New Hope for Aging Eyes
Vision problems might seem inevitable, but recent advances may lead to a clearer future
En español | Charles Friedlander had the heebie-jeebies about cataract surgery. A gastroenterologist, Friedlander, 75, was no stranger to surgery. Still, “it’s always nerve-racking having someone do something to your eyes,” he says. But on this early spring Friday, he’s calm and relaxed on a gurney at New York Eye and Ear Infirmary of Mount Sinai, awaiting his second procedure in four weeks. “The first went so well, I thought, let’s get the other eye done,” he adds.
The focal point of Friedlander’s surgery is the artificial lens his ophthalmologist, Tal Raviv, will insert in place of the stiff, cloudy natural lens in Friedlander’s right eye. Called the Tecnis Symfony, the replacement is a newly approved, first-in-class EDOF — extended depth of focus — lens.
“It’s such a big leap forward that the Food and Drug Administration has recognized this as a completely new category of lens,” Raviv says.
Most cataract-replacement lenses allow you to focus only near or far; patients must choose in advance which distance they would prefer to see well. A full-range EDOF lens, which allows patients to see their entire depth of vision clearly, has been the holy grail of cataract surgery for many years, Raviv explains, but early versions were more prone to glare and halos — side effects that are reduced (although not eliminated) with the Symfony lens, for which Raviv is a consultant. The Symfony provides sharp focus from far away to the critical middle distance, where people view computers, countertops and dashboards, while minimizing bothersome aberrations. (Reading a book may still require reading glasses.)
If Friedlander also had glaucoma — as about 20 percent of Raviv’s patients do — the ophthalmologist could simultaneously install a tiny stent that drains fluid from the eye, relieving pressure that can damage the optic nerve. The iStent, which is about the size of a 1 in the date on a penny, is “the smallest implant the FDA has approved for use in the human body, and it’s revolutionizing glaucoma treatment,” Raviv says.
Friedlander’s surgery seems over in the blink of an eye. Raviv takes about three minutes to soften the cataract with intense bursts of laser light, making it easier to remove. “The result is faster recovery,” he notes. Next, Friedlander is wheeled to a darkened room where Raviv peers at his patient’s spotlighted lens through a microscope while an advanced system measures the eye and projects the surgery on a flat-screen TV. About nine minutes later, the new lens is in place.
Sitting in a recovery room a half hour later, Friedlander already sees better. “The light is cleaner and crisper,” he says. After a weekend recovering, he’s back to work at his gastroenterology practice. “Before surgery I couldn’t read at all through my left eye and needed strong glasses through my right,” he continues. “Now I don’t need glasses at all. My vision is back to what it was in my late 40s.”
Advances such as these are changing the way eye doctors treat every major age-related problem. “It’s an exciting time in eye health,” says Julia Haller, ophthalmologist in chief at Wills Eye Hospital in Philadelphia.
Here are some innovations you can set your sights on:
Proteins that make up the eye’s light-focusing lens start to clump with age, gradually making vision clouded, blurry and sensitive to glare. The Symfony lens is just one of the recent breakthroughs.
Post-op adjustment: During cataract surgery, your ophthalmologist has to estimate the correction your replacement lens needs, but shifts that occur with healing can throw the correction off, resulting in less than optimal results, says ophthalmologist Nick Mamalis, codirector of the Intermountain Ocular Research Center at the University of Utah. The RxSight Light Adjustable Lens lets doctors alter its power two to four weeks after surgery, when the eye has healed and refraction has stabilized.
A fix for old replacement lenses: If you’ve already had cataract surgery, you may one day be able to upgrade your existing lens. A system in the pipeline by Perfect Lens uses a laser to change the correction on a standard lens already in your eye. If your eyes change over time, you could keep adjusting the same lens without needing another surgery.
Poor night vision together with sensitivity to glare may indicate the beginning of cataracts.
Fluid circulating in the eye maintains healthy pressure levels because the excess drains through a meshwork of outflow canals. If this meshwork falters and fluid builds up, pressure in the eye can damage the optic nerve and lead to vision loss. Not every patient responds to current medications, however, and traditional glaucoma surgeries are major procedures with rare but potentially serious side effects.
Breakthrough meds: Vyzulta, approved by the FDA in November 2017, belongs to an existing class of drugs called prostaglandin analogs and works by releasing nitric oxide, providing a dual action to lower pressure in the eye. Rhopressa, recently approved, belongs to a new class of medicines called Rho kinase inhibitors; they target cells in the eye’s drainage meshwork to restore outflow.
Microinvasive glaucoma surgery (MIGS) is a relatively new development that, while not always as effective as traditional glaucoma surgery, causes less trauma and has fewer side effects. The FDA-approved iStent, a tiny tube that restores the traditional outflow of fluid through the eye’s drainage meshwork, is implanted using an incision so small that surgeons view it through a microscope. (An even smaller version, the iStent inject, has recently received FDA approval.) The similar CyPass Micro-Stent opens a fluid pathway through a different channel. Both are installed at the time of cataract surgery, so the added surgery risk is even smaller.
