University Place

The Aging Eye

[Marge Murray, U.W. Health]

I’m Marge Murray with U.W. Health, and I am thrilled to welcome you all to our “Better With Age” It’s hard to think about aging well without our eyes following along with us. So, I’m very happy to introduce Dr. Stephen Sauer who is a Comprehensive Ophthalmologist with U.W. Health. I believe he sees patients at U-Station and somewhere else, and he is here to talk about your aging eye, and I’m assuming how to make it see as long as it can. So, welcome.

[applause]

[Stephen Sauer, Associate Professor, Department of Ophthalmology, University of Wisconsin-Madison School of Medicine and Public Health]

The talk that I would like to discuss today is about the aging eye. I should tell you first that I don’t have any financial disclosures.

[slide titled, Financial Disclosures, with the bulleted point – none]

I’m an Associate Professor at the University in the Department of Ophthalmology. I spend a substantial amount of my time teaching at the Veterans Hospital, but I also maintain a clinical practice where I see patients –

[Dr. Stephen Sauer, on-camera]

– in Comprehensive Ophthalmology. And so, I’m very familiar with the kinds of things that we’ll be talking about today in the talk.

So, normally when I do this, I like to give a little pre-test to see what kind of information or knowledge people have about this content beforehand. And what I’ll ask you to do is just make a mental note of – there are four questions. We’ll discover – well go through and reveal the material as we go through the talk. And at the end we’ll revisit the pictures, and you’ll have an opportunity to see if what you thought you – the answer was, was in fact what it was.

So, the first question is: what kind of eye problem would cause the vision –

[slide titled, #1 – What eye problem causes the vision to look like this?, and features two photographs where the central part of the photos appears blurry and wavy]

– to look like this? And what we see is this blurry spot in the middle of the ‘Money Market’ newspaper page, but also, we see this kind of wavy, gravy portion of the vision in that building – in the photo of the building. So, if you know what that is, just tick it off in your brain, and – and we’ll revisit this at the end.

[new slide titled, #2 – What eye problem causes the vision to look like this?, and features a photo of a woman tending to garden plants but the overall image is hazy]

The second question is, what kind of eye problem would cause the vision to look like this? And what we see is a picture of a woman tending her flowers, but there’s this grayish central area that seems foggy and blurry.

[new slide titled, #3 – What eye problem causes the vision to look like this?, and features a photo of two kids with the central area in focus but the peripheral areas black]

The third picture is: what problem would cause the vision to look like this? And what we see here is an area where things seem to be really clear and crisp, but it’s darker and grayer and blacker around.

[new slide title, #4 – What eye problem causes the vision to look like this?, featuring a photo of a couple in two kayaks with the upper 2/3rds of the photo in focus, but the bottom third of the photo in black]

And then finally, what kind of eye problem would cause the vision to look like this? And what we have here is this whole bottom of the field of vision, this whole bottom of the picture, is – is black. Keep that in mind –

[Dr. Stephen Sauer, on-camera]

– and we’ll reveal the answers as we go and come back to it at the end.

I think I should say at the beginning that most older people have good vision. It changes as we get older, but if there are problems that arise, they can generally be treated if they’re caught early.

[slide titled, Anatomy of the Eye, featuring two illustrations, the first is an illustration of the eye looking at it from the front with the iris, pupil, and cornea pointed out; the second illustration is of a cross-section of the eye from the side with the iris, pupil, cornea, lens, retina, macula, and optic nerve indicated]

It’s helpful to take a moment and just talk a moment about the structure of the eye. When you look at the front of the eye, the colored part is called the iris, and the white part is called the sclera, and the cornea is the clear window on the front of the eye. And so, when you look in cross-section, you see the cornea in the front. And then the iris, which is this pinkish part here, because it’s a cross-section. The lens of the eye sits behind the iris. And then the retina is the part that lines the back of the eye. This optic nerve here –

[Dr. Stephen Sauer, on-camera]

– is the cable that sends the vision back to the brain.

So, what’s normal? What can you expect as you get older? Well, most people, as I said, have –

[slide titled, Normal Changes of Aging, featuring a bulleted list noting that – most people have good vision, need for reading glasses is normal, changes of eyeglasses is normal, eyes occasionally more irritated, eyelids and external tissue change]

– good vision. It’s normal to need reading glasses. It’s normal for the strength of those glasses to change as we get older. The eyes are usually a little more irritated at times, and the external tissue of the skin and the eyelids can change.

