- I'm Marge Murray with UW 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 UW 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)  - 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.  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 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 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 the answer was, was in fact what it was.  So the first question is: what kind of eye problem would cause the vision 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 photo of the building.  So if you know what that, just tick it off in your brain, and we'll revisit this at the end.   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.   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.   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 black.  Keep that in mind, 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.   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 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 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.   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, 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 some sample problems for each of these sections, mostly by showing you some pictures and just describing what we see.  So this Basset Hound appearance 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.   Ptosis, if you look at 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.   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. 

  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.   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.  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, 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 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 just feels terrible."  Occasionally we can run into patients who have tumors.  And what we see here is this little irregularly shaped area here, this little lumpy, bumpy spot 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.   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.   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.  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, 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 is 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 deposition of cholesterol deposits that can occur with age.  It doesn't necessarily mean that you have high cholesterol.  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.   Sometimes people can have a growth on the side of their eye. 

 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 an 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 and then quiet down.  But pingueculum can sometimes progress into something called a pterygium.  And again, you can see this triangular-shaped...   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.  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.   We'll talk a minute here 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 of the eye.  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. 

  This fluid moves from behind the iris into the front of the eye, and then it drains out here.   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 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.   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, but 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.   We also look inside the eye to look at the optic nerve to assess the integrity and the health 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.  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 arcuate area starting here kind of extending up and around, and this is an area 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, is really uninvolved.  But this area around it is affected.   Acute glaucoma is a problem for some people where the pressure can rise very quickly, 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. 

 People can lose a lot of vision in a matter of hours.  Most of the time this is an extremely painful experience, and it brings people to the emergency room.  But it is something that we encounter occasionally.  Cataract, 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.   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 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 that has the cataract.   And you can just see how the light would be impeded from getting to the back of the eye in this eye.  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 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.   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 reversed with surgery.   I just thought I would show this picture.  It's kind of an interesting historical perspective.  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 surgeon with basically 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 possible solution.  And there were a lot of infections, and this was just a last-ditch attempt to try to restore some measure of vision.  But things have come a long way.  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.  And then what we do is we put an implant, after taking out the cataract here, we put an implant inside the natural sac or capsule that holds the cataract.  So we make a hole 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.  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.  And so, what this picture represents is somebody who's got a cataract plus astigmatism.  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.   And similarly, there are multifocal intraocular lenses that allow patients to see not just far away, but also close up.  And we do that by providing a multiple array of focal points.  And this picture's not important to understand exactly, but 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 street signs telling them which way to go, and they can see their speedometer, but 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.   I'll take just a few minutes and talk a little bit further about the retina and also the macula.  This is the tissue that lines the inside of the back of the eye.  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.   Macular degeneration is something that generally affects the center of vision.  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, fence posts, traffic signs, they have this wavy appearance to them.  And that's a sign that there's something going on in the macula.   We'll have patients that we follow with macular degeneration have this home test called an 'Amsler Grid.' And anytime 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 it should be checked out.   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.   There are two types: the dry form is the more common.  About 90 percent of people have the dry form, 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 and under the retina.   There's no treatment for dry macular degeneration, although we do know that antioxidants like 'Preservision' and 'Occuvite' can actually slow the progression.  So 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, 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 lieu of intraocular intravitreal injections now. 

 So there's a family of molecules, these anti-VEGF molecules that inhibit new blood vessel growth.  And that's something that's the standard treatment now.   There are two types of diabetic retinopathy.  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.   So it's important to control your blood sugar.  We use laser, but also these VEGF injections can be used to treat certain kinds of diabetic retinopathy.   Vascular occlusions are another form of vision loss 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 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. 

 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-- 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 like.  And this could be the result of a vascular occlusion.  It's very common to get a vitreous separation.  People describe floaters.  "Oh, Doc, 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, Jello-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 how symptomatic it will be 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 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.   We have specialists that are very important 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 to remain functional in their homes, balancing their checkbook, managing their affairs.  And so I think it's just important to remember that most people as they get older have good vision.  And if there are problems or changes that occur, if they're caught early, very often something can be done to help minimize the potential change that could occur.   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.  This macular degeneration can cause this central blurring, or wavy-gravy kind of appearance to the center vision.  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.   Glaucoma can cause a permanent peripheral visual loss. 

 The central vision is the part that's last to go.   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 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)