser "explodes" the floater to create more little ones).

We can discuss the process of vitreous degeneration and the role of antioxidants- any studies out there?? Would love to see that because this is such a common complaint (from this author as well!!!! ;-)). I'm sure the role of antioxidants has been just scratched at the surface so if we are on to something here, we'll all be happy!!!
From: Spencer Thornton
Date: Sun, 21 Oct 2007 08:15:18 -0500
To: Jeffrey Anshel Ellen Troyer
Subject: Re: Thoughts on floaters
Jeff, Delighted to see your response.
Studies I did years ago on the micro-anatomy of the vitreous, with Jan Worst of Gronegran, Netherlands, showed that floaters in the healthy eye were not just more visible congenital floaters – they were developmental elements from the depolymerization of the hyaluronic acid and syneresis, leading to cells and other organic clusters floating free in the vitreous humor. This occurs in the healthy eye, and more prominently in the unhealthy eye.

On the role of antioxidants, I think Ellen is on to something. It’s hard to pin down some of my colleagues because they want to throw in all sorts of secondary modifying factors.

I have used YAG laser on anterior vitreous floaters with some success, but I think you are right about the creation of more “little” floaters when ablating larger (and more posterior) floaters. ST
From: "Dr. Jeffrey Anshel"
Date: Mon, 22 Oct 2007 08:23:42 -0700
To: Spencer Thornton Ellen Troyer
Subject: Re: Vitreous Floaters
Vitreous floaters come from several sources, including the chemical changes in clear substances like hyaluronic acid (as clear egg albumen can be changed into hard, non-transparent egg white). These chemical changes may be due to UV or infra-red light, or other stress factors that produce free radicals in the vitreous. The bottom line is that inasmuch as we know that antioxidants neutralize free radicals, formulations of broad spectrum multiples, with vitamins, antioxidants, and essential trace minerals may have a beneficial effect on free radicals in the vitreous, helping to reduce the incidence and severity of degenerative floaters.

People ask me why there are so few scientific studies on the genesis of floaters and the effect of nutraceuticals, and I point out to them that scientific studies cost a great deal of money and financial grants are generally made for development and evaluation of pharmaceuticals, not nutraceuticals. Compelling evidence is there however, and we are gradually learning that formulations like Macula Complete do have a free radical quenching effect, potentially benefiting the vitreous as well as the retina.

Jeff Anshel

What will we learn from this debate? The research is ongoing. Stay tuned.


Mrs. Debra Wynn said...

This exchange is amazing.

I learned a lot (no definitions I've read before have explained floaters so clearly), and will be watching for more comments.

Thanks for sharing so candidly.

Ann said...

It’s so neat to see how you toss around ideas and hypotheses about questions that your patients ask! I like to see that doctors are really listening and trying to help!!

Ellen Troyer, MT MA said...

Just a thought!

We know that nutritional stuatus affects optimal bone marrow development of self-renewing immune system stem cells that produce the minute by minute appropriate number of white blood cell phagocytes necessary to gobble up extracellular debris in the entire body, including in the vitreous.

Here's the interesting question: Is there a genetic tendency to develop floaters?

If so, we also know that nutritional status affects the macromolecule nucleic acids, including double helix-deoxyribonucleic (DNA) and protein synthesis ribonucleic (RNA).

These acids signal intracellular genetic instructions responsible for disease susceptibility.

Could these immune system responses possibly include vitreal responses like floaters and retinopathy?

Angie said...

I think every time a patient has a question or concern doctors should discuss the answers like you just did. 3 minds are better than 1.

Unhappy doc said...

The science question being discussed was raised by an optometrist in a private optometric internet forum. It was not in response to a patient question as this blog post is suggesting.

If you want more information about your floaters use google or Wikipedia.

Jeffrey Anshel, OD said...

The question was asked of ME by a doc who has had inquiries from various patients. I asked the doc if it was OK to post this on a blog (with no name attached) and it was OK'd.
If you're recommending patients get their medical information from wikipedia, we better re-evaluate our medical education system. While I'm sure there is much good information contained in Wikipedia, there is also no control as to what can be published. Mis-information can be worse than no information.

If you sign your post as an "unhappy doc", I hope that doesn't rub off on your patients!

Ellen Troyer, MT MA said...

Angie, This is not a new concept.

Most forward thinking eye care professionals are involved in closed internet forums, so they do discuss issues that affect your eye health - and with a lot more than three professionals.

Unhappy Doc said...

Hey Jeff,

Don't make fun of getting medical information off the internet - we all do it since visiting medical libraries is no longer necessary.
Most all peer-reviewed studies are avaible on-line days before journals are mailed.

Savvy motivated patients have access to almost all the information we have access to and wikipedia information is right on the money over 95% of the time in my opinion.

The issue is - sometimes patients misunderstand what they are reading on-line?

suzysoo said...

I urge any doctors reading this to have a look at this forum where you will see the devastating affect severe vitrous floaters are having on people's lives: career, studies, relationships, mental wellbeing and quality of life. It is far from a trivial complaint: