Sir,

The deaf-blind essayst and novelist Helen Keller from Alabama used to quote: in XX century: The only thing worse than being blind is having sight but no vision.

Even aesthetically speaking visually impaired subjects who especially suffer from atrophic bilateral maculopathy (a progressive number of cases increasing day after day, nowaday) experiment a tragic delusion regard safe and regular subjects: the exterior aspect reveals a normal visage that appears fully regular albeit being the vision bleary and confused (because of the mono or bilateral grey or black spots), the stride results angular, amphibolic and drifting, and even a common external observer can state that there is something wrong and abnormal, the final result is irksome and odd and the person who suffers from this rare disease feels as an ishmael.

We will try to face the concern from the aesthetic and psychological point of view and have to recognize that there should be only a surgical remedy that is the employ of stem cells, even if results are debatable.

As far as sub thresold laser rays it is better to let bygones be bygones.

The surgical approach rebounds exclusively in the province of the aesthetic surgery: results belong to a cosmeticological synopsis.

Eminent medical staff from Xcell Center GmbH “Public Hospital Eduardus Krankenhaus in Cologne (Germany), has performed early as 2008 the first stem cells transplants in the world on the eyes of his patients, obtaining excellent clinical and functional results.

In fact, the surgeons have been the first ophthalmologists to perform an inoculation of autologous stem cells in Germany. As a result of this experience and experimentation, he has developed a new methodology that is able to stimulate the stem cells already present in the body and to reactivate them with a specific natural medicines combination howbeit it must be asserted that these clinical issues may be never applied on a vaste scale, throughout the entire globe.

Even if this methodology allows to obtain similar results than those obtained with the collection and grafting of autologous stem cells, this treatment is eligible to the following eye diseases.

Keratoconus; Macular degeneration; Retinitis pigmentosa; Stargardt’s disease; Macular edema; Floaters; Vitritis; Uveitis; Progressive optic nerve atrophy; Trauma to the optic nerve; Corneal leucomas; Glaucoma; Cataract; Dry eye syndrome; Blefarocalasi; Strabismus; Progressive and high myopia; Presbyopia; Diabetic retinopathy.

Diseases of the cornea: recurrent or permanent ulcers, corneal dystrophies, corneal Haze.

Endothelial dystrophy of the cornea.

And finally; Rejuvenation; Beauty treatments.

Now, therefore, Age-related macular degeneration (Age related Macular Degeneration, AMD atrophic type or more commonly called atrophic maculopathy is a serious eye disease that affects the macula, that is the portion of the retina richest in photoreceptors and responsible for central vision fine and detailed that allows to recognize a face, read, perform precision work, drive the car etc.

We want to assert that the person who suffers from this disease is to be reputed a 100% handicapped subject.

Usually the waste material that forms drusen is phagocytosed and digested by the RPE cells, but as we age and cellular activities slow down, this material is no longer properly eliminated and settles under the RPE.

The drusen, while small and present in limited numbers, do not in themselves cause any damage to the structure or functionality of the retina and the visual impairment may be absent or so mild that it is not perceived. The increase in the number and size of drusen can instead cause a significant deterioration of vision, especially when the drusen begin to flow towards the central area of the retina, giving rise to larger clusters called confluent drusen.

The confluent drusen cause a progressive alteration of the structure of the central retina, up to determining gods drusenoid detachments, i.e. the separation of the retinal pigment epithelium from the sensorineural retina; in such circumstances, the RPE cells – essential for photoreceptor viability – undergo atrophy and cause the progressive death of the cones and rods present in the macula, thus leading to the terminal stage of atrophic AMD, also known as geographical atrophy (geographic Atrophy, GA) and characterized by a high degree of structural disorganization of the macula.People with atrophic AMD in initial phase they usually have no symptoms; in intermediate stage on the other hand, they can report a blurred vision, altered color perception, distorted or wavy vision, difficulty in visual adaptation in the transition from a bright environment to a less illuminated environment, intolerance to very strong sunlight.

In the terminal stage geographical atrophy leads to the loss of central vision, which manifests itself with the appearance of a central scotoma, a dark or missing area in the center of vision, which prevents reading and sometimes the ability to recognize faces. The damage is all the more serious the greater the retinal area involved in the structural alteration.

The times from the initial phase of atrophic AMD to its terminal phase are sufficiently predictable and can vary greatly from patient to patient.

Several risk factors for AMD have been recognized, the most important being the old age, familiarity, smoke, excessive exposure to sources of UV rays without eye protection, the unbalanced diet (too rich in animal fats and low in vegetables and antioxidants), the lack of exercise,hypercholesterolemia,hypertension not controlled, etc.

Given the danger of AMD, it is very important to keep in mind the risk factors for this pathology and try to adopt a lifestyle as healthy and careful as possible from an early age, allowing to prevent or at least delay its onset.

A major clinical study called AREDS2 has shown that taking high doses of certain dietary supplements (Vitamin C, Vitamin E, lutein, zeaxanthin, zinc e copper and ω3) is effective in reducing noticeably the risk of evolution of ARMD towards the most advanced form of the disease, that is the geographic atrophy or the exudative form. Patients diagnosed with atrophic ARMD should take these supplements as prescribed by their eye doctor.

