BMC Ophthalmology
Research article
TOZAL Study: An open case control study of an oral antioxidant
and omega-3 supplement for dry AMD
Francis E Cangemi*
Address: Vitreo-Retinal Associates of New Jersey, 119 Prospect Street, Ridgewood, New Jersey 07450 USA Email: Francis E Cangemi* - [email protected] Received: 6 November 2006Accepted: 26 February 2007 BMC Ophthalmology 2007, 7:3
2007 Cangemi; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: The primary objective of this prospective study was to measure the change from
baseline in visual function – Best-Corrected Visual Acuity (BCVA) via the Early Treatment Diabetic
Retinopathy Study (ETDRS) chart, contrast sensitivity, central 10 degree visual fields and retinal
imaging (angiograms and photographs) at 6 months in subjects with atrophic (dry) age-related
macular degeneration treated with a targeted nutritional supplement.
Methods: 37 mixed gender patients with a mean age of 76.3 +/- 7.8 years were enrolled at 5
independent study sites and received standard of care with a novel formulation of a nutritional
supplement. Results were compared to a placebo cohort constructed from the literature that was
matched for inclusion and exclusion criteria. A paired t-test was used to test a null hypothesis and
a two-sided alpha level of 0.05 was used to determine statistical significance.
Results: 76.7% of subjects receiving the nutritional supplement demonstrated stabilization or
improvement of BCVA at 6 months. Subjects gained an average of 0.0541 logMAR or one-half of a
line of visual acuity (VA) over the 6-month period. There was a statistically significant improvement
in VA from baseline with P = .045. The results provide strong evidence that the treatment being
studied produces an improvement in VA.
Conclusion: Treatment with this unique nutritional supplement increased VA above the expected
baseline decrease in the majority of patients in this population with dry macular degeneration. The
results of the TOZAL study agree with the LAST and CARMIS studies and are predictive for
positive visual acuity outcomes in the AREDS II trial. However, patients will likely require
supplementation for longer than 6 months to effect changes in additional visual parameters.
atrophic, or non-exudative, AMD is the most common Age-related Macular Degeneration (AMD) is a progressive form and is characterized by progressive devitalization of disorder associated with central vision loss and is the lead- retinal pigment epithelium (RPE) and the formation of ing cause of visual impairment and blindness in people fatty deposits under the RPE known as soft drusen [1].
over the age of 60. More than 15 million Americans over Although the underlying cause of AMD is unknown, risk the age of 60 have AMD with an additional 50 million factors have been defined and include age greater than 50, Americans at risk for developing the disorder [1]. Dry, Caucasian race, nutrition, smoking, atherosclerotic vascu- (page number not for citation purposes) BMC Ophthalmology 2007, 7:3
http://www.biomedcentral.com/1471-2415/7/3 lar disease, genetics, and sunlight exposure [1-4]. At this The microcurrent in this study was self-administered by time, there is no known cure for AMD. Patients not receiv- the patient, 2 treatments each day, using an automated ing treatment have demonstrated a loss of VA at 6 months microcurrent stimulator with a preset current of 800 of at least 0.8 lines and up to 1.5 lines [5-7].
micro-amps at frequency settings of 292 Hz (6 minutes),30 Hz (3 minutes), 9.1 Hz (2 minutes), and 0.3 Hz (1 Multiple studies have suggested that manipulation of minute) for a total of 12 minutes. The sham device was nutritional factors can play a significant role in slowing identical to the treatment device, including LED indica- the onset or limiting the effects of AMD [8-13]. In 1996, tors and audible tones; however, there was no electrical Richer et al found that a broad-spectrum antioxidant and current output. Electrical current administered at levels mineral supplement was effective in delaying AMD- below 1 milliamp (1,000 micro-amps) has no detectable related vision loss, but was unable to reverse existing vision loss [14,15]. The Age-Related Eye Disease Study(AREDS), sponsored by the National Eye Institute, dem- MCS treatment was found to have little significant effect onstrated that high levels of antioxidants and zinc were on any of the efficacy endpoints and thus was abandoned.
able to reduced the risk of development of advanced AMD Only the nutritional supplement aspect of the study is by approximately 25% [16]. In 2004, the Lutein Antioxi- reported and discussed here (ie, patients receiving sham dant Supplementation Trial (LAST) demonstrated that MCS and nutritional supplement, n = 37).
nutritional supplementation with lutein or lutein togetherwith antioxidants, vitamins, and minerals improved vis- Each subject was scheduled for 5 visits (Figure 1). During ual function and symptoms in patients with atrophic age- the first visit, subjects who met the inclusion and exclu- sion criteria (Table 1) and signed a consent to participateunderwent a comprehensive eye examination including Nutritional supplements have become the first line of medical and ophthalmic history, refraction, BCVA meas- defense for clinicians in battling dry AMD. Vitamin and ured by ETDRS (logMAR) at 4 m, biomicroscopy, intraoc- mineral formulations are a valid therapeutic tool and are ular lens evaluation, intraocular pressure, dilated fundus many orders of magnitude less toxic than aspirin and exam, fluorescein angiogram and retinal photographs, contrast sensitivity, full threshold visual fields, and macu-lar testing (central 10° threshold visual filed). Addition- The Taurine, Omega-3 Fatty Acids, Zinc, Antioxidant, ally, each subject completed the Visual Function Lutein (TOZAL) study sought to identify the potential benefits of a novel supplement designed to limit the riskof AMD and progressive vision loss while also reducing or During the second visit at week 1, BCVA (logMAR) and eliminating the risk of adverse events.
contrast sensitivity were measured and the nutritionalsupplement was dispensed. The TOZAL nutritional sup- plement formulation used in this study is outlined in This study was approved by an independent ethics com- Table 2. This is a novel supplement formulation and is mittee and an independent review board and was con- currently patent pending. Subjects were instructed to self- ducted at five independent clinical sites. The study was administer the oral supplements at 2 capsules 3 times per day concurrent with food intake. Treatment compliancewas assessed at each subsequent visit via a daily patient Study Design
This prospective, double-blind, 6-month trial enrolled 73subjects with at least 1 eye diagnosed with dry AMD. There During the third visit at week 2, BCVA (logMAR) and con- were 5 independent study sites: site 1 enrolled 19 patients, site 2 enrolled 15 patients, site 3 enrolled 13 patients, site4 enrolled 12 patients, and site 5 enrolled 14 patients.
During the fourth visit at week 11, BCVA (logMAR) and Patients were randomly assigned 1 of 2 treatment arms: 1) contrast sensitivity were measured. In addition, retinal microcurrent stimulation (MCS) treatment and nutri- photographs, fluorescein angiogram, macular testing, and tional supplement (n = 36), and 2) sham MCS and nutri- full threshold visual fields were conducted.
The final and exit visit was at week 24 and was a repeat of In 1998, Allen et al reported that patients with dry AMD the first visit in addition to a compliance assessment.
treated with a combination of nutrients and microcurrentelectricity showed slowing or reversing of the progress ofAMD for most subjects [18].
(page number not for citation purposes) BMC Ophthalmology 2007, 7:3
http://www.biomedcentral.com/1471-2415/7/3 Figure 1 gn
Study design.
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http://www.biomedcentral.com/1471-2415/7/3 Table 1: Inclusion and exclusion criteria
Inclusion Criteria• Signed written consent• Between the ages of 50 and 90, inclusive• Any race or gender• Diagnosis of nonexudative (dry) AMD in at least 1 eye having > 10 large soft drusen 63 μm in diameter, within 3,000 um of the fovea center, documented on macular exam, retinal angiography and fundus photographs• Able to understand and comply with the requirements of the trial• BCVA in the trial eye(s) of 20/32 to 20/125 inclusive as measured by ETDRS (logMAR)• Subjects must not have conditions that limit the view to the fundus (eg vitreous hemorrhage, cataracts, an epiretinal membrane). All subjects with = 2+ nuclear opacities and/or significant central opacity (PSC or ASC) > 1+ will undergo Potential Acuity Meter (PAM) testing. If the vision is = 2 lines improved on PAM over standard acuity measurement then the subject will not be eligible for the trial• Subjects must be available for a minimum trial duration of approximately 6 months• Subjects must agree to take only the nutritional supplement that is provided during this study• Subjects or eyes must not meet any of the exclusion criteriaExclusion CriteriaAny of the following excluded a subject from the trial:• Currently enrolled in an ophthalmic clinical trial• Eyes with concomitant macular or choroidal disorders other than AMD and with indefinite signs of AMD• Eyes with a diagnosis of exudative (wet) AMD with active subretinal neovascularization (SRNV) or CNV lesions requiring laser photocoagulation in the study eye• Subjects with significant ocular lens opacities causing vision decrease• Subjects with amblyopia• Subjects with optic nerve disease (neuropathy, atrophy, papilledema), unstable glaucoma as defined by intraocular pressures greater than 25 mm Hg, 3 or more glaucoma medications, C/D of 0.8 or greater and visual fields consistent with glaucoma; history of retina-vitreous surgery, degenerative myopia, active posterior intraocular inflammatory disease, chronic use of topical ocular steroid medications, vasoproliferative retinopathies (other than AMD), rhegmatogenous retinal detachment, and inherited macular dystrophies• Subjects with demand type pacemakers or epilepsy• Subjects with uncontrolled hypertension (defined as diastolic of 90 or greater and systolic of 150 or greater)• Subjects with recent history (within the previous year) of cerebral vascular disease• manifested with transient ischemic attacks (TIA's) or cerebral vascular accidents (CVA's)• Subjects with a history of AIDS• Subjects who have received any previous experimental procedure in either eye or the use of any investigational drug or treatment within 30 days prior to enrolling in the trial• Subjects who have had intraocular surgery in trial eye within 3 months prior to enrolling in the trial• Smokers or any tobacco use Objective Measures
The primary safety variables were unexpected ocular or The primary objective was to measure the change in BCVA systemic findings, adverse event rate, and temporary and from baseline to 6 months in subjects with non-exudative permanent discontinuation. Investigators were required macular degeneration treated with a nutritional supple- to report any treatment-related adverse events or serious ment. The secondary efficacy variable was objective signs non-treatment-related adverse events and severe adverse Table 2: Nutritional supplement formulation
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http://www.biomedcentral.com/1471-2415/7/3 Adverse events included any undesirable clinical occur- measured as visit 2 (week 1). Change from baseline was rence in a subject whether considered related to treatment evaluated at weeks 11 and 24. Repeated measures mixed or not. Serious adverse events included those in which model (Proc Mixed, SAS, 8.2) was fitted to compare mean information suggested that treatment caused or may have change in VA from baseline between the groups, with Visit caused or contributed to death or serious injury including, and Treatment-by-Visit interaction included as main but not limited to, permanent decrease in BCVA (≥ 2 effects, baseline VA as covariate, and Eye as the within- lines) or hospitalization. Significant adverse events included those that required medical intervention or war-ranted discontinuation (temporary or permanent) from A secondary analysis set was also constructed, comprised the clinical trial. These events were non-sight-threatening of 1 eye per patient meeting the 20/32–20/125 entrance conditions that were determined to be device-related.
VA criteria. If both the left and the right eye met the crite- Non-significant adverse events were events that did not ria, the "best" eye was used.
warrant discontinuation from the clinical trial.
The safety analysis set consisted of all randomized sub- Subjects could discontinue or withdraw from the trial for jects who received at least 1 dose of treatment. Incidence any reason. Investigators could discontinue a subject if, in of unexpected ocular or systemic findings, adverse events, his/her opinion, it was in the best interest of the patient, and temporary/permanent discontinuation were tabu- if there was non-compliance with study visits, if there was lated and evaluated using Fisher's exact test. All tests were more that 25% non-compliance with self-administration of treatment, or if there was protocol deviation.
Placebo Arm
Demographics and Baseline Characteristics
The IRB for this study determined that standard of care for Demographics and baseline characteristics of the 37 age-related macular degeneration must include an Age- patients receiving the nutritional supplement are outlined Related Eye Disease Study (AREDS)-type nutritional sup- in Table 3. Subjects enrolled in the TOZAL study were plement and that no true placebo arm would be permissi- matched for inclusion and exclusion criteria with the ble. A placebo arm was constructed from a review of the MIRA-1 study. Subjects in both cohorts were similar literature. The exclusion and inclusion criteria used for the across age, gender, ethnicity, and mean baseline BCVA [7].
Multicenter Investigation of Rheopheresis for AMD(MIRA-1) trial were followed for the TOZAL study. Patient Visual Acuity Outcomes
demographics between subjects enrolled in the MIRA-1 In the per-protocol analysis, the mean change from base- study and the TOZAL study were similar. All subjects in line in ETDRS BCVA (logMAR) was calculated at 3 and 6 the MIRA-1 study received an oral supplement consisting months (Figure 2). While the placebo arm experienced a of 400 mg vitamin C, 200 IU vitamin E, 40 mg zinc, and negative mean ETDRS line change of 1.49 lines at 6 3,000 IU beta-carotene [7]. The results from the placebo months (loss of VA), the treatment group demonstrated a arm of the MIRA-1 study are used as a comparator in this positive mean ETDRS line change of 0.54 lines at 6 months (gain in VA). The mean logMAR line differencebetween the treatment and placebo-control groups was Statistical Analysis
2.03 lines at 6 months postbaseline. A continual improve- Sample size and power calculations were based on the pri- ment in BCVA (logMAR) over time was demonstrated in mary efficacy endpoint. Results from two rheopheresis the treatment group, while overall, the placebo arm con- studies (Brunner and MIRA-1) were used to estimate the mean change expected [7,19]. Thirty-four patients wereincluded in the per-protocol analysis.
At 6 months, of those subjects in the treatment arm,56.7% experienced improved BCVA (logMAR), 20.0% Statistical analyses were performed using SPSS for Win- maintained their BCVA (logMAR), and 23.3% experi- dows (SPSS 14.0, SPSS Inc., Chicago, IL). A paired t-test enced worsened BCVA (logMAR). Overall 76.7% of was used to test the null hypothesis, with the average VA patients improved or maintained their BCVA (logMAR) score the same at baseline and follow-up. A two-sided with the TOZAL nutritional supplementation (Figure 3).
alpha level of 0.05 was used to determine statistical signif-icance.
Secondary Outcomes
Fluorescein angiogram, retinal photographs, contrast sen-
Primary efficacy endpoint analysis consisted of all rand- sitivity, full-threshold visual fields, macular testing (cen- omized and dispensed subjects with baseline and at least tral 10° threshold visual field), and the Visual Function 1 post-treatment VA recorded. Baseline was equated to VA (page number not for citation purposes) BMC Ophthalmology 2007, 7:3
http://www.biomedcentral.com/1471-2415/7/3 Table 3: Demographics and baseline characteristics
Questionanaire-25 (VFQ-25) were found to have little sig- quent events were systemic gastrointestinal (GI) reactions, including gastric upset, reflux, nausea, and taste perver-sion. The majority of these events occurred in patients Statistical Analyses
who had not followed the prescribed procedure of taking The average (SD) VA score was 0.409 (0.196) versus 0.355 the supplement concurrent food intake. After adjusting (0.184) for baseline and follow-up respectively, t = -2.09; their treatment schedule to always administering the df = 33; P = .045. Figure 4 demonstrates the average (and nutritional supplement with food, the majority of GI 95% confidence interval [CI] for the average) VA score at issues resolved. Overall, there does not appear to be any baseline and at follow-up. Tables 4 and 5 show a statisti- significant adverse events related to the nutritional sup- cally significant increase in the VA score from baseline to follow-up. Thus, the null hypothesis, the average VA scoreis the same at baseline and follow-up, was rejected and it Discussion
was concluded that there was a statistically significant Visual Acuity
improvement in VA from baseline to follow-up. Table 5 Left untreated, patients with AMD are at risk for substan- shows that the average increase in VA was 0.0541 and the tial vision loss. The literature suggests that without inter- 95% CI for the average increase was (-0.107, -0.0013).
