Researchers are always looking for answers. That's their job. But with the vast and fast progress being made in all areas of medical research, today's researchers are looking for answers to questions that didn't even exist 20, 10, or even 1 or 2 years ago. Questions like:

• How can we perform an eye transplant?
• How can we make an artificial eye that a patient can see with?
• How can the optic nerve be repaired?
• How can we grow a new retina?
• How can we enable the blind to see?

These and other questions, questions that haven't yet even been thought of, will be answered—eventually. Just when and how the breakthroughs come that will lead to these answers will depend on study, research, and experimentation.

Even though we don't know how or when, or even in what order these questions will be answered, we can make at least a few predictions. While some are based on expected progress in science and technology, others are based on already-evident trends in society.

Many of the changes we will have to deal with are being spawned by competition for patients and the health-care dollar. Others are forced on both doctor and patient by a government that is attempting to regulate the medical profession more, while spending less money on federal and state health-care programs.

It is clear that there are a lot more doctors in practice than there used to be. In most medical specialties, the system seems to be oversupplied, and ophthalmology is no exception.

In addition, optometrists, whose numbers are double those of ophthalmologists, are assuming an ever-expanding role in the diagnosis and treatment of eye disease. Many states now have optometric drug laws that allow optometrists to use drugs for the diagnosis and treatment of eye conditions. Whether the scope of optometry will extend to minor surgical procedures and the use of lasers is still unclear.

Some of this competition has been a good thing. Doctors try harder to please their patients and keep them coming back for regular checkups or treatment. As in other markets, the suppliers who satisfy the consumer—and do so at the right price—are most likely to stay in business and be successful.

On the other hand, consumers are often finding that they have fewer choices than they used to. Companies are signing contracts with clinics and health plans to provide medical care for their employees at reasonable rates. Once the contracts are signed, the patients don't always get the doctors they want at the time and place that is most convenient.

High-volume medicine works well under certain circumstances, but there are times when all of us need a little extra attention. Will we get it in the medical marketplace of the future? It's too soon to tell.

New Surgical Horizons

We do know that surgical procedures are getting better, faster, and more successful. Cataract surgery is a good example. Fifteen years ago, patients were kept in the hospital for three days so the doctor could be sure the healing process was taking place on schedule. Now patients go home an hour after their surgery and have very few restrictions on their activities. That's the kind of development that's good for the doctor, the patient, and the health-care system.

Why are today's cataract operations so much better and the recovery so much faster? You can credit better microscopes, better sutures, and better and sharper surgical instruments. And you can bet that things are going to get better still.

Intraocular lenses have helped people with cataracts get their normal vision back. Contact lenses and intraocular lenses, which replace the traditional post-surgery "Coke bottle" glasses, are constantly being improved.

Bifocal intraocular lenses are also in development. They will let you see both near and far—the theater marquee across the street and the phone book in your hand—without the aid of glasses.

Also likely to become popular: New foldable intraocular lenses that can be rolled up like a taco and slipped into the eye through a tiny incision. Because that incision heals more quickly than a standard incision, visual recovery after cataract surgery will be even faster. We may even have drugs that speed along the healing process and prevent the occasional complication that now occurs.

There may even be drugs one day that prevent cataracts altogether.

You can also be sure that lasers will become an even more important tool for the eye doctor. These focused beams of light are already being used for cutting, burning, and removing diseased parts of the eye.

New advances and developments are constantly being made in reshaping the cornea with lasers and supersharp diamond knives. The aim of this type of high-tech surgery is to correct nearsightedness and other refractive errors.

There is still a great deal of research to be done in this field, because we still don't always know how the eye is going to respond to being reshaped. Not every patient gets the same amount of correction from the same amount of cutting.

In a few years, we may be better able to predict how an individual will respond to a laser cut. Then more people may be able to trade in their glasses for a reshaped cornea.

This Little Light of Mine, I'm Going to Let It Shine

Most diseases are looking for cures. But a laser is a cure looking for more diseases. It is probably the single most important advance in the history of eye treatment in the last 25 years.

