Eyeworld

28 October 2018 EW NEWS & OPINION by Vanessa Caceres EyeWorld Contributing Writer Similarly, Dr. Lauer will discuss smoking when he sees patients with age-related macular degeneration (AMD) or diabetic eye disease who also smoke. Smokers can have more severe diabetic retinopathy, more severe and prolonged thyroid eye disease complications, and possibly in- creased progression of optic nerve deterioration with open angle glau- coma, Dr. Mendelsohn said. All of this correlates with Dr. El- Hasan's point that ophthalmologists may play a larger role in the smok- ing discussion than they assume. Dr. Mendelsohn is passionate about discussing smoking with pa- tients and said that he and his staff bring it up with all patients, from the early teen years up. "My staff and I think that about 50% of our smokers eventually stop smoking due to consistent reminders about the health-related dangers," he said. He also has observed that almost all of the smoking patients do not know about the ocular risks. "The ocular side effects seem to be what makes them stop. This new piece of information seems to be a game changer," he said. Here's yet another reason to discuss smoking: "Ophthalmologists should talk about smoking not just because smoking affects the eye and visual system, but because we are caring physicians first, before we are eye doctors," said Benjamin Ticho, MD, associate professor, University of Illinois Eye & Ear Infirmary, The Eye Specialists Center, Chicago. "Smokers who'd like to be healthier need encouragement and consid- eration, not condemnation and criticism." Quitting When patients say that they want to quit, there are several recommen- dations that ophthalmologists can make. A first move is to refer them back to the primary care provider for additional help, said Dr. Scott, who will also send a letter to that provider. "If they don't wish to quit, I say that they are adults and it's their choice, but it's my responsibil- ity to tell them the associated risks," she said. Dr. El-Hasan said the American Lung Association's Freedom From Eye physicians can have a crucial role in the battle against tobacco use E veryone has heard the mes- sage that smoking is bad for them, but that message doesn't necessarily stop everyone from quitting. Although you may assume that primary care providers are warning patients about tobacco dangers, ophthalmologists can play a crucial role in spreading the message about smoking's health effects, said Afif El-Hasan, MD, volunteer spokes- person, American Lung Association, and pediatrician, Kaiser Permanente, San Juan Capistrano, California. In fact, he thinks that warnings from eye doctors may be even more effective because of the simple but powerful message that smoking can cause someone to lose vision. "It's wonderful to have a frank discussion about this with patients," Dr. El-Hasan said. Who's still smoking? The percentage of U.S. adults who smoke has declined by more than 50% since 1964, which is when the U.S. Surgeon General first warned of tobacco's health dangers, according to the National Cancer Institute's Cancer Trends Progress Report. However, the decline in smoking has slowed since 1991. Ophthalmologists have a gen- eral sense that patients are smoking less, although it is also dependent on geographic location. Plus, there are new potential dangers to con- sider. "My impression is that fewer people smoke, but the younger generation is vaping," said Andrew Anderson, MD, Eye Physicians of Washington, Washington, D.C., and board member, Prevention of Blindness Society of Metropolitan Washington. Alan Mendelsohn, MD, Eye Surgeons & Consultants, Hollywood, Florida, has a unique perspective based on where he practices. "South Florida has a larger number of smokers per 1,000 inhabitants than the national average because there is a noticeable increased prevalence of smokers among those who have immigrated from Central America, South America, Cuba, and Puer- to Rico and now reside in South Florida. This is a consistent topic in my office with any patient, from teenagers up," he said. The growing prevalence of marijuana smoking also comes up in these conversations, said Andreas Lauer, MD, professor of ophthal- mology, Oregon Health & Science University, Portland, although that's a topic worthy of its own debate. Broaching the topic With smoking still an issue for about 16% of the U.S. population, and more in some states, how can ophthalmologists broach the topic of smoking's ill effects? You could use the electronic medical record (EMR) as a starting point. "It's required to ask about smoking history and is an automatic question in our EMR system," said Maria Scott, MD, medical director, Chesapeake Eye Care and Laser Cen- ter, and LASIK surgeon, TLC Laser Eye Centers, Annapolis, Maryland. "That gives us a good opportunity to talk about the detriments of smok- ing." Another approach is to bring it up when treating problems that could be smoking-related. "As a cor- neal specialist, I see many patients coming in for treatment of dry eye and cataracts," said Ravi Patel, MD, Eye Associates of Central Texas, Round Rock. "These are easy tran- sition points to raise the topic with the patient. When patients come in frustrated with their vision or the discomfort from their dry eyes, it's a great time to explain how smoking accelerates vision loss from cataracts and limits my ability to improve their dry eyes," Dr. Patel said. Many patients may have heard about smoking's association with cancer and cardiovascular disease but not cataracts, AMD, and dry eye, Dr. Patel said. Dr. Patel finds it powerful to show patients a photo of their retina, cataract, or ocular surface to help them fully understand smoking damage. How should ophthalmologists address smoking risks with patients? Smoking related dry eyes A patient with visually significant cataract Source (all): Ravi Patel, MD continued on page 30

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