It is good to remember that taking these food supplements reduces the risk of progression of atrophic ARMD.

The patient usually in the initial stages of the disease has no symptoms and for this reason it is very important to undergo eye examinations periodically, especially in the case of familiarity with the disease and in these cases it is also useful to undergo a predictive genetic test. In the more advanced stages of the disease, the patient reports more precise symptoms, a blurred vision in the central area, with a normally preserved peripheral vision and sometimes the presence of a blind spot that progresses and becomes larger and larger over time. Precisely in these medium-advanced stages of atrophic AMD, the presence of confluent drusen can give rise to localized phenomena of inflammation, which can trigger the transformation from atrophic AMD to Neovascular AMD, a much more aggressive and dangerous form than the atrophic one, which has a slow progression.

For this reason, it is important that patients with atrophic AMD undergo regular clinical and instrumental monitoring through diagnostic tests such as optical coherence tomography (OCT) high resolution to be able to analyze every single retinal layer and therefore every micrometric change, the fluorescence angiography (FAG) and the indocyanine green angiography (ICGA) to analyze the anatomy and integrity of blood vessels and identify any abnormalities. A careful and scrupulous monitoring of the retina, in fact, can prevent the onset of the exudative form leading in a very short time to the loss of central vision, helping the patient to preserve vision for as long as possible.

Until recently, patients with atrophic maculopathy could only be recommended an improvement in lifestyle, wearing protective ultraviolet (UV) eyewear,but right now, tanks to the AREDS2 studies taking dietary supplements, scientific evidences do exist which they proved to be effective in slowing the evolution of the disease.

We focuse their attention to the most important molecule of this combinaison idest the zeaxanthin:

Zeaxanthin is one of the most common carotenoids in nature, and is used in the xanthophyll cycle. Synthesized in plants and some micro-organisms, it is the pigment that gives paprika (made from bell peppers), corn, saffron, goji (wolfberries), and many other plants and microbes their characteristic color [1,2].

The name is derived from Zea mays (common yellow maize corn, in which zeaxanthin provides the primary yellow pigment), plus xanthos, the Greek word for “yellow” (see xanthophyll).

Xanthophylls such as zeaxanthin are found in highest quantity in the leaves of most green plants, where they act to modulate light energy and perhaps serve as a non-photochemical quenching agent to deal with triplet chlorophyll (an excited form of chlorophyll) which is overproduced at high light levels during photosynthesis [3]. Zeaxanthin in guard cells acts as a blue light photoreceptor which mediates the stomatal opening [4].

Animals derive zeaxanthin from a plant diet [2]. Zeaxanthin is one of the two primary xanthophyll carotenoids contained within the retina of the eye. Zeaxanthin supplements are typically taken on the supposition of supporting eye health. Although there are no reported side effects from taking zeaxanthin supplements, the actual health effects of zeaxanthin and lutein are not proven [5], and, as of 2018, there is no regulatory approval in the European Union or the United States for health claims about products that contain zeaxanthin.

As a food additive, zeaxanthin is a food dye with E number E161h.

Several observational studies have provided preliminary evidence for high dietary intake of foods including lutein and zeaxanthin with lower incidence of age-related macular degeneration (AMD), most notably the Age-Related Eye Disease Study (AREDS2) [6]. Because foods high in one of these carotenoids tend to be high in the other, research does not separate effects of one from the other [7].

Three subsequent meta-analyses of dietary lutein and zeaxanthin concluded that these carotenoids lower the risk of progression from early stage AMD to late stage AMD [8].

Since the stalemate phase of the concern, the unique, the sole, the only one way to try to counteract the progressive development and the worsening of the rare syndrome of the atrophic bilateral maculopathy is not but the combinaison of the microelements (vitamines and minerals and carotenoids and ω3), that is apt to slow the aggravation of the disease for longtime and for the future!!

Finally a light at the end of the tunnel for the unfortunate subjects that cannot enjoy the blessing of light and vision and sight.

REFERENCES

1. Encyclopedia.com. “Carotenoids“. Retrieved 6 May 2012.

2. “Lutein +Zeaxanthin Content of Selected Foods. Linus Pauling Institute, Oregon State University, Corvallis. 2014. Retrieved 20 May 2014.

3. Bassi R, Dall’Osto L. Dissipation of light energy absorbed in excess:the molecular mechanisms. Ann Rev Plant Biol. 2021;72:47–76.

4. Kochhar SL, Kaur GS. Transpiration“. Plant Physiology:Theory and Applications (2 ed.). Cambridge University Press. 2020. pp. 75–99.

5. Koo E, Neuringer M, Sangiovanni JP. Macular xanthophylls, lipoprotein-related genes, and age-related macular degeneration. Am J Clin Nut. 2014;100(Supplement 1):336S–346S.

6. Krishnadev N, Meleth AD, Chew EY. Nutritional supplements for age-related macular degeneration. Curr Opinion Ophthalmol. 2010;21:184–9.

7. Wang X, Jiang C, Zhang Y, Gong Y, Chen X, Zhang M. Role of lutein supplementation in the management of age-related macular degeneration:meta-analysis of randomized controlled trials. Ophthalmic Res. 2014;52:198-205.

8. Evans JR, Lawrenson JG. Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration. Cochrane Database Syst Rev. 2023;9:CD000254.