[new slide titled, Common Eye Problems in Older Adults, featuring another bulleted list, the first being – The Big Three]

So, when we talk about ‘what are the common eye problems as we get older?’ we often talk about the big three. There are more –

[the slide animates on the bulleted list – eyelid problems, cornea problems, Glaucoma, Cataract, Macular Degeneration, Vascular Occlusions – with Glaucoma, Cataract, and Macular Degeneration all underlined and in bold type]

– but I’ve highlighted here in bold and underline what ‘the big three’ are: glaucoma, cataract and macular degeneration. But there are also eyelid problems, cornea problems and there are problems with the blood vessels, or vascular occlusions that can affect the eye also.

I’ll spend some time going through –

[Dr. Stephen Sauer, on-camera]

– some sample problems for each of these sections, mostly by showing you some pictures and just describing what – what we see.

So, this Basset Hound appearance –

[slide titled, Dermatochalasis, featuring a photo of a person whose eyelids and surrounding skin are drooping at the sides]

– of this person, you can see that there’s a lot of saggy, droopy skin that just sort of hangs down. Gravity, as we know, will take its toll. From tip to toe, things tend to sag. This can be corrected. It’s a surgical procedure that is essentially a lid-lift or a lid-tuck, and this is something that happens, but can be corrected surgically.

[new slide titled, Ptosis, featuring a photo of a person who has droopy eyelids that does not affect the surrounding skin like Dermatochalasis]

Ptosis, if you look at the – this patient’s right eye compared to the left eye, you’ll see that the eyelid is droopy. Again, this can be a normal change of age. It can be something that can be corrected with an outpatient surgical procedure. Sometimes it’s associated with another complex neurologic problem, but often it’s just an aging change that can happen to one eye or to both eyes.

Outpatient procedure, both of these two.

[new slide titled, Entropion, featuring a photo of a patient whose skin around the eyelids is puffy with the eyelid turning in toward the eyeball]

Entropion is when the eyelids turn in toward the eyeball. And you can see in this picture that the lower eyelid, instead of the eyelashes coming out and away like they would normally do, they’re actually rolled into and onto the eye. And you can imagine how uncomfortable this would be. But again, this can be corrected with an outpatient surgical procedure.

[new slide titled, Ectropion, featuring a photo of a patients eye in which the eyelid is falling away from the eyeball]

The flip side of this is something called ‘ectropion,’ where the eyelid here, you can see, the eyelashes here are present in their normal position, but the whole eyelid is actually falling away from the eye. It causes a similar kind of exposure or irritation on the eye. So, the eye can be very red, but from a slightly different source. But this again is a correctable, out-patient surgical procedure.

[new slide titled, Blepharitis, featuring a photo of a patients eye in which the eyelids have crusty or flaky discharge at their bases]

Blepharitis is very, very common. It’s something that affects the eyelashes, and I talk about this with my patients. I mean, it’s a bit like having dandruff of the eyelashes.

[Dr. Stephen Sauer, on-camera]

There’s flakiness, there’s crustiness that can be red and angry and inflamed. It can flare up and then wax and wane of its own accord. But there are some things that we can do to help mitigate this and to lessen the irritation.

Rosacea –

[slide titled, Rosacea, featuring a photo of a patients eye which has very red eyeballs as well as redness and inflammation around the eyelids]

– a very common problem that can affect the face, the chest, but it can also affect the eyelids. And what we see here, it’s a little – little tricky, but you can see that there’s clearly a lot of redness of the eyeball itself on either side of the cornea. But there’s also some irregularity and some inflammation here along the eyelid margin. These are the things that we look for as ophthalmologists. The patients will tell us, “My eye just, it – it just feels terrible.”

[new slide titled, Tumors, featuring a photo of a patient who has small bumps on the inner part of their eyelid]

[Dr. Stephen Sauer, on-camera]

Occasionally we can run into patients who have tumors. And what we see here is this little irregularly –

[return to the previous Tumors slide]

– shaped area here, this little lumpy, bumpy spot –

[new slide titled, Herpes Zoster, featuring a photo of a patient whose eyes have swelled almost shut and has large scabbing on their forehead]

[return to the Tumors slide]

– on the inner – on the inner surface of the eyelid. And this is something that really – especially when the size or the color or the shape of these kind of growths might change, then we definitely want to take a look, do a biopsy, and find out exactly what’s going on. We can catch them and treat them if they’re caught early.

