The eyes have it

The treatment of ophthalmological diseases has never been more advanced, but preventing them is even better.

David Zadok (photo credit: COURTESY SZMC)
David Zadok
(photo credit: COURTESY SZMC)
The eyes are the windows to the body. Philosopher Henry David Thoreau even called them the “jewel of the body.” Since you never get more than two and because (unlike the ears) there is as yet no technological replacement, you had better take care of them.
Some 400 people spent a Friday morning this month learning about the eyes, how to protect them and how physicians with the most advanced equipment treat the many diseases that can affect them in an aging world.
They packed the Hedi Steinberg Auditorium on the fifth floor of Jerusalem’s Shaare Zedek Medical Center for a free, two-and-a-half-hour session of lectures by the hospital’s ophthalmologists and surgeons. The 13th event in the hospital’s Shishi Bari (Healthy Friday) program, with people in the overflow crowd sitting on folding chairs in the aisles, it was so popular that it will apparently be repeated at a later date; the lectures will also appear permanently on the medical center’s website and on YouTube.
As the hospital is geared to developing according to the needs of the community, said SZMC director-general Prof. Jonathan Halevy, the 10th floor in the main building was turned into a comprehensive heart center from prevention through treatment, surgery and rehabilitation because of the dearth of cardiac facilities in the capital. When the Misgav Ladach maternity hospital closed, SZMC greatly expanded its obstetrics branch and now delivers 22,000 babies – more than any hospital in the world – each year. As chronic neurological diseases surge and stroke victims had to be treated as fast as possible, Halevy said, it opened a comprehensive brain and neurosurgery department two years ago, saving many patients from a life of disability.
Now it has stocked its expanded ophthalmology department with advanced diagnostic equipment, lasers and more and hired a new chairman, Prof. David Zadok (who replaced the retiring Dr. Yaacov Rosenman) and numerous experienced specialists, and treats 35,000 patients a year.
Cornea expert Zadok who completed advanced studies at the University of California at San Diego, was previously deputy head of ophthalmology at Assaf Harofeh Medical Center in Tzrifin. At the Shishi Bari program, Zadok focused on dry eyes, a disease that affects women (because of their tendency to have a higher prevalence of autoimmune disease) more than men and becomes more common in both genders as they age. It can cause redness, pain, infections, the feeling of a foreign body in the eye and vision problems.
“It really bothers people and affects 15% to 20% or even more of the elderly,” said the department head.
Dry eye can be diagnosed using various means, from slips of special paper to equipment that assesses the concentration of salts to an infrared camera that picks up the location, number and size of tear glands. Zadok noted that “artificial tears” sold in pharmacies are not very effective, and of those that help, drops with preservatives may be harmful. As a preventive measure or even as treatment, one can consume omega 3 fatty acids, which are anti-inflammatory and found in fish, nuts, eggs, flaxseed and vegetables, as well as in capsules.
One way to treat dry eye is to open up clogged tubes connected to the tear glands. Another is to use special contact lenses that hold tears on the cornea and a method to warm and massage the eyeball or produce light flashes or magnetic stimulation for the production of lubricants.
GLAUCOMA IS a more common eye disease than it was because people have longer life expectancies, said Dr. Lilach Drori-Wagschal, a senior ophthalmologist in the department. Fortunately, while this used to bring an almost-inevitable sentence of blindness, today it can be treated, especially in the earlier stages.
“Glaucoma is a quiet thief of vision,” she noted, “and millions of people around the world have gone blind because of it. Glaucoma doesn’t hurt, cause redness or discharge. By the time it advances, the patient’s vision is hurt.”
The retina is composed of millions of nerve fibers that bundle together and exit to the brain through the optic disc located at the back of the eye. The optic disc has a center portion called the “cup” that is normally quite small in comparison to the entire optic disc.
The image of the retina seen through optical equipment is a red sphere with blood vessels and the optic nerve head. In a healthy eye, she said, there is normal flow of aqueous humor through the drainage canal, but if the fibers are damaged – like water dripping on a rock and causing erosion – vision can be harmed.
“In glaucoma, fluids inside the eye are unable to leak out for various reasons. They accumulate, putting pressure on the optic nerve leading to the brain. This can cause irreversible damage to sight. When the patient becomes aware of it, it’s too late.” The result is a condition called “glaucomatous cupping.”
Cell death causes the cup to become larger in comparison to the optic disc, since the support structure is not there. “Even when half of the fibers are damaged, a person may see OK,” said Drori-Wagschal, but when damage progresses, one loses central vision. Suddenly, the patient feels as if he’s seeing the world through a small keyhole.
Thus, to prevent this process, upon reaching one’s 50th birthday – and before if there is a family history of glaucoma – one should visit an ophthalmologist at least once a year to be tested, painlessly, for intraocular pressure.
The rate of glaucoma at the age of 40 is only 2%, but it rises to 10% over 80. Among the treatments for early stages of glaucoma are drugs (taken daily), argon-laser treatment (selective laser trabeculoplasty) and surgery. Laser treatment takes only a few minutes, she said, but often it has to be repeated periodically. If it doesn’t ameliorate the condition, the alternative is surgery. A hole can be made, but if it exposes the eye to bacteria, infections may result.
