If, as the proverb goes, "The eyes are the windows to the soul," then the retina provides an unobstructed panorama of the health, not only of your eyes but your entire body. "We can spot 80 percent of all diseases by looking at the retina," says Dr. Neil F. Notaroberto of EyeCare 20/20. "The retina itself gets more blood flow than any other organ in the body."
"Inside the eye (the retina) is the only place you can see arteries and tissue inside the body without cutting into it," says Dr. Ted Brown, who founded Uptown Eyecare in 1999. "Sometimes you can even see it pulsating with the heartbeat. We're definitely looking at a lot of things back there; there are a lot of indications of a healthy body."
This means annual eye checkups are important tools for detecting developing medical conditions even before a person notices symptoms.
"The retina gives us an insider's view of the blood vessels in the body," says Dr. Jeanne Herman of St. Charles Vision. "For example, in people who have diabetes or kidney disease, there is damage to those vessels in those organs. The vessels in the back of the eye mimic those vessels in other organs, and we can give doctors a heads up to check those areas."
Bleeding on the back of the eye can indicate diabetes or high blood pressure, and narrowing of the arteries can signal the development of cardiovascular disease or other problems. On the front of the eye, the cornea tends to get cloudy with age, Brown says, but sometimes it is due to lipid deposits, which can indicate high cholesterol.
"Especially with things like diabetes, a lot of times an eye doctor will be the one to raise that flag," he says. "They say, 'Hey, there is some bleeding in the back of the eye,' and tell [the patient] to see their doctor."
Optometrists and ophthalmologists say there is a clear correlation between physical well-being and eye health. "As with anything, diet and exercise is so important in maintaining all tissues in the body, including the eyes," Brown says. "There are certain vitamins that are geared specifically toward maintaining your eyes' health, but it's more important to make sure you're getting the proper nutrients (overall). Don't smoke. It tends to cause more breakdown in the arteries. There seems to be an increase of macular degeneration with people who smoke."
When it comes to your eyes, prevention and early detection of problems are key to maintaining your vision into old age. An annual checkup is recommended even for people who don't need to correct their vision with glasses, contacts or laser surgery.
Brown says a good checkup should include a vision test, a check of the external part of the eye to make sure there's no disease, and an examination of the inside of the eye — the retina and optic nerve — to look for signs of macular degeneration, retina tears or detachments, damage to the retinal tissue from diabetes or hypertension, narrowing of the arteries, which can restrict blood flow, and more.
"With most things with the eyes, by the time you notice you're not seeing well, [the condition is] advanced ... and can be hard to help," Brown says. "Like with anything, early diagnosis is so important. By getting your eyes checked once a year, you can catch things before they lead to vision loss."
Dilation of the pupils also should be part of the checkup because it allows the doctor the best view into the back of the eye. "Dilation gets more and more important as a person gets older because there's an increased risk of cataracts and retinal disease," Brown says. "Also, as a person gets older their pupils typically get smaller, so it's more difficult to see the back of the eye without dilating."
Herman adds to those components an optical coherence tomography, or OCT, a scan of tissue in the back of the eye that helps diagnose diseases such as glaucoma and macular degeneration as well as monitoring conditions like bleeding caused by diabetes and high blood pressure. She also uses corneal topography for mapping the front surface of the cornea to detect diseases on that part of the eye as well as aiding in properly fitting contact lenses. St. Charles Vision also routinely uses Optomap to keep a record of a patient's eye condition over time. "It allows us to have a hard-copy data image of the tissue in the back of the eye so we can look from year to year to see if there are changes and early signs of disease," she says. "That's the most important part of the eye exam, getting a look at the back of the eye. It can help in detecting systemic diseases.
"We also have a corneal endothelial cell photograph. It images the cells on the inside layer of the cornea and helps us to detect corneal disease — not just disease caused by regular degeneration but also injuries from extended-wear contacts."
The most traditional way to correct vision imperfections is eyeglasses, which can be customized to improve myopia (nearsightedness, or blurry vision when focusing on distant objects), hyperopia or presbyopia (farsightedness or difficulty seeing objects that are close), astigmatism (blurred vision) or all three conditions at once. Most lenses are available in ultra-lightweight, impact- and scratch-resistant versions. Glasses frames come in a range of sizes, designs, colors and prices, and over the years have become fashion accessories that carry famous designer names like Dolce & Gabbana, Bulgari, Coach, Gucci and others. A good optometry office will have professionals on staff to help you pick the right frame for the shape of your face, your complexion and your lifestyle. Opticians also will adjust your glasses for optimum comfort and visual acuity.