[return to the Herpes Zoster slide]

Zoster, Herpes Zoster. It’s shingles, essentially. Shingles that can affect the face and the scalp. It’s typically in one side, left or right. And it may actually involve the tip of the nose. You can see some little red dots here on the tip of the nose, but more substantially, this scarring and scabbing that can occur is part of the redness and then a rash and then scabbing and scarring. It can be quite painful.

[new slide titled, Cornea, featuring an illustration of a cross-section of the eye with the cornea indicated and highlighted and its definition – The cornea is the clear window at the front of the eye]

If we move further on toward the eye, away from the skin and the eyelids around the eye and we move to the eyeball itself, I mentioned the cornea is this clear window on the front of the eye.

[new slide titled, Dry Eye, featuring a photo of a patients eye in which the pupil has a matte appearance and does not seem wet]

Dry eye is a very common problem for folks as they get older. We know that the production of tears is under some hormonal control. Women tend to be more affected by dry eye than men. But what we see here, instead of this very smooth, reflective surface of a lake kind of appearance on the surface of the cornea, it’s got this grainy, irregular, rough kind of appearance. And this can be quite irritating, and it can affect the quality of vision. Most often patients will describe it, “Well sometimes it’s clear,

[Dr. Stephen Sauer, on-camera]

– but I pick up a book and I read, and then after about five minutes, it just gets blurry, and I have to stop reading. And that’s often a sign that there could be some dryness or instability of the tear film on the surface of the eye.

Corneal arcus in some – is

[new slide titled, Corneal Arcus, featuring a photo of a patients eye in which there is a halo or white ring around the pupil]

– is a – a term that we use to describe this circular white ring around the periphery of the cornea. It’s a normal finding. It’s just a – a deposition of –

[Dr. Stephen Sauer, on-camera]

– cholesterol deposits that can occur with age. It doesn’t necessarily mean that you have high cholesterol.

[return to the Corneal Arcus slide]

But in much younger patients, if we were to see something like this, we might be concerned about that. But it’s very common to see this in folks as they get older.

[new slide titled, Pingueculum, featuring a photo of the white of a patients eye that has a growth sticking out of it]

Sometimes people can have a growth on the side of their eye. Its this – you’ll see this irregularly triangular-shaped area here. It’s typically on the inside along the horizontal meridian of the eye. But it’s usually on one side or the other. It could be both. But it’s usually exposure to sun causes a bit of change in the cells and they can proliferate in this irregular kind of fashion. And it can get inflamed and irritated –

[Dr. Stephen Sauer, on-camera]

– and then quiet down. But –

[slide titled, Pterygium, featuring a photo of a patients eye in which the triangle shaped area of Pingueculum has progressed to a layer of tissue across the side of the eyeball]

– Pingueculum can sometimes progress into something called a Pterygium. And again, you can see this triangular-shaped –

[new slide titled, Glaucoma, featuring an illustration of a close-up area of the eye where there is an aqueous flow from the ciliary boy where the fluid forms and then moves across the lens of the eye and exits out further along the upper part of the eye. The slide notes that – glaucoma is a disease of the optic nerve and it is a leading cause of blindness in the U.S., especially for older adults]

[return to the Pterygium slide]

– tissue that’s full of blood vessels and it basically creeps and crawls across the cornea and sometimes can involve the line of sight. Or it can creep across the cornea and cause distortion, and that can very much affect the vision. But this is something that can be addressed surgically. They can be removed. And the techniques that we have for this kind of procedure have improved greatly over the past decade.

[Dr. Stephen Sauer, on-camera]

These Pterygia used to come back quite frequently after they were removed, and they would come back worse than before. But the techniques that we have today are quite successful in removing it.

[return to the Glaucoma slide]

We’ll talk a minute here about some – about glaucoma. Glaucoma is a problem that affects the optic nerve, and it’s the leading cause of blindness in the U.S. Now this picture is designed to show you – it’s a section –

[new slide tiled, Glaucoma, featuring the previous photo of the two kids in the middle of the picture who are in focus but the rest of the photo around the kids is black]

– of the eye.

[return to the Glaucoma slide that has the close-up illustration of the eye and the aqueous flow]

And it’s designed to show you that behind the iris, there’s this area of the eye that produces the fluid that keeps the eye formed. And this fluid drains.

[return to the Glaucoma slide with the two kids surrounded by blackness]

[return to the Glaucoma slide with the close-up illustration of the eye and the aqueous flow]

This fluid moves from behind the iris into the front of the eye, and then it drains out here.

