Written with the help of contributing author Linda Robinson, MSN, CPXP, RN, Vice President of Clinical Excellence, MDM Healthcare
Surveys year-after-year report in the United States that blindness ranks in the top 3 of most feared health problems along with cancer and AIDS. Tragically, the Centers for Disease Control and Prevention (CDC) reports that approximately six million Americans have vision loss and one million have blindness. More than 1.6 million Americans who are living with vision loss or blindness are younger than age 40.
MDM Healthcare VP of Clinical Excellence Linda Robinson, MSN, CPXP, RN recently sat down with David G. Miller, MD, President and Medical Director of Cleveland Eye and Laser Surgery Center, to discuss ocular health, chronic eye diseases, and groundbreaking care to slow the progression of vision loss, prevent blindness, and even restore sight.
“Twenty-million people and growing with this disease; really, it's one of those fascinating statistics where the number of people are showing some signs of age-related macular degeneration may be 10% at 70, 25% at 80, and 50% of people hitting their 90s show some signs of age related macular degeneration,” said Dr. Miller. “So, if you're fortunate enough to have a long life, these things are just a much more likely risk.”
According to Dr. Miller, the realm of retinal surgery and diseases has increasingly shifted its focus toward macular degeneration over the past few decades. This heightened emphasis is largely tied to the aging demographic. The formal term for this condition is age-related macular degeneration (AMD), which has a genetic component prevalent in specific families and is notably linked to the aging process. This requires two key factors to align: a familial history of the condition, or the inheritance of specific genes from both parents, coupled with living long enough to encounter the ailment.
Given the rising lifespan of individuals, including the elderly population and the generation of baby boomers, more people reaching their 80s and 90s than ever before, macular degeneration has substantially grown into a prevalent diagnosis. Robinson spoke of her father’s struggles with AMD—most notably the inability to see what was in front of him, decreasing his quality of life. Losing the ability to drive, enjoy sports, and watch TV was extremely difficult for him. This, coupled with hearing loss, limited his ability to interact with the world around him. Robinson could tell that her dad felt very isolated because of his loss of sight.
“A disability acquired late in life, along with the whole aging process; it can bring on a lot of mental changes including possibly depression, which maybe your father was suffering from, whether it's hearing loss or visual loss, or your mobility as an elderly person,” said Dr. Miller. “Losing the freedom you used to have in life can be quite life-altering, and naturally quite depressing.”
These types of symptoms are not uncommon to see with AMD patients.
Dr. Miller describes the visual field of a patient with AMD.
“The macula is the center part of the retina, the retina is the inside lining of your eye. And it's kind of like the film screen in a movie theater. It's where the image is projected so that your brain can see it. And if you can imagine the middle of the movie screen being kind of pockmarked or moth eaten. That's what you're seeing when you're a macular degeneration patient. And as the disease progresses, those, mothy areas kind of coalesce together and form one big blank spot in the middle of vision, these patients can drop to the level of what is called legal blindness.”
He further describes how patients can navigate through a room and can see through their peripheral vision that someone has entered a room but cannot recognize their face. Patients over time become unable to read, write checks, watch TV, drive, etc. They can, however, function in their own home but require assistance.
Dr. Miller went on to explain the two types of macular degeneration.
“There's dry disease, and there's wet disease. And people often confuse the term dry eye with dry macular degeneration. That's completely unrelated, and dry eye is a very common condition.”
He explained, the term dry macular degeneration is used in contrast to wet macular degeneration. Both conditions affect the same part of the retina, known as the macula. In dry macular degeneration, the macula experiences a gradual deterioration, similar to “hair loss or balding.” The cells within the macula progressively decrease in number, leading to what's referred to as atrophy.
On the other hand, he explains, wet macular degeneration often follows a prior phase of dry disease.
“The macula responds to losing those patches of the macula, your eye tries to almost heal itself and grows abnormal blood vessels into that space that then break open leading to bleeding and scarring. So, the breaking open, bleeding, and leaking are the terms that go with wet macular degeneration.”
He continues to add that both types can result in similarly poor vision over time. Wet macular degeneration tends to cause more sudden and acute visual loss, often occurring within months. Conversely, the progression of dry disease is generally slower, taking about a decade to significantly impair vision.
Fortunately, there are treatments available for wet macular degeneration, which can help mitigate the rapid vision loss associated with this form. While treatment options for dry macular degeneration are somewhat limited, there have been breakthroughs in this area as well. It's important to recognize that even though “the majority of patients experience the dry disease, the more severe damage is done by the wet disease itself.”
Robinson brought up how her father who suffered with wet macular began to see things and make up stories around what he saw. She was concerned that it was dementia, but Dr. Miller explained the phenomenon of Charles Bonnet syndrome and how it is a topic at his office weekly. He explained how the brain is kind of fabricating these images.
“You get this very fragmented image on your retina,” said Dr. Miller. “It’s the movie screen, but, you know, literally half the movie screens missing. So, your brain fills in the blanks, and makes a whole image.”
He states that patients and their families are reassured to hear that this is a natural response to macular vision loss and they are not developing a psychiatric illness. Currently there are no medications specifically targeted at addressing Charles Bonnet syndrome. He also added that it is true that losing central vision can lead to disorientation. The combination of age-related mental changes and the loss of clear vision can leave patients less connected to time, space, and their surroundings.
Dr. Miller recommends maintaining good health to prevent macular degeneration. Research indicates that people who exercise regularly, uphold healthy blood pressure levels, refrain from smoking, and maintain a nutritious diet with ample dark green vegetables exhibit a reduced risk of age-related macular degeneration. Certain vitamins also appear to offer protective effects, and there's a potential role for them in prevention. Dr. Miller also recommends monitoring your vision regularly starting in your 40s.