Contact lenses continue to gain popularity as an alternative to eyeglasses as improvements are made in their comfort, longevity and corrective abilities. Like glasses, contact lenses require an eye exam so an optometrist or ophthalmologist can tailor a prescription to your specific needs. In addition, an eye care professional must measure your eyes and consider their shape so each lens fits the cornea correctly. Herman uses corneal topography to get the best fit for contacts.
Until recently, patients with astigmatism, an abnormally shaped cornea, thinning of the cornea (keratoconus), people who need bifocals and those who have experienced complications from eye surgery were not considered good candidates for contact lenses. That has changed with the introduction of a new hybrid called SynergEyes, available at St. Charles Vision. SynergEyes are made of both hard lenses, which give the wearer clearer vision, and soft lenses, which provide comfort, often making them an option for patients who previously had a difficult time wearing contacts. They start at about $800, including the eye exam, fitting and contact lenses.
"It's a great lens," Herman says of SynergEyes. "It is a multifocal contact lens: you can see distant and near through the same contact lens. There are no lines (as there are in bifocal or graduated lenses). The patient is actually looking through the distance and the near power at the same time and the brain figures out which one you want to use. It also can help correct astigmatism."
A solution for patients with presbyopia, an inability to focus on near objects usually brought on by aging, may be monovision lenses, in which a contact is worn in only one eye to help with focusing on small print or near objects and the dominant eye is used for distance viewing without the aid of a lens. Some monovision patients are fitted with a contact for distance in the dominant eye and another for near objects in the nondominant eye. Using the same theory, some surgeons are now performing monovision LASIK in which one eye is corrected for distance and the other for seeing near objects.
"Just like with all contacts, not everyone is a good candidate (for SynergEyes or monovision)," Herman says. She adds that some people complicate the use of contact lenses by failing to properly clean them or by wearing them for too long a time, both of which can lead to eye irritation or injuries.
"Contacts are definitely not for everybody, although they have made improvements so they can be used by more people," Brown agrees. "The best thing to keep in mind with contacts is that if your eyes are irritated, the contacts are going to make that worse. It's important to have a backup pair of glasses. If someone gets an eye infection, they can't wear the contacts."
The most common problems among contact wearers, he says, are allergies, corneal ulcers, conditions caused by sleeping in contacts too often or not cleaning them properly, viral and bacterial infections and irritation caused by getting something in your eye under the lens. Brown recommends patients see their doctor right away if they experience any discomforts. "Until someone looks at your eye and diagnoses [the problem], you can't prescribe the right drops or treatment," he says. "With a corneal ulcer, there are certain bacteria that can perforate a cornea in 24 hours, then you're talking about a corneal transplant."
LASIK Vision Correction
More and more people are turning to surgeons like Dr. Jeffrey Singer, who operates a private practice and is a clinical instructor of ophthalmology at Tulane University Medical Center, to permanently correct vision imperfections through laser surgery. Singer, who has performed more than 20,000 laser-assisted in-situ keratomileusis (LASIK) procedures to reshape the cornea, now uses the latest custom laser, CustomVue LASIK, which is based on NASA technology developed to correct the vision of fighter pilots.
"The technology just keeps improving," says Singer, who performs several hundred surgeries a month. Each surgery is done on an outpatient basis in his office and takes five to 10 minutes. "For the most part, with the CustomVue technology, 98 percent of people see 20/20 after surgery." It works with nearsightedness, farsightedness and astigmatism, he says.
His successes keep his business booming. "I probably do the most [vision correction surgeries] in the state," Singer says. "Two-thirds of our patients come in from word-of-mouth referrals. Ninety-nine percent of my patients say they would do it again. It's definitely a wow! phenomenon."
Having laser eye surgery doesn't predispose patients to problems like detached retinas or infections, he says. "With any surgery, there is some risk," Singer says. "Some people will see glare or halos. Less than 3 percent of people ever need another surgery, but there are no guarantees."
Before accepting a patient, Singer conducts a free screening to ensure they are a good candidate for the surgery. "The age range is 18 and older," he says. "There is no upper range, but we have to look for cataracts in people over 60. Economically, corrective surgery pays for itself in a couple of years" by saving patients the cost of continually replacing glasses and contact lenses. The surgery costs about $800 per eye.
Singer also performs other ocular surgeries for glaucoma, cataracts and retina problems, sometimes implanting lenses — even for people with astigmatism — that mean people who have had cataract surgery don't need to wear glasses after the procedure. Some of those lenses even have ultraviolet filters to protect eyes from sunlight.