Lasers were first used for eye surgery in the 1960s, and since then they have been used to maintain, improve, and in some cases restore sight to countless hundreds of thousands of men, women, and children around the world.

The word laser is an acronym. It was created by taking the first letters of five words—light amplification by stimulated emission of radiation.

To create a laser, you put specific gasses in a tube and then pass a powerful electrical current through it. Ophthalmic lasers usually use one of three different gases: argon, which produces green or blue-green light; krypton, which produces a red or yellow light; or neodymium-yttrium-aluminum-garnet (Nd-YAG), which produces an infrared light.

Argon and krypton lasers are referred to as photocoagulators. The light they emit is absorbed by the pigmented tissues in the eye and converted into heat. This heat burns or cauterizes the tissue, leaving scar tissue. This sort of laser is often used to reattach a detached retina or repair retinal tears or holes, because the scars can be placed to hold the retina to the back of the eye. Even though the eye is blind at the spots where it is scarred by the laser, the scars are small and don't interfere with vision.

These lasers are also used in cases of diabetic retinopathy to burn out and close leaking blood vessels in the eye and to try to limit the damage done by macular degeneration. They are also used in cases of sickle-cell retinopathy, a disease most common among black patients.

Glaucoma sufferers can also benefit from the argon and krypton lasers, which are used to increase drainage, allowing the release of the blinding pressure caused when fluids build up inside the eye. An argon laser can also be used to remove tumors on the eyelid without damaging the eyelid or even leaving much of a scar.

The Nd-YAG laser is a photodisrupter. Instead of burning the tissue, it destroys it by exploding it. It has many uses, such as the cutting away of iris adhesions and the destruction of vitreous strands that could cause a retinal detachment.

This type of laser is also used after some cataract operations when a patient's membrane begins to cloud up and obscure vision. The laser is used to open a hole in the clouded membrane.

Lasers do all this and more, and they do so without the need of a scalpel, incision, or stitches. This means there's no chance of an infection. The laser also has the ability to pass through the clear portions of the eye without damaging them, or even causing any pain. This means that the procedures can be performed on an outpatient basis.

Thanks to sophisticated microscopic aiming and delivery systems—some of which are actually computer controlled—an eye surgeon can operate at a level of precision impossible with a conventional scalpel.

While the list of uses for lasers in eye surgery is long today, it will be even longer tomorrow as researchers develop both new uses and new lasers. One laser probe being developed could actually be inserted inside the eye itself though a tiny hole—about the size of the hole left by a hypodermic needle—in the sclera. Such a laser would allow a surgeon to operate with even greater accuracy than is possible today.

Lasers are already crucial to treating diseases of the retina, and they will certainly become even more important in the future. As technology improves, so will our ability to better focus the laser beam to wipe out abnormal blood vessels without damaging nearby normal tissue. Our ability to treat macular degeneration and diabetic retinopathy will also improve.

Paralleling these developments in lasers, the pharmaceutical industry is making exciting progress in research programs to develop new drugs to treat diabetes, cataracts, and other problems. Such drugs will accurately target certain abnormalities in the body's chemistry, and strike only at them—ignoring everything else.

Our ability to home in on these abnormalities has been greatly enhanced by the sciences of immunology and molecular biology. The high-tech companies you read about in the paper are the innovative pioneers in this futuristic approach to controlling diseases of the eye and other parts of the body.

Finally, we are learning a great deal more about how diseases are inherited and the genetic tendencies that lead to specific medical problems.

As scientists "map" the genetic material, a project that will be completed early in the twenty-first century, we will have a better idea of which tiny part of a chromosome is responsible for which particular characteristic. This will allow us to predict who will develop diabetes, who will lose sight from macular degeneration, and who will get cataracts at an early age. Scientists may also be in a position to prevent a trait from developing (with diet or drugs), or even to modify the genetic material by deleting or replacing the abnormal gene.