Loss of peripheral vision is a key sign of glaucoma.
Age-related macular degeneration (AMD) has a genetic component, but weight gain, smoking and not wearing sunglasses are among the lifestyle factors that increase your risk for the disease. It occurs when the macula — the central portion of the light-sensing retina at the back of the eye — becomes damaged, resulting in distortion and vision loss in the center of your field of view. In the “wet” form of the disease, leaky blood vessels and scar tissue can dramatically accelerate vision loss. Taking AREDS2 supplements (a combo of vitamins C and E, zinc, copper, lutein and zeaxanthin) may slow the disease’s progression. For wet AMD, regular injections of drugs into the eye can inhibit a protein called vascular endothelial growth factor (VEGF), which promotes the growth of abnormal blood vessels. There are also surgical options available. But these treatments can only slow, not stop, the progression of AMD, which can result in severe blindness.
Gene therapy: We’re nearing the day when genetic causes of diseases such as AMD can be prevented or cured with gene editing. “A deactivated virus loaded with a corrected gene would penetrate cells and insert new code into your DNA like a cut-and-paste on your computer,” Haller explains. In December 2017, the FDA approved this approach for a disease that causes blindness in children — the first gene therapy for any inherited disease. Experts foresee major progress in the next decade, perhaps even programming the body to create its own anti-VEGF medication.
Next-gen stem cells: You’ve heard of embryonic stem cells — and the controversies about using them. Now there’s a different category of cells that can be derived from your own body and used to grow a variety of new cells and tissues, including specific retinal cells that go bad in macular degeneration. A commercially available therapy could arrive within 10 years.
An eye telescope: This is the first and only FDA-approved surgical device for people who have end-stage macular degeneration. One eye’s lens gets replaced with the tiny Implantable Miniature Telescope, which magnifies the field of view and improves central vision. The device is currently limited to those who haven’t undergone cataract surgery, but a new study is investigating whether swapping the telescope for a previously installed intraocular lens can safely help patients.
Not seeing well when you enter a dim area is often the first hint of macular degeneration.
With age, glands in the eyes produce fewer tears, as well as fewer oils that prevent tears from evaporating. More than 16 million Americans suffer symptoms; the problem is especially common in women. Over-the-counter artificial tears may help. Otherwise, doctors can prescribe anti-inflammatory eye drops to help restore glands to normal function, but these treatments aren’t effective in all people and can take months to work. Another option is for a doctor to insert small plastic plugs in the corner of each eyelid near the nose to help hold tears in the eyes.
Game-changing medications: Xiidra (lifitegrast) is a topical drug that treats eye inflammation by blocking a specific antigen. “It can have an effect in as early as two weeks,” says Terry Kim, an ophthalmologist at the Duke University School of Medicine. Coming soon is an eye drop with lubricin, a complex glycoprotein with novel lubricating properties.
Gland aid: The LipiFlow Thermal Pulsation System works to clear glands lining the eyelids and improve oil secretions. During an in-office procedure, a device applies pulsing heat and pressure to the eyelid, liquefying and pushing obstructions out of the gland while protecting the eye. Patients in a small Harvard study reported improved symptoms up to three years after a single 12-minute treatment.
Eye treatment through the nose: The TrueTear Intranasal Tear Neurostimulator — a handheld device that delivers tingling energy pulses into your nose — triggers natural tear production. In a study, it significantly increased tear output in 97 patients with moderate to severe dry eye.
Implantable eye drops: Dry eye can be tough to treat, partly because people get tired of putting in eye drops. Systems under development would allow deposits of medication to be implanted in eyes for gradual release over a period of months. Also, researchers are investigating ways to formulate drugs using tiny nanoparticles that could penetrate better so you don’t have to use them as often.
Straight lines that look wavy could signal macular degeneration.
Near- or Farsightedness
Lenses lose flexibility over time, so they’re less able to change shape to focus on different distances.
Light-changing inlays: Inlays are implanted under the cornea to change light before it reaches the lens. The Kamra inlay uses a pinhole to sharpen focus in a way that’s similar to closing the aperture of a camera. “Inlays are a new category of devices that may minimize the need for reading glasses,” ophthalmologist Tal Raviv says.
Eye-training programs: Preliminary research suggests that staring at fuzzy lines called Gabor patches for 30 minutes a few times a week can train the brain to see better up close. Some ophthalmologists say you shouldn’t get your hopes up, but the GlassesOff app for iOS and Android devices ($25 for three months) provides easy access to a similar program that claims to sharpen newspaper-size print after three months.
Richard Laliberte, an award-winning health journalist, has written or coauthored five books.