[return to the Glaucoma slide with the two kids surrounded by blackness]

And someone with advanced glaucoma might end up with a visual problem like this. What happens is that the increased pressure in the eye, and there’re probably some other factors involved too that we’re beginning to –

[Dr. Stephen Sauer, on-camera]

– understand that can affect the optic nerve and damage the retinal cells that transmit the vision. But the center of vision is usually the last to go. People will often not even know that they’re losing their side vision unless they cover one eye accidentally or for some other reason. But this is a picture of someone might see with advanced glaucoma.

[slide titled, Glaucoma is a puzzle with three major parts, featuring an illustration of three puzzle parts clicked together one labeled – pressure in the eye, the second – optic nerve damage, and the third – visual field loss. The slide also has these labels in a bulleted list]

And so, we think of glaucoma as a puzzle. And there are lots of different parts that help us to determine whether or not somebody has glaucoma. The pressure in the eye is one of them. Whether or not the optic nerve shows any signs of any damage, and whether or not the visual field shows any damage. And so, I showed a picture of what a patient might see –

[new slide under the Glaucoma title, featuring a photo of a patient who has their eye in front of a device that blows air into the eye and note that – a tonometry test measures pressure inside the eye]

– but well, this is a picture that just shows how we might measure the eye pressure. Some people fondly, or not so fondly, remember the air puff test that usually you get people the first time unawares and then it’s just not going to work from that point forward. But we numb up the eye, of course, and we can check pressure this way.

[new slide under the title, Glaucoma, and featuring a photo of an ophthalmologist looking into a patients eye using a ophthalmoscope and the slide notes that – your ophthalmologist can examine the optic nerve for damage with an ophthalmoscope]

We also look inside the eye to look at the optic nerve to assess the integrity and the health of the optic nerve.

[new slide still under the Glaucoma title, featuring a patient in front of a large machine where they are testing the peripheral vision as a nurse sits next to them administering the test and noting that – a visual field test checks for any blind spots due to damage of the optic nerve]

And we also will have patients take a visual field test where you sit at this machine. This woman is here taking the test, and this bowl-shaped device will flash a light, and the patient will push a button when they see the light.

[new slide still under the title, Glaucoma, featuring two computerized readouts of the field vision test – one in which the shape of the test is mostly light grey and indicating that this is a normal visual field and one with large areas of dark grey and black on the shape and indicating that this field test shows severe visual loss. The slide also note that the results of the visual field test indicate where damage has occurred]

And it might produce something like this. Anything where you see black, or gray is an area of concern. And so, in this picture here there’s this – this arcuate area starting here kind of extending up and around, and this is an area of – of the image of the optic nerve. And they follow fairly characteristic patterns. And then this visual field over here is normal. So, you can see the difference in the amount of gray and black for someone who has visual field loss. And think of that picture where the center visual field, where my cursor is –

[Dr. Stephen Sauer, on-camera]

– is really uninvolved. But this area around it is – is affected.

Acute glaucoma is a problem for some people where the pressure can rise very quickly –

[slide titled, Acute Glaucoma, featuring a photo of a pair of patients eyes which show a heavy film over the top of the lens of the eye as well as two illustrations – one the previous illustration of the aqueous flow and a new illustration where the flow is blocked by trabecular meshwork leaving no place for the pressure to release]

– very suddenly. It’s not terribly common, but it can happen. And in this picture, you’ll see that this person’s eye over here is very red and the cornea – you can hardly see all of the brown iris because the cornea is swollen and cloudy compared to the brown iris and the white eye over here. So, there’s clearly a problem with this right eye.

And if you think back to that picture where the pressure, the fluid is produced behind the eye and drains in front of the iris, here the fluid drains behind the iris, but for some reason the iris is pushed up against the cornea here and so the fluid has nowhere to drain. And it just accumulates inside the eye, and the pressure goes up. And people can lose a lot of vision in a matter of hours. Most of the time –

[Dr. Stephen Sauer, on-camera]

– this is an extremely painful experience, and it brings people to the emergency room. But it is something that we can – that we encounter occasionally.

[new slide titled, Cataract, featuring an illustration of a cross-section of an eye with the lens of the eye indicated and noting two bullet points, one defining a cataract as a clouding of the naturally clear lens, and the second noting that it can be compared to a frosty or foggy window]

Cataract, the lens – the natural lens inside the eye. Normally it’s clear, but it gets cloudy. It’s just part of the normal oxidation process of getting older. Certain diseases can make it happen more quickly. But most people compare it to a frosty or a fogged window.