vention, patients with AMD will experience a loss in VA ofat least 0.8 lines and up to 1.5 lines at 6 months [5-7].
A post-hoc power analysis reveals that a sample size of 34achieves 80% power to detect a difference of 0.062 The LAST study reported Snellen equivalent VA improve- between the baseline and follow-up average acuity score ments in both intervention groups (Group 1 L: lutein 10 assuming a standard deviation of the differences (follow- mg; Group 2 L/A: lutein 10 mg/antioxidant/vitamin and up minus baseline) of 0.126 and with a significance level mineral broad-spectrum supplementation formula), with (alpha) of 0.05 using a two-sided paired t-test. If the true mean eye improvements of 5.4 letters for group 1 L (95% population change (follow-up minus baseline) was - CI, 2.7–8.0, P = .01) and 3.5 letters for group 2 L/A (95% 0.062 with a standard deviation of 0.126, then this study CI, 0.8–6.1, P = .04) [13].
would have had an 80% chance of detecting this differ-ence at the 0.05 level of significance.
The 6-month LUXEA study demonstrated that supple-mentation with carotenoids, lutein, and zeaxanthin can Adverse Effects
improve mesoptic contrast acuity thresholds and visual There were no significant systemic or ocular adverse performance at low illumination [20].
events related to the nutritional supplement. The most fre- (page number not for citation purposes) BMC Ophthalmology 2007, 7:3
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in 0.5

Supple ment
Mean ETDRS line change at 3 and 6 months.
The CARMIS study treated 153 patients with AMD ment prescribed in the TOZAL trial allowed for 76.7% of (AREDS category 3, 4) and VA of greater than 20/32 (0.3 subjects to improve or maintain their VA, with up to 0.5 LogMAR) with lutein 10 mg, zeaxanthin 1 mg, astaxan- lines of VA improvement at 6 months.
thin 4 mg, vitamin C 180 mg, vitamin E 30 mg, zinc 22.5mg, and copper 1 mg (AZYR SIF®, Sifi Italy). Patients Nutritional Supplements
received baseline, 6-month, and 1-year follow-up with Countless studies support the use of high-dose vitamins, ETDRS and the 39-item NEI-VFQ. After 1 year, treated antioxidants, omega-3 fatty acids, zinc, and carotenoids in patients showed stabilization of VA and significantly bet- the treatment of AMD. In addition, studies on the serum ter ETDRS scores (87 +/- 6) compared to controls (80 +/- levels of compounds including vitamins A, C, and E, car- 7; P = .02). VFQ-39 scores were significantly increased in otenoids, zinc, selenium, and fibroblast growth factor in the treatment group (P = .001) [21].
subjects with AMD suggest that low levels of these com-pounds put patients at greater risk for the development of The AREDS formula does not address the vast majority of AMD [8-13]. However, recent reports of adverse events patients who want to improve visual function while pre- associated with specific supplement components empha- venting advanced AMD. The targeted nutritional supple- size the need for improved supplement formulation.
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http://www.biomedcentral.com/1471-2415/7/3 ts with improved or maintained BCVA at 6 Percent of subjects with improved or maintained BCVA at 6 months.
