The Eyes Have It

When I was a little boy, eyeglasses were a symbol of "elder" status. My grandparents wore them, but neither my parents nor any of us eight children wore them; I assumed you had to be a certain age to even need them.

All that gradually changed as I grew older and saw my father, then mother, then, at 20, myself, come to need them. Along the way I've met and interacted with many vision-impaired people.

In fact, I am one of them, needing prescription eyewear to correct my less-than perfect eyesight. This is an excellent pair of articles about our plight.

Enjoy.

The New York Times
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February 28, 2006
Personal Health
Sane Steps May Save Your Precious Central Vision
By JANE E. BRODY

Dr. Sidney Schreiber, a cardiologist from Scarsdale, N.Y., was in his mid-70's and still working in the lab and caring for patients when he noticed that he could not see clearly with his right eye.

A visit to his ophthalmologist produced a discouraging diagnosis. Dr. Schreiber had macular degeneration, a rapidly progressive form at that, and within three years he lost 90 percent of his vision, leaving him functionally blind.

An estimated 10 million Americans have this progressive retinal disease, though most are not as severely affected as Dr. Schreiber, and some are not yet aware that they have the painless condition. It afflicts one person in four older than 75 and is the leading cause of legal blindness in Americans over 55.

The numbers affected will continue to climb as the population ages, prompting an escalating race to develop more effective treatments and, perhaps, even preventives, including measures based on recently identified genetic factors that raise the risk of developing the disease.

A Familiar Regimen

Meanwhile, there is much that people can do now to ward off this disabling condition or slow its progress. Interestingly, the very same steps that lower the risk of high blood pressure, heart disease, diabetes and some cancers can also help protect the eyes.

Though peripheral vision remains intact, macular degeneration robs people of their central vision, making it hard or impossible to read, write, drive, watch television, see the time, recognize faces and see where they are going.

Still, many who are seriously afflicted manage to pursue active lives. The late Don Knotts, a co-star of "The Andy Griffith Show" and "Three's Company," was 57 when his disorder was diagnosed. But he continued to work almost until his death on Friday at age 81.

"I got pretty depressed for a while," the American Macular Degeneration Foundation quotes him as saying. "And then one day I said to myself, 'I bet a blind person would give his right arm to have the vision I have.' "

Although most patients are over 55 when found to have what is commonly called age-related macular degeneration, some develop macular disease as children or young adults. Marla Runyan was in the fourth grade when she was struck with a juvenile form of the disease. Yet she finished college and competed twice in Olympic running events despite being legally blind.

Dr. Schreiber, the cardiologist, was an accomplished artist when macular degeneration forced him to abandon his hobby and his career. Like Mr. Knotts, he lapsed into a serious depression for nearly two years, emerging only after a visitor from Lighthouse International showed him all he could do with low-vision aids.

Encouraged by his wife, Freda, who became his eyes, he gradually resumed his favorite activities, with modifications. He visits museums (his wife reads the legends aloud), listens to recorded books ("I've never been so well-read"), gardens (though he sometimes pulls up flowers instead of weeds) and has resumed painting, his artistic talent apparently intact judging from a recent rendition of poppies in a vase.

He has even been able to put his medical training to good use. Now 84, he is scientific director of the American Macular Degeneration Foundation, which sponsors research and provides support and information. It also publishes a quarterly newsletter and has produced the helpful "Hope & Cope" DVD, both available for a $25 contribution. The foundation can be reached at P.O. Box 515, Northampton, Mass. 01061-0515 or at (888) 622-8527. Its Web site is www.macular.org.

The macula is a dense collection of light-sensitive cells in the middle of the retina along the back of the eye. These cells are used for the "straight-ahead" vision needed to read, sew, drive and see fine details. Most cases of macular degeneration begin and remain in one or both eyes as what is called the dry form of the disease. Yellow deposits called drusen form under the retina, increasing in number and size until they destroy macular cells and blur central vision.

The disorder can progress so slowly that deteriorating vision is not noticed until it is quite advanced. But as it worsens, more light may be needed to read and faces may become hard to recognize. Far less often, macular degeneration occurs as the wet form, leading to a rapid loss of central vision when abnormal blood vessels grow under the retina and leak blood and other fluids, raising the macula off the wall of the eye. In about 10 percent of cases, dry macular degeneration eventually develops into the wet form.

Looking for Early Signs

Dr. Schreiber said: "I might have had the dry form for 10 years, for all I know. It's probably my fault for not seeing an eye doctor every year."

Which raises a critical point. Early signs can be readily detected by a thorough eye exam in which the pupil is dilated, allowing the doctor to examine the retina and optic nerve for signs of trouble. People 50 and older should have such exams yearly, or twice a year with signs of disease.

A simple test can be done in any doctor's office (or at home) to detect vision distortions that might not otherwise be noticed. It uses a graphic device called the Amsler Grid, a box of cross-hatched lines with a black dot in the center. Covering first one eye, then the other, a person stares at the black dot. If any of the straight lines appear wavy or missing, that could be a sign of macular degeneration.

Prevention and Treatment

The established risk factors offer strong clues to avoiding or delaying onset of the condition. They include smoking, obesity, high blood pressure, sedentary living, overexposure to sun and a diet deficient in green leafy vegetables and fish.

Other risk factors are being a woman, farsighted or Caucasian and having light eye or skin color, cataracts and a family history of the disorder. Two factors, oxidation and inflammation, appear to cause macular injury. Studies sponsored by the National Eye Institute found that daily consumption of a high-dose formula of antioxidants and zinc could reduce the risk that early macular degeneration would advance.

Various products sold over the counter contain this formula or one like it: 500 milligrams of vitamin C, 400 I.U. of vitamin E, 15 milligrams of beta carotene, 80 milligrams of zinc oxide and 2 milligrams of copper. Smokers should avoid products containing beta carotene, which may increase their risk of lung cancer.

In addition, most experts recommend a supplement of lutein, zeaxanthin or both, carotenoids found in dark green leafy vegetables like spinach and collards. Twinlab makes a supplement, Ocuguard Plus, that contains lutein.

Several drugs, Visudyne by QLT and Novartis and Macugen by Eyetech Pharmaceuticals and Pfizer, have also been shown to slow deterioration of eyesight in wet type macular degeneration. One Visudyne patient in six is said to have shown improved vision, a most exciting advance. Another drug awaiting approval, Lucentis by Genentech, may also help.

This is the first of two columns on vision problems. Next: Living with low vision.


The New York Times
March 7, 2006
Personal Health
Latest in Technology Gives Life a Clearer Focus

By JANE E. BRODY

Is low vision limiting your world?

This condition, which can result from a number of eye diseases, including age-related macular degeneration and diabetic retinopathy, often results in depression and social isolation.

But vision rehabilitation services, the use of low-vision aids and help from family members, friends and caretakers can bring back a productive, enjoyable and independent life for most people who are visually impaired.

Remarkable advances have been made through electronics, computerization and miniaturization to create devices that can help patients read, see and function well again. New and better gadgets are continually being developed at places like the Schepens Eye Research Institute.

But the devices are useful only if patients can afford them, know how to select those that are most likely to help, and receive training and practice in their use. All too often, people spend heavily on devices that are either not right for them, or they never learn to use them properly.

Knowing Where to Turn

The cost of low-vision aids is not yet covered by insurance. Before wasting money on products that may be less than useful, patients should consult an eye doctor who specializes in low vision. Even with professional help in selecting an appropriate vision aid, arranging a trial period to test the equipment may be wise.

A great place to start is Lighthouse International, a source of referrals to low-vision specialists around the world and educational and rehabilitation services for both old and new low-vision aids. This 100-year-old nonprofit organization, at 111 East 59 Street, New York, N.Y. 10022, can also be reached by phone (800-829-0500), e-mail (info@lighthouse.org) or through its Web site (lighthouse.org).

Also helpful is Prevent Blindness America at (800) 331-2020 (preventblindness.org), which, among other services, can help patients find support groups in their areas.