[new slide under the Cataract title, featuring the previous photo of the woman tending to her garden where the photo was hazy]

Recall the pictures that I showed you at the very beginning. This is a pretty reasonable picture of what somebody with a cataract might experience where the central vision just becomes gray or cloudy, or it’s like you just haven’t done spring cleaning on the windows and there’s a lot of dust and film on the windows.

But this can be –

[new slide noting that – Cataracts are the primary cause of reversible vision loss in the United States, and featuring two illustrations of a cross-section of the eye from a 45 degree angle, one on the left showing a clear lens and the one on the right showing an eye with a cataract and a blurry lens]

– corrected surgically. It’s a reversible cause of vision loss. Glaucoma, on the other hand, it’s irreversible. But cataracts can be corrected surgically. This picture just shows a clear lens over here and a cloudy lens over here. So, this is the eye [indicating the right illustration] that has the cataract.

[Dr. Stephen Sauer, on-camera]

And you can just see how the light would be impaired – impeded from getting to the back of the eye in this – in this eye.

[new slide still under the title Cataracts, featuring four photos of four different cataracts each with various levels of cloudiness from light to almost solid white over the lens]

Lots of different kinds of cataracts. This is the primary surgical procedure that I spend my work doing, working on. There’s this nuclear component, it’s like a peanut of an M&M. It’s the central portion that becomes cloudy. Sometimes there can be these cortical or spoke-like opacities that can come across into the center of vision. Don’t need to go through all of these, but just a sample –

[new slide under the title of Cataracts, featuring four more photos of different cataracts]

– that there are lots of different kinds of cataracts. There are these rosette cataracts, these Christmas tree cataracts, these polychromatic crystals – they’re quite beautiful to look at from my perspective. I think they’re kind of interesting. But patients have a different story about that.

[new slide titled, Common Misconceptions, featuring a bulleted list of what a cataract is NOT –
A film over the eye, caused by straining the eye, spread from one eye to the other, a cause of irreversible blindness]

But misconceptions: there are many. It’s not a film over the eye. It’s not caused by straining. It’s not spread from one eye to the other, and it’s not irreversible. It’s something that can be corrected and –

[Dr. Stephen Sauer, on-camera]

– reversed with surgery. I just thought I would show this picture. It’s kind of an interesting historical perspective.

[slide titled, Cataract Surgery, featuring an illustration of oriental Indian men performing surgery on a womans eye – one holding the patient and one poking a needle in the eye]

Cataract surgery was first described, at least couching was first described in India 4,000 years ago. And you can see here that one person in the back of the patient holding their head steady, and then the – the – the surgeon with basically a – a – a hand-held device with this little point on it. And they would hold the patient still and stick this point into their eye and wiggle it around until this mature cataract fell into the back of the eye.

And you can imagine without anesthesia how bad things must have been to entertain this as a –

[Dr. Stephen Sauer, on-camera]

– as a possible solution. And – and – and there were a lot of infections, and – and – and this was just a – a last-ditch attempt to try to restore some measure of vision. But things have come a long way.

[slide titled, Cataract Surgery, featuring two illustrated cross-sections of the eye – one on the left having a cataract and one on the right having its lens removed and replaced and noting that during surgery – the naturally cloudy lens is removed, and a clear intraocular lens (I.O.L.) is inserted]

Nowadays the cataract here is removed through a very small incision. You can see this little line here. It’s about three millimeters, two and half millimeters wide. If you were to stack three dimes together, two dimes together, that’s about how wide the incision would be for modern cataract surgery.

[Dr. Stephen Sauer, on-camera]

And then what we do is we put an implant, after taking out the cataract here, we put an implant inside the – the natural sac –

[return to the Cataract Surgery slide]

– or capsule that holds the cataract.

So, we make a hole in front – in the front of the sac, take out the cataract, and then we have this foldable lens that unfolds. It goes in like a taco and unfolds inside the eye.

Pretty amazing.

[new slide titled, Toric Intra-ocular Lens, showing an illustrated cross-section of an eye and showing an illustrated Toric inter ocular lens and its relation to the astigmatic cornea in front of it]

Lots of different kinds of implants these days. It used to be just a standard, what we would call, a monofocal or spherical cataract lens, or intraocular lens. A Toric lens corrects astigmatism, which sometimes the shape of the cornea is not uniform in all of its axes, or all directions. And that creates astigmatism. And we have an implant now that can accommodate and correct for that.