“Macular rarely strikes both eyes at the same time. A simple test you can do is “once a week when you're reading the Sunday paper with a cup of coffee, you close the left eye and you read the headlines and a couple of paragraphs and then your right eye and do the same thing with both eyes can do that you're probably 98% Certain nothing bad is happening. And if something is wrong, or those eyes can't read, go see someone.”
Another area of Dr. Miller’s expertise is diabetic retinopathy.
“Diabetic retinopathy is a leading cause of blindness in American adults under the age of 60 and is the most common eye disease in people with diabetes, he said”
In the United States, 37.3 million people have diabetes, and it is also increasing at an alarming rate 1-in-10 people have diabetes. Miller states that “diabetic retinopathy is the No. 1 cause of vision loss among the working age population.
“The progression of diabetic retinopathy is influenced by blood sugar control and the duration of diabetes,” he said.
Dr. Miller said in the initial five years, retinopathy symptoms are generally minimal, but they become more pronounced after this period. Significant damage occurs around the five-year mark, with signs starting to manifest. Over a decade, more individuals display signs, and by 20 years, around 95% of people with poorly controlled blood sugar experience diabetic bleeding in their eyes, even if they are not yet aware of it.
He said the severity of diabetic retinopathy depends on the duration of diabetes and the level of blood sugar control. Symptoms tend to appear late in the disease progression.
“Typically, by the time they get symptomatic, it's a very late sign of diabetic retinopathy,” Dr. Miller said
Visual symptoms include “blurred vision similar to macular degeneration, or in more advanced cases, bleeding into the vitreous jelly within the eye, resulting in floaters, cobwebs, or even complete vision loss when the eye fills with blood.”
“It’s very important to manage your diabetes every day, and to get annual eye exams,” Dr. Miller said “This is crucial because if it is detected there are treatments that can slow it down or even reverse it.”
He explained that treatment options primarily involve laser procedures conducted in the office using laser beams to safely cauterize bleeding spots at the back of the eye, ensuring no harm to vision. Additionally, a cutting-edge treatment involves injections similar to those used in macular degeneration cases. These injections can effectively halt bleeding or even reverse it through multiple injections over several years. In more advanced cases, such as when bleeding reaches the vitreous gel or retinas detach due to diabetes-related scar tissue, successful outcomes are often achieved through surgery in the operating room.
Most retinal detachments are linked to aging rather than trauma, contrary to belief. Most of these cases are associated with the natural aging of the vitreous gel within the eye. As the vitreous gel in the eye ages, it shrinks and thins within a surrounding sack. Over time, this gel can contract abruptly, tearing the retina and causing symptoms like “flashing lights, some little lightning bolts and floaters.” Timely, medical attention is crucial, as small tears can be treated with laser therapy, preventing detachment. If left untreated, the retina can detach.
“The retina falls off of the back of the eye, almost like wallpaper coming off a wall,” said Dr. Miller. “Retinal detachment requires more complex surgical intervention.”
He discusses how one common treatment to fix a retinal detachment involves removing vitreous fluid and replacing it with a gas bubble to push the retina into position for healing. Maintaining the face-down recovery position is essential for successful healing. This positioning, often for about a week, aids the gas bubble in pressing against the retina for proper healing. Various equipment, including massage tables and specialized chairs, can assist patients in maintaining this position during recovery. Dr. Miller said this is “pretty challenging, but most people pull it off.”
Recently, Dr. Miller was invited to join Akron Children's Hospital Medical Center in Ohio as a retinal surgeon in their pediatric ophthalmology department. His interest was piqued by the “groundbreaking genetic treatments for children born blind.” These treatments involve injecting a virus under the retina to alter DNA, leading to restored vision. This type of genetic treatment is already approved, and there is more new technology on the horizon. This technology is also being adapted for adults, offering a long-term cure with a single injection.
This advancement in genetics is transforming medicine, promising significant improvements in treating genetic defects and enhancing pharmacotherapy.
“It's a very exciting time in medicine,” Dr. Miller said. “Genetic alteration genetics supplementation is going to be really quite remarkable over the next couple of decades in terms of both pharmacotherapy and correcting genetic defects for people.”
He said the potential to restore lifelong sight for pediatric patients is incredibly promising.
“Many brilliant minds are working on these advancements, and I'm confident we'll see significant progress in the next decade.”
For eye health Dr. Miller recommends to do what your mom always told you.
“Eat healthy, exercise, don’t smoke, and be aware of your body. If something isn’t right in your vision you're checking it, you’re getting it checked out. Don't ignore it!”
David G. Miller, MD serves as the President and Medical Director of Cleveland Eye and Laser Surgery Center, the largest retinal surgical facility in the region. He completed a vitreoretinal surgery and diseases fellowship at the Massachusetts Eye and Ear Infirmary, an international center for treatment and research in addition to a teaching hospital of Harvard Medical School. Best Doctors Inc. has recognized Dr. Miller in its list of top retinal disease specialists every year since 2011. He is a charter member of the prestigious Retina Hall of Fame and is a Vitals Patients' Choice Award winner. Dr. Miller’s principal areas of interest are diabetic retinopathy, retinal detachment, and macular degeneration and he has also recently joined Akron Children’s Ophthalmology as a retinal surgeon. Dr. Miller participates in many research studies and speaks locally, nationally, and internationally about vitreoretinal diseases.
To delve deeper into Dr. Miller's insights, you can listen to the full PX Space podcast interview below.