Diseases of the Retina
Vision-stealing retinal diseases require treatments from specialists like Singer and Notaroberto, who specializes in restoring and maintaining vision in people who suffer retinal detachments, macular degeneration, glaucoma and diabetic retinopathy.
"Things have come a long way from the '80s and '90s," he says. "Retinal detachments can be repaired in the office more often than not now." Retinal detachments are very serious and require immediate attention to save sight. The first signs a person notices generally are flashes of light when they are in a dark environment, or so-called floaters (ball or strings that appear to move across the eye).
"Retinal detachments will start, usually, with a tear or a hole," Notaroberto says. "Flashes of light ... is a sign there is pressure on the retina. Floaters you may or may not see. That's a vitreous jelly (that is a normal part of the eye). When it pulls off the retina as we age, it can consolidate into a ball. These floaters can be little pieces of the retina itself that are coming off and are pulled into your visual axis. The majority of the time, the flashes or floaters are benign, but sometimes it can be disastrous."
When the holes or tears in the retina are small, Notaroberto uses a laser to cauterize and tack them down, or cryotherapy to freeze them in place. He also can inject a gas into the eye to hold it in place against the retina until it heals and reattaches. If the tears are large and progressive, he employs a scleral buckling procedure that tightens the eyeball like a belt around the waist and allows the retina to reattach itself. In the worse cases, he takes the jelly out of the eye and replaces it with silicone oil, which is very heavy, until the retina heals, then drains the oil and fills with eye with clear fluids. In the interim, however, the patient cannot see very well.
Retinal detachments often are the result of an injury — a hit on the head, a trauma such as a car accident or a poke in the eye — but it also can be a result of aging. "The inside of the eyeball is filled with vitreous jelly that is 99 percent water and 1 percent protein," he says. "It has enough fibers to keep it structurally sound and fills up the whole orb. As we get older, we lose some water and the concentration of the jelly changes. It shrinks and pulls off the back of the eye. Sometimes some of the retina is torn off." It also can result from intrathoracic pressure, such as lifting heavy objects while holding your breath, which increases pressure in the eye. Notaroberto says some people have a genetic predisposition to retinal problems.
Glaucoma results from increased pressure in the eye, which causes blind spots, poor night vision and loss of peripheral vision. It can lead to damage of the optic nerve and is the second most common cause of blindness in the United States. It usually is treated with medications or surgery to decrease the pressure. "African Americans are more predisposed to glaucoma than the general population," Notaroberto says. "It's been called the silent thief of vision. It's preventable; that's why it's important to get annual examinations. [Doctors] can easily detect it by a complete dilated examination."
The two most common problems Notaroberto deals with are macular degeneration, in which vision is lost in the middle of the eye, and diabetic retinopathy, in which high amounts of sugars in the blood corrode the arteries and cause them to leak fluid or burst. Damaged blood vessels also prevent adequate oxygen from reaching vital organs, including the eye, causing the organ to die.
"In my practice, the No. 1 pathology I deal with is diabetic retinopathy," he says. "It can be a catastrophic disease. The second most frequent is macular degeneration, the leading cause of blindness in white adults over 55 in America.
"Our science is not advanced enough to give us the answer as to why it happens, but the risk factors are age, smoking, genetic history, and some studies suggest sunlight exposure. There's also some evidence that systemic diseases play a part."
Notaroberto has a variety of tools he can use to treat the two conditions, including several types of laser therapies such as a thermal laser and infrared laser, or he can inject the eye with steroids or other medications, including vascular endothelial growth hormone, which causes the retina to grow new vessels. In his view, blindness is not an acceptable outcome.
"I believe there is always hope," he says. "I never tell [patients] there is nothing I can do for them. There is new stuff coming out every year. There are treatments available for almost every form of macular degeneration. Some are preventative and some are after the fact to stave off more damage."
For the most advanced form of macular degeneration, for example, there are drugs that stop the abnormal inflammation of blood vessels that cause vision loss. "Up to 90 percent of people will have no further damage, and up to 40 percent will have recovery of vision," he says.
The key to all vision problems is early detection.
"I have seen people who are in their 50s and 60s and have never had their eyes checked and are at the verge of losing all their vision," Brown says. "By the time we see those (people), it's too late to fix anything with glasses or contacts. A lot of times things happen so gradually that you don't recognize it's happening."
"We can spot 80 percent of all diseases by looking at the retina, taking angiograms of the retina, etc.," Notaroberto says. "The earlier you can get into treatment, the higher your chances of recovery."