[Dr. Stephen Sauer, on-camera]

And so, what this picture represents is somebody who’s got a cataract plus astigmatism.

[new slide under the Toric Intra-ocular Lens heading, now showing three illustrations of a lone tree at the end of a field with a blue sky behind it; the first illustration shows the tree and its surroundings out of focus and hazy and is titled – vision affected by cataracts and astigmatism. The second illustration is of the same tree scene but now the haziness is gone but the tree is still blurry and is titled – vision after cataract surgery with a traditional intra-ocular lens and astigmatism. The third illustration is a clear, in focus illustration of the tree and is titled – vision with Toric intra-ocular lens]

If you were to take out the cataract alone, things would be brighter and somewhat more clear, but the astigmatism remains. But if you have a cataract and astigmatism and you have a Toric implant, not only does the image become more bright and clear, but it becomes more crisp and sharp.

[new slide titled, Multifocal Intra-ocular Lens, featuring three illustrations. At the top is an illustration of the eyes lens showing parallel lines indicating light entering the lens and then being diverted by the lens into a single focal point. The two illustrations underneath the lens illustration are two cross-sections of an eye showing the multifocal problem with the eye in the first and the way the multifocal intra-ocular lens solves the problem in the second illustration]

And similarly, there are multifocal intraocular lenses that allow patients to see not just far away, but also close up.

[Dr. Stephen Sauer, on-camera]

And we do that by providing a multiple array of focal points. And this picture’s not –

[return to the Multifocal Intra-ocular Lens slide]

– important to understand exactly, but –

[new slide still under the heading – Multifocal Intra-ocular Lens, showing two new illustrations of a point of view from behind the steering wheel of an automobile with the driver holding a cup of coffee in the center of the illustration. In the first illustration, the cup of coffee is out of focus while the road, buildings, pedestrians, and other cars are in focus. The second illustration shows everything – including the cup of coffee – in focus for the entire illustration]

– this picture probably shows the more important functional outcome. Which, if you see here, the driver’s in the car in the big city and they see the signs here ‘right turn only’ and they can see the – the street signs telling them which way to go, and they can see their speedometer, but the – the coffee cup here is not so clear. It’s a little blurry right here. And this might be what you’d get from a standard implant. But with a multifocal implant, not only can you see those distance things, but now you can see that it looks like Vito’s coffee or something. You can see more clearly the things that are up close.

[Dr. Stephen Sauer, on-camera]

I’ll take just a few minutes and talk a little bit further about the retina and also the macula. This is the –

[slide titled, Retina/Macula, showing an illustrated cross-section of an eyeball and pointing out the retina and macula at the back of the eye]

– tissue that lines the inside of the back of the eye.

[new slide titled, Retinal Problems, and noting that retinal disorders account for about a third of all legal blindness and followed by this list of retinal issues in a bulleted list: Macular Degeneration, Diabetic Retinopathy, and Blood Vessel blockage or vascular occlusion]

Retinal problems account for about a third of all causes of legal blindness. Macular degeneration, diabetic retinopathy and vascular occlusions account for the majority of these.

[Dr. Stephen Sauer, on-camera]

Macular degeneration is something that generally affects the center of vision.

[slide titled, Macular Degeneration, and featuring two photos from earlier in the talk, one of a list of Money Market funds with the central part of the image blurry, and a second a photo of a university building where the central part of the building looks out of focus and wavy]

So, it’s sort of the opposite of glaucoma, where the center vision is the part that’s affected. Whereas the side vision is not. And typically, patients might experience this phenomenon where vertical lines become wavy. Telephone poles –

[Dr. Stephen Sauer, on-camera]

– fence posts, traffic signs, they have this wavy sign – wavy appearance to them.

[return to the Macular Degeneration slide featuring the building and Money Market list]

And – and that’s a sign that there’s something going on in the – in the macula.

[new slide titled, Amsler Grid, featuring a photo of a ten-by-ten grid of black squares on a white background with a black dot in the center and showing a distortion of the grid in the lower left corner indicating how a person with macular degeneration might see the grid. The slide also notes that a person with macular degeneration sees distortions on the grid]

We’ll have patients that we follow with macular degeneration have this home test called an ‘Amsler Grid.’ And anytime these – this – this graph paper- appearing grid shows any kind of wavy-gravy-ness to it or perhaps a splotch that’s missing, that’s a sign that something’s going on, and – and it should be checked out.