Low vision is not the same as blindness, but it can make normal life a tremendous challenge. As Dr. Eleanor E. Faye, a low-vision ophthalmologist in New York and longtime affiliate of Lighthouse, pointed out about people with low vision:

"Daily life becomes complicated when they are unable to read their mail, check price tags in stores, read nutritional information on food packages, drive, sew or travel alone. Social isolation often becomes the rule when they can no longer see facial details or enjoy simple activities such as playing cards or going to a movie. Even their health may be compromised when they cannot recognize medications or labels or when they lose interest in cooking because the microwave panel or stove dials are indiscernible."

There are both adaptive aids and optical aids. The former include large-type books and recorded books (available from the Library of Congress); talking clocks and calculators; boldface, Braille and talking watches; big button telephones; large-print cards and address books; easy needle threaders; bump dots to help with location (for example, on an oven dial, computer or telephone) and high-intensity lamps and lighting.

The variety of devices is endless. Magnifiers, for example, come in different strengths and styles. There are hand magnifiers, stand magnifiers, pocket magnifiers, magnifiers that look like tiny telescopes and others that look like glasses. Some are worn, others attach to lamps, and some have built-in lights.

Optical aids include simple and advanced electronics. They include closed-circuit television systems (even portable ones), special goggles onto which images from a video camera are projected and computer programs that enlarge text and switch it from black on white to white on black, reduce distracting color to black and white, and convert text to speech.

Computer accessibility aid is available for PC users through microsoft.com/enable and for Mac users through apple.com/accessibility. Before buying any device to make a computer more accessible, be sure it has adequate memory and the needed ports.

Training and practice in the use of optical aids is critical to success. Even learning to use a simple magnifier can require practice. For example, a hand magnifier should be held straight — tilting will distort the image — and on the paper, not lifted to the eyes.

But in focusing on devices, low-vision patients often neglect simple "housekeeping" aids. For example, the Low Vision Center in Bethesda, Md., suggests that hallways and staircases have good lighting that shines on the walls, floor, steps and railings. Mark the edges of steps with contrasting strips.

When working on a task or reading, good lighting should be provided throughout the room. Move lamps close to the work area and light it from both sides to eliminate shadows. Reduce glare by covering shiny surfaces with carpeting or clothes, placing shades on bare bulbs, using adjustable blinds and curtains on windows, and sitting where you don't look directly at a window.

Provide contrast wherever possible. Avoid clear drinking glasses. Rather, use a dark glass for a light-colored drink, and vice versa. Likewise, place foods on plates of contrasting colors. Use contrasting-colored drawer pulls and door handles throughout the home.

In the bathroom, use a toilet seat that contrasts with the wall and floor, and place contrasting-colored tape on the edge of the sink if it is the same color as the wall. Use different colored containers for shampoo and conditioner and use soap that is a color different from the wall. A lighted magnifying mirror is useful for shaving and applying makeup.

To keep track of medications, ask the pharmacist to provide a large-print label and information sheet. Color-code different medications or use bump dots.

Outdoors, the Low Vision Center suggests painting gates and doors in different colors from fences and walls to aid in their location.

Helping a Low-Vision Person

Family, friends and helpers can do much to aid the functioning and safety of people with low vision. Always ask first if help is wanted or needed. A person with limited vision may want to retain as much independence as possible.

When you approach a person with low vision be sure to identify yourself, and tell the person when you leave the room. In social situations, grasp the person's hand in greeting — your extended hand may not be seen. Try to avoid sudden changes in illumination, like having the person go from a brightly lit room to a dark one.

Night lights should always be used wherever there are dim areas and in bedrooms at night. Furniture should contrast with the walls and be positioned to avoid collisions day and night. Needless to say, trip hazards like shoes, clothing or books left on the floor are unacceptable.

In guiding a person with impaired vision, be precise. Say, for example, "There's a flight of steps going upstairs directly to your left," not just, "There are steps over there."

In serving food, identify what is on the plate using the clock — "the meat is at noon, the potatoes at 4, the string beans at 9."
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