It is well documented that smoking can double your chances of losing your sight.1 Smoking causes harm to eye tissue and causes age-related macular degeneration (AMD). AMD affects about 500,000 people and is the leading cause of adult blindness. Approximately 54,000 people in the UK have AMD as a direct result of smoking, with 17,800 of these becoming completely blind.2
Smoking is the major modifiable risk factor for AMD in both ‘wet’ and ‘dry’ forms.3,4 Smoking at least doubles or triples the risk of developing AMD, which tends to develop earlier in smokers.5,6,7 Non-smokers living with smokers almost double their risk of developing AMD. Smoking causes oxidative stress and damages the retina, reduces blood flow in eye tissue and promotes ischaemia, hypoxia and micro-infarctions.8,9
Heavy smokers (15 cigarettes/day or more) have up to three times the risk of cataract as non-smokers.12,13,3,14 A review of the evidence revealed that smoking particularly increased the risk of nuclear cataracts.8,3
In Graves’ disease, the thyroid gland becomes overactive, secreting too much thyroid hormone.14 An eye disorder known as thyroid eye disease (TED) is a serious complication. Protrusion of the eyes, double vision and loss of vision, sometimes causing blindness, can occur. There is strong evidence of a causal association between smoking and the development of thyroid eye disease.15,16 People with Graves’ disease who smoke, have a four times higher risk of developing these eye complications compared to non-smokers.17,18
Smoking can make diabetes-related sight problems worse; it can also increase your chance of getting diabetes or indeed make its management more difficult. Complications of diabetes made worse by smoking include retinopathy, heart disease, stroke, vascular disease, kidney disease, nerve damage, foot problems and many others.12
Smoking increases free radicals, which accelerate ageing, and alter the body’s ability to absorb or extract necessary vitamins and minerals from food.19
There is a strong link between smoking and high blood pressure, cataracts and diabetes, all of which are cited in being risk factors for glaucoma.12
Dry eye syndrome is more than twice as likely to affect smokers as non-smokers.12
A smoking cessation scheme
In Brent (where my practice is located), one in five people smoke with the average man living 10.6 years less than the average for the UK. Most early deaths are cardiovascular in nature and the chief contributory factor is smoking. The impact of smoking on the local health economy is huge.
During an eye examination, the optometrists in the practice identify smokers and then offer advice on routes for obtaining smoking cessation advice available in our locality. The referral, if it leads to ‘a quit’, would attract a small fee for the practice.
The optometrists in the practice raise awareness of smoking and its impact (rather than cause alarm) and emphasise advice on quitting is available. The implications and risks must be made clear.
A hand-out detailing the associated risks will be given to the patient for information as well as advice on local help groups and government initiatives available on how to quit. A local telephone help line has been set up, specifically for people wishing to seek help on how to stop.
Once referred to the pharmacy, they will follow a pathway as described in Figure 1.
It is also possible for an optometrist to be trained to carry out the assessments and write a prescription for the patients to get required medications to help them quit smoking. In Brent, we have one optometrist trained to be able to do this.
Brent Clinical Commissioning Group (CCG) found the number of takers for smoking cessation advice was declining so they asked all service providers how it was that such a large proportion of smokers were not being referred. My practice was approached by a local pharmacy to be involved in the scheme primarily because our exposure to our residents was of ‘well’ people who may not necessarily visit the pharmacy or their GP. The aim initially was to refer patients who wished to get advice on smoking cessation to the local pharmacy for a review.
The pharmacist trained all staff at the practice on how to introduce the topic of smoking cessation, provided leaflets and a direct number to book appointments.
Key role for optometrists
We have a duty to offer advice on all eye care to our patients. Often smokers are exposed to information that smoking can kill them, and they will often say they know people who have been smoking for a number of years with no effect. When it is explained that smoking can lead to blindness and visual disability, which will affect a person’s free movement and ability to run a normal life, the message is heard in a different way. Optometrists are uniquely positioned to do this.
Optometrists build a rapport of trust, which is established over the years; also, each time a sight test is carried out a full patient history is taken, thus allowing questions on lifestyle and habits.
Local CCGs will often have targets on numbers of ‘quits’, and the fact that optometrists see ‘well’ patients that may not seen by GPs or pharmacists, is alone a good reason for creating a referral centre. It is best to go in partnership with a provider first, such as a local pharmacy, and (if there is the capacity) there is no reason not to be trained and accredited to offer the service.
References
1 www.rnib.org.uk/eye-health-looking-after-your-eyes/smokimg-and-sight-loss
2 http://newsvote.bbc.co.uk/mpapps/pahetools/print/news.bbc.co.uk/1/hi/health/353346
3 Zhang X1, Kahende J, Fan AZ, et al. Smoking and visual impairment among older adults with age-related eye disease. Prev Chronic Dis, 2011 Jul;84:A84.
4 Wang AL, Lukas TJ, Yuan M, Du N, et al. Changes in retinal pigment epithelium related to cigarette smoke: possible relevance to smoking as a risk factor for age-related macular degeneration. PLOS One, 2009;44:e5304.
5 The Royal College Of Opthalmologists. Age-Related Macular Degeneration. Guidelines for Management. September 2013.
6 Seddon JM. Genetic and environmental underpinnings to age-related ocular diseases. Invest Opthalmol Vis Sci, 2013; Dec 13;5414:ORSF28-30.
7 Chakravarthy U1, Wong TY, Fletcher A, et al. Clinical risk factors for age-related macular degeneration: a systematic review and meta-analysis. BMC Opthalmol, 2010; Dec 13;10:31.
8 US Department of Health and Human Services. How tobacco Smoke Causes Disease: The Biology and Behavioural Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA:US Department of Health and Human Services. Centre for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.
9 Thornton J, Edwards R, Mitchell P, et al. Smoking and age-related macular degeneration : a review of association. Eye Lond, 2005; Sep;199:935-44.
10 Age-related macular degeneration. RNIB 2013.
11 Royal National Institute for the Blind RNIBSave our Sight. no date.
12 https://www.gov.uk/govt/policies/reducing-smoking.
13 Verity DH, Rose GE. Acute thyroid eye disease TED: principles of medical and surgical management. Eye Lond, 2013; Mar;273:308-19.
14 Bedinghaus T. Five eye-opening reasons to stop smoking. April 30, 2013 updated.
15 Phillips ME, Marzban MM, Kathuria SS. Treatment of thyroid eye disease. Curr Treat Options Neurol, 2010; Jan; 12 1:64-9.
16 Thornton J, Kelly SP, Harrison RA, Edwards R. Cigarette smoking and thyroid eye disease: a systematic review. Eye Lond, 2007; Sep;21 9:1135-45
17 Gillespie EF, Smith TJ, Douglas RS. Thyroid eye disease: towards and evidence base for treatment in the 21st century. Cur Neurol Neurosci Rep, 2012; Jun;12 3:318-24.
18 Hegediüs L, Brix TH, Vestergaard P. Relationship between cigarette smoking and Graves’ opthalmopathy. J Endocrinol Invest, 2004; Mar: 273:265-71.
19 www.rbib.org.uk/eye-health-looking-after-your-eyes/smoking-and-sight-loss
? Rakesh Kapoor is an optometrist in practice in Brent