[new slide titled, Age-Related Macular Degeneration [AMD], with the following bulleted list about AMD – Macular tissues deteriorates, Mild to severe loss of vision, Not total blindness, Most common cause of visual loss over the age of 60]

So, what is macular degeneration? Well, the macular tissue degenerates, and it can cause mild impairment of vision or substantial loss of vision. It’s not total blindness, because your side vision is preserved. It’s just that for reading and central vision, that’s the part that can be most severely affected. It’s the most common cause of visual loss over the age of 60.

[Dr. Stephen Sauer, on-camera]

There are two types: the dry form is the more common. About 90 percent of people have the dry form –

[slide titled, Macular Degeneration – Two Types, with a bulleted list one bullet labelled Dry (non-exudative) and noting that it is the most common form of AMD, and the other bullet labelled Wet and noting that this variety is about 10% of AMD cases and occurs when abnormal blood vessels under the retina leak fluid, blurring central vision]

– and about 10 percent have the wet form. And the wet form is the kind where there’s leakage and bleeding underneath the retina because there are abnormal blood vessels that creep in from behind the eye into the and under the retina.

[new slide titled, Treatment for Macular Degeneration, featuring a bulleted list for the Dry and Wet varieties of AMD. Under dry the treatment is listed as multivitamins and under the wet treatment is listed as either laser or injection (anti-VEGF)]

There’s no treatment for dry macular degeneration, although we do know that antioxidants like ‘Preservision’ and ‘Occuvite’ can actually slow the progression. So –

[Dr. Stephen Sauer, on-camera]

– for our patients that have dry macular degeneration, that’s a common treatment that we would recommend. It can slow the progression. There are some things you can do to modify the risk factors. For example, don’t smoke. You can minimize your exposure to ultra-violet light by wearing sunglasses and glasses that have ultraviolet light protection. And people with high blood pressure tend to have a little higher problem with this also.

For the wet form –

[return to the Treatment for Macular Degeneration slide]

– that’s the more sudden, acute form. And we often recommend – it used to be laser, but that’s actually falling out of favor in – in lieu of intraocular intravitreal injections now. So, there’s a family of molecules, these anti-VEGF molecules that inhibit blood vessel –

[Dr. Stephen Sauer, on-camera]

– new blood vessel growth. And that’s something that’s the standard treatment now.

There are two types of diabetic retinopathy.

[slide titled, Diabetic Retinopathy – Two Types, featuring the bulleted list of non-proliferative and proliferative and also featuring two illustrated cross-sections of two eyeballs showing the two types]

There’s a non-proliferative type. And these two pictures kind of illustrate – maybe you can see that there’s lots of little red dots here. These little micro-aneurysms and these little white spots. So, there’s abnormal blood vessels that can leak and bleed in diabetic retinopathy. But rather than being here in the macula, they can also be throughout the retina. And then what can happen if it’s untreated is you can see these areas here like a sea fan or some coral here or here. There can be new blood vessels that actually grow into the eye. And those are fragile. They can leak and bleed and cause scarring and permanent loss of vision.

[new slide titled, Treatment for Diabetic Retinopathy, featuring the following bulleted list – Control Blood Sugar Levels, Laser, Injection (anti-VEGF)]

So, it’s important to control your blood sugar. We use laser, but also these VEGF injections can be used –

[Dr. Stephen Sauer, on-camera]

– to treat certain kinds of diabetic retinopathy.

Vascular occlusions are another form of vision loss –

[slide titled, Vascular Occlusions, featuring an illustration of a cross-section of an eyeball and showing hemorrhages in the retina at the top of the retina and normal arteries and veins at the bottom of the retina. Additionally, there is an inset illustration showing an obstructed vein in detail. Next to the illustration is a bulleted list for vascular occlusions – blood flow is blocked in the optic nerve, or retinal vein or artery, it is painless, vision loss can be minimal or severe]

– where it’s a bit like having a stroke in the eye. And so, this picture here shows a little blockage of one of the veins. And there’s this engorgement and backflow of the blood that’s not able to trans – not able to leave the eye because of this obstruction here. And that deprives the tissue in the retina of oxygen. And it starves the retina, and it’s an irreversible cause of blindness.

It may not be a large area of blindness, depending upon where it occurs.

[Dr. Stephen Sauer, on-camera]

But it could be quite substantial also.