CI for average) visual acuity at baseline Average (and 95% CI for average) visual acuity at baseline Results of several large studies suggest that supplemental beta-carotene increases the risk of developing lung cancerin heavy smokers [22-24]. Thus, it has been recom-mended that subjects with a history of smoking avoid sup-plemental beta-carotene as part of an AMD preventionprogram. However, an increased intake of foods rich in avoided [27]. In an attempt to address these potential risk beta-carotene has not been found to pose a heightened factors, the TOZAL supplement was designed with 200 IU risk for the development of lung cancer among current and non-smokers [25]. Other carotenoids derived fromwhole foods (lutein, zeaxanthin, and lycopene) are also Supplemental zinc has been found to decrease the rate of not associated with increased risk for lung cancer [25].
loss of VA associated with AMD [16]. High doses of zincwere included in the AREDS supplement (80 mg as zinc The supplement prescribed in the TOZAL study was oxide), as well as copper (2 mg) to help prevent copper designed to address the risk of lung cancer among smok- deficiency associated with zinc supplementation. In the ers receiving supplemental beta-carotene by focusing on AREDS study, 7.5% of participants receiving a zinc-con- beta-carotene derived from whole foods. The TOZAL sup- taining nutritional supplements vs 5.0% of participants plement contained 18,640 IU of natural beta-carotene receiving no zinc in their nutritional supplement reported urinary tract problems that required hospitalization, aswell as increased rates of anemia (anemia results were Recent data link high doses of vitamin E to a 13% increase found not to be statistically significant) [16]. In an effort in the risk for heart failure [26]. In addition, a separate to limit the adverse effects associated with high-dose zinc, study found that doses of 400 IU or more of vitamin E the TOZAL supplement was designed with 69.6 mg zinc increased the chance of early death or, according to the and 1.6 mg copper. No urinary tract adverse events or ane- [23,24] authors, "all-cause mortality" and should be mia were reported during the TOZAL trial.
Table 4: Paired samples statistics
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http://www.biomedcentral.com/1471-2415/7/3 Table 5: Paired samples test
95% Confidence Interval of the Difference In 1998, van den Berg et al found that lutein negatively Additional material
affected beta-carotene absorption when the two weregiven simultaneously [28]. This decrease in absorption Additional File 1
may affect the amount of beta-carotene available for con- version to retinol. In the AREDS study, lutein was not a constituent of the formula, thereby circumventing the issue. As newer formulas are developed that contain lutein, consideration must be given to administering vita-min A in addition to beta-carotene. In the TOZAL study, Additional File 2
this adjustment was made by administering 18,640 IU of natural beta-carotene and 10,000 IU of vitamin A.
While toxicity has occurred at dosages of vitamin A of upto 50,000 IU/day for a period of 18 to 24 months, [29-32]an intake of 10,000 IU/day has not been associated withtoxicity and is considered safe.
The author wishes to acknowledge the following researchers and study
centers who participated in this study: Richard Rosen, M.D., New York Eye The present study confirms previously published reports & Ear Infirmary; Baruch Kupperman, M.D., Ph.D., University of California on the direction and magnitude of improved visual acuity Irvine; Frederick Davidorf, M.D., Ohio State University; Brain Berger, M.D., in dry AMD [13,20,21]. That we did not find improve- ments in other visual function parameters such as the con-trast sensitivity function, is likely related to the short The author also wishes to thank the following for their considerable con-tributions with respect to biostatistical consultations and analysis: David M. duration of this study. The National Eye Institute's AREDS Harris, Ph.D., Bio-Medical Consultants; John Burkhart, Ph.D., Burkhart and II trial will follow a qualitatively similar supplement (i.e., Associates; Steven D. Creech, M.S., Statistically Significant Consulting, LLC.
the AREDS II formula has lower zinc, higher omega-3,lutein and zeaxanthin in some of its treatment arms) as Funding for the study and for the manuscript preparation was provided by TOZAL (without the addition of taurine). The results of the TOZAL study reported here support the potential forpositive visual outcomes in the AREDS II trial.
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