It has been said that the next decade will be the biotechnology decade. There is every reason to believe that this is true. Ophthalmology and medical science will certainly be swept along by the new and exciting developments that thousands of brilliant scientists around the world are working on every day.

The ultimate beneficiaries will be the patients who may one day escape the ravages of today's common diseases, and the doctors who strive daily to help their patients.

Low Vision: A Nagging Problem

Despite all of today's high technology and everything else that can be done for the eyes, there are times when nothing works—not surgery, not medication, not taking care of yourself, not even taking all the right vitamins and eating all the right foods and avoiding all the wrong ones.

Low vision still happens—frequently. Next to arthritis and heart disease, it is the single most common disability among senior citizens. Nearly two million Americans have low vision.

A person has low vision when the vision in his best eye—even while wearing corrective lenses—is somewhat worse than 20/70. Low vision is not blindness. As a rule, a person with low vision can tell that something is there, in front of him, but not what—or even who—it is.

There are numerous causes of low vision: cataracts, glaucoma, macular degeneration, diabetic retinopathy, accidents, birth defects, and the natural aging process are just the most common ones.

There are also numerous types of low-vision problems. Sometimes there are problems with the entire eye. In other cases, such as macular degeneration, a person loses central vision but still has peripheral vision. Other types of low vision include the reduction or loss of color vision, reduced focusing power, and problems adapting to changing lighting conditions.

People with low vision can learn how to use low-vision aids. They will not have 20/20 vision, but they will be able to make good use of whatever vision they have left to read, get around, and lead a fairly normal, active, and independent life.

Although people can learn to use low-vision aids, not all of them do. Some refuse to try. Some try for a little while, get frustrated, give up, declare themselves to be blind, and quit trying.

Trying the various low-vision aids, finding the ones that are right for you, and learning how to use them effectively aren't easy. Each step can be hard and frustrating work—but not nearly as hard and frustrating as blindness.

Some people do learn to use the aids but refuse to use them in public. They're embarrassed. As a result, they either turn into hermits, so that no one can see that they have a problem, or they stumble around in public denying that they have any sort of problem.

The keys to learning how to use low-vision aids are motivation, adaptability, realistic expectations, and a willingness to experiment.

There are a variety of low-vision aids, ranging from large-print books and magazines and high-intensity lamps to different types of lenses and electronic image enlargers.

Some are designed for close work and others for distance vision. Most people need a combination of low-vision aids to use at different times for different vision needs.

More and more eye doctors are beginning to specialize in low-vision training. If you have low vision, and your doctor doesn't handle the condition, ask for a referral to a doctor who does, or to a nonphysician low-vision specialist.

The cost of low-vision therapy and equipment can vary depending on your vision, insurance, age, and current state and federal regulations. In some cases, it could be reimbursable or tax deductible.

Low-Vision Lenses

There is a wide variety of lenses available. These include powerful regular and bifocal eyeglass lenses; hand-held, mounted, or wearable magnifying lenses; and telescopic lenses that mount on a section of your eyeglasses. Research is also under way into the possibility of implanting special lenses directly inside the eyes of low-vision patients.

There are some trade-offs in finding the right lenses. You will probably need several of them for different uses. It is also important to keep in mind that the lower the amount of magnification you use, the wider your field of vision.

There are also inexpensive, flat, plastic magnifying lenses available that can be placed on the page you are reading and can also be used as a bookmark when you are done reading.

People with low vision might also want to keep a pair of binoculars handy, especially when they are outdoors. They are quite handy for viewing street signs, billboards, theater marquees, store signs, and other distant objects.

Low-Vision Electronics

Closed-circuit TV systems are available that let you aim a camera or scanner at what you want to read or see. The image is then enlarged and shown on a TV set or computer screen in front of you.

Many electronic systems can be operated with what is called a joystick, so that the person using it doesn't even have to read and punch a keyboard to control the image being transmitted.

Electronic systems can usually provide greater magnification than optical systems. Many of them are quite portable and are battery powered. In fact, research is already under way to develop a portable electronic low-vision enhancer that could be worn on a person's belt.