And so, the closer to the optic nerve that this blockage occurs, the larger the impact might be. And this could be –

[new slide under the Vascular Occlusion heading featuring the photo from earlier in the talk of a man and woman in kayaks with the lower third of the image in black to show how a person with a vascular occlusion would see that scene]

– somebody might wake up in the morning and say, “I can’t see anything below my hand.” And this might be a picture that represents what that could be – could be like. And this could be the result of a vascular occlusion.

[new slide titled, Vitreous Separation, featuring an illustration of a cross-section of an eyeball showing the vitreous gel separating from the retina at the back of the eyeball. Additionally, there is a bulleted list with the following points – vitreous gel shrinks and pulls away from the retina, it is common with aging, symptoms are a sudden onset of flashing lights and floaters, and it can lead to retinal detachment]

It’s very common to get a vitreous separation. People describe floaters. “Oh, Doc, I – I woke up and there was this flash of light. And now I’ve got this big, giant floater in my eye, and it just keeps getting in the way of my vision.” Well, the vitreous is this jelly-like material inside the back of the eye. And as we get older, it turns from a firm, Jell-O-like consistency to a more soupy kind of consistency. And it will pull away from its attachment at the back of the eye. And very often gives folks a very substantial floater. But it’s very common; everybody will get one. It may be more or less noticeable. There’s no way to predict –

[Dr. Stephen Sauer, on-camera]

– how symptomatic it will be for – for some people. But importantly, it can lead to a retinal detachment. And so, it’s one of those things where, if it’s a noticeable event and you [have] sudden change, we ask people, hope people, will come in and get checked out. Because what can happen is that vitreous –

[slide titled, Retinal Detachment, featuring an illustrated cross-section of an eyeball and showing part of the retina pulled away from the back of the eyeball. Additionally, there is a bulleted list with the facts about retinal detachment – the retina is pulled away from its normal position, it is repaired with surgery]

– that’s no longer attached at the back of the eye here now has a new attachment somewhere else in the eye because it’s separated from here. And it can actually pull and put a tear in the retina, and then that soupy fluid can fall into the back of the eye and cause a retinal detachment.

[Dr. Stephen Sauer, on-camera]

We have specialists that are very important –

[slide titled, Low Vision, featuring three photos – one of a doctor at a computer with an elderly gentleman with the computer screen set on a high contrast setting, one of an elderly woman using a magnifying glass to read a restaurant menu, and a third a photo of a variety of devices that can be used by persons with low vision. The slide also notes that there are more high-tech devices available, from talking clocks to video scanners]

– to the overall care of folks with their vision. And low vision specialists are professionals who have special training in low vision. And there are lots of devices and hand-held aids and computer-based aids that can help people, even if they have macular degeneration or other substantial visual loss –

[Dr. Stephen Sauer, on-camera]

– to remain functional in their homes, balancing the checkbook, managing their – their affairs.

And so, I think it’s just important to remember that most people as they get older have good vision.

[slide titled, Most older people have good vision, featuring a photo of an elderly woman with glasses who is tending to her garden, and noting that – when vision problems do occur, early diagnosis and treatment by an ophthalmologist can help maintain an enjoyable lifestyle]

And if there are problems or changes that occur, if they’re caught early, very often something can be done to help minimize the – the potential change that could occur.

[Dr. Stephen Sauer, on-camera]

And so, I’ve given you the answers here for the post-test. I’ll go through the pictures one more time. Hopefully this does look familiar now.

[return to the initial set of slides – this one titled #1 and featuring the slide with the Money Market list with the blurry central part and the university building whose walls appear wavy]

This macular degeneration can cause this central blurring, or wavy-gravy kind of appearance to the center vision.

[return to slide #2, featuring a photo of a woman tending her garden where the photo appears hazy]

Cataract can cause this central or overall graying of vision. I should mention also that people often will complain of starbursts at night from a point source of light, whether it’s a headlight or a streetlight.

[return to the slide marked #3 featuring the photo of two boys at the playground where the boys are vignetted in the middle and around them it is all black]

Glaucoma can cause a permanent peripheral visual loss. The central vision is the part that’s last to go.

[return to the slide marked #4, featuring the photo of the man and woman in kayaks with the lower third of the photo in black]

And this altitude, what we would call an altitudinal visual field defect can be the result of a vascular occlusion. This can also actually be the result of a –

[Dr. Stephen Sauer, on-camera]

– retinal detachment, depending upon how much of the retina is involved.

So that’s all I have. I hope that’s – I just wanted to give you a survey of some of the more common things that occur in the aging eye. And I hope that that’s been an informative bit of information for you.

[applause]