Such a system would be like a miniature TV studio that could take pictures of what the patient was facing, process and enhance the images, and then transmit them through optical fibers to special TV-monitor glasses worn by the patient.

Low-Vision Lighting

Proper lighting is often as important as the low-vision aid it is used with. In fact, a good low-vision aid without proper lighting can be useless, whereas a lot of light can help a person see better even without low-vision aids.

As a rule, people with low vision see better under standard light bulbs than they do under fluorescent light tubes. But there are a number of different types of light bulbs. You should experiment with different ones until you find the type you need to see your best.

Large-Print and Talking Books

Both Reader's Digest and The New York Times publish large-print editions, the same size type that you are reading now, and both are available by mail. Other publications also have large-print editions. There are also large-print reference books such as dictionaries and atlases, as well as large-print crossword puzzle books. Almost all libraries stock large-print books.

Talking books are also available at bookstores or through your local library and the Library of Congress.

Talking books and other material for the blind and the visually impaired can often be mailed postage free. Talk to your local postmaster to find out about the current rules and procedures.

There are also computer programs available that use a scanner coupled with a voice synthesizer to "read" a book or magazine to you.

In some cities there are radio reading services for the visually impaired and handicapped. These radio stations usually broadcast on one specific frequency, and a special radio receiver is required to hear them. The services usually read the local newspapers as well as some national newspapers and magazines, best-selling books, and community news and events.

For information about what kind of help is available in your area, and who to talk to about it, first check with your eye doctor. But don't be surprised if your eye doctor doesn't know. Doctors deal with medicine, not low-vision aids. You can also check with your local department of social services, nearest office of the National Society to Prevent Blindness, or any other local group that deals with the visually handicapped.

Appliances, Gadgets, and Other Aids

There are many aids and appliances for people with low vision. These include:

• Timekeeping devices such as talking digital clocks and other clocks and watches with large numbers, or large numbers that are projected onto a ceiling or wall.
• Kitchen appliances such as kitchen timers with extra-large numbers, appliances with large buttons and dials, easy-to-read measuring cups and spoons, and largemouth funnels.
• Household gadgets such as large-number push-button phones, large-print playing cards, talking bathroom scales, talking calculators, TV screen enlargers, sewing machine magnifiers, needle threaders, large-print plastic labelers, padlocks that are opened with special magnets; and signature and letter-writing guides that fit over stationery, envelopes, and checks.

These and other aids are available from medical and convalescent supply houses and some mail-order catalogs.

You can often devise your own low-vision aids, as well. First determine what it is you have to accomplish and what could be done to make it easier. Here are ten examples.

• Replace fluorescent fixtures with conventional lights.
• Exchange talking letters with friends and family. Send cassettes back and forth.
• Put a bright light in your closet so you can see exactly what clothes you are taking out and whether they match.
• Replace your telephone notepad and pencil with a large pad of paper and a fat felt-tip pen to make sure that all notes are written large and dark enough to be read.
• Buy large, brightly colored, and distinctively shaped containers for food, drinks, pills, or other things you use every day.
• Get a large key ring, something that you cannot overlook.
• You can also buy little plastic circles that fit on the round ends of your keys. They come in different colors and textures so you can find a specific key more easily.
• Make sure all medication is labeled in large print.
• If you have to take liquid medicine, you can get a tube-type measuring spoon at almost any pharmacy. Use a dark felt-tip pen to mark off the measuring point to show how much you have to take.
• Spend some time learning to tell the difference between coins by feel. Pennies, nickels, dimes, and quarters are all different sizes and weights, and with a little practice you should be able to tell the difference without looking at them. Separate your paper money in your wallet by denomination. Keep $1 bills in one section of your wallet. Keep your $5 bills next to them, but folded in half. Stick $10 and $20 bills in other parts of your wallet.

With a little forethought and some help from technology both simple and advanced, you can learn to make the most of your vision—even low vision.

Eric Rost

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