Therefore, said Drori-Wagschal, the ophthalmological surgeon can make a very small hole in the layers and cover it with tissue. A reservoir of liquid (bleb) is created. But this involves a scar, and intraocular pressure can return. In such a case, there is a minimally invasive operation to insert a valve into the eye without sutures. A tiny, flexible tube the width of a human hair and six millimeters long can be permanently inserted using an injector. By introducing a harmless, blue-colored liquid under only local anesthesia, the surgeon can immediately determine whether the fluid can seep out; the dye is washed out of the eye within a short period.
DR. JOEL Hanhart, a Swiss-born ophthalmologist who heads the retinal vascular unit, focused on age-related macular degeneration (AMD) and retinopathy resulting from uncontrolled diabetes.
Less than 15 years ago, these conditions were much less treatable. He presented the case of a 54-year-old diabetic who complained about fuzziness in his right eye. Examining his retina, the doctor found hemorrhage and edema in the tissue. When he examined the left eye, about which the man had no complaints, the doctor found a pathologic vessel over the optic disc as well. Left untreated, this vessel would certainly lead to bleeding and visual loss. Lasers can prevent those complications, he said.
“Most patients were told to balance their blood glucose level and they generally improved. The same recommendations are in effect today, but the diagnosis and treatment are completely different. New imaging technology allows us to see much better which areas don’t get enough oxygen. Moreover, we photograph the macula and see its layers and any edema. In addition to more advanced lasers, we have seen a revolution with the injection of material into the eye” said Hanhart. “It is painless when we give a local anesthetic. The retina looks more normal and visual acuity is much improved.” At first, the injection is every month, but as the condition improves, this is often reduced.
Hanhart related the case of a 70-year-old woman with AMD, who suddenly can’t see in one eye. Fluids were demonstrated within and below the retina. The doctor injects the drug into the eye, causing the vessel to be sealed so it no longer leaks.
Thanks to the new technology, Hanhart said that  a lesser proportion of the Israeli population is given “blindness certificates” by the authorities.
DEALING WITH cataracts is the specialty of Dr. Adi Abulafia. Surgery to remove the cloudy lens of the eye is one of the safest and most common operations in the world. It is performed on some 60,000 Israeli patients a year.
The procedure, she said, involves no sutures, as the cut is only two millimeters long and the plastic lens is folded in half when inserted. An artificial intelligence calculator involved in the process of cataract operations was developed in 27 centers – including SZMC – in 14 countries around the world.
While there are standard lenses that can improve one type of vision – distant, medium or close – they have limitations and require the use of reading glasses, but ophthalmology researchers are working on multifocal internal lenses that will be able to cope with all distances. Still, there may be night blindness while driving. There is no perfect technology yet, she said.
About a fifth of patients with cataracts also suffer from astigmatism – an irregularly shaped eyeball. They may be given premium contact lenses with a “cylinder” inside or be referred for refractive surgery if the lenses are uncomfortable.
The surgeon has to mark the place for the cut.
“In our department, we have advanced equipment with a microscope that determines the axis where the cut is made. In the future, there will be ‘smart lenses’ that will change the focus to different distances and even monitor glucose in the blood, could change focus from near to far, could monitor glucose in blood or the condition of the eye and even zoom in and out,” Abulafia said.
“Two years ago, there was a journal article written in China that showed drops that improved cataracts in dogs. So maybe we ophthalmologists won’t have to remove them in surgery, but until then, we are here for you.”
COMBINING OPHTHALMOLOGY and plastic surgery, the Russian-born Dr. Elena Drabkin – who heads the departments oculoplastics unit – discussed eyelid surgery for removing benign tumors that are esthetic problems and malignant tumors that can be medically dangerous. There are some 200 different operations involving the eye. Excessive exposure to UV light can cause tumors. In the elderly, eyelids may turn inward or outward, as the ligaments weaken.
“It is not esthetic and it can also lead to infections. Old people also may develop excess eyelid skin that prevents them from seeing properly; they need blepharoplasty (“eyelid lifts”). It can make them seem seven to 15 years younger, said Drabkin. She performs surgery to repair congenital eye problems in children; some are born with the inability to open their eyes or lids that don’t close. Even eyes that are too far from each other can be “moved.”
She recommended wearing sunglasses outdoors, as when people are exposed to glare, they wrinkle their eyes to protect them. She also urged people to eat a lot of antioxidants and get a good night’s sleep.
FINALLY, DR. David Smadja, head of refractive surgery and director of the research and innovation unit in the ophthalmology department presented helpful ways to protect the eyes and avoid eye diseases and trauma.
“Always wear protective glasses when you are working with something that can harm the eyes,” he said. In the US military, soldiers are wearing them and this has brought down trauma injuries by 70%. The IDF, too, is starting to hand them out.” He also endorsed the use of sunglasses.
In addition, he warned against rubbing your eyes.
“It’s a natural reflex, but in can introduce bacteria into your eyes and cause infections.” If you rub them often, he said, it can weaken the structure of the eye and cause keratoconus – a non-inflammatory eye condition in which the normally round dome-shaped cornea progressively thins, causing a cone-like bulge to develop. This results in significant visual impairment.
For those (most) of us who spend a lot of time looking at TV, computer and smartphone screens, Smadja recommended 20/20/20: Every 20 minutes, look 20 feet (six meters) into the distance for 20 seconds. If not, you will probably suffer from dryness that can harm your vision. Go to your eye doctor regularly from age 50 or younger, at least once a year, for early detection of glaucoma, AMD and other diseases.
A most important, final recommendation is not to smoke, as this toxic habit promotes AMD and raises the risk of cataracts and other eyes diseases – not to mention all the other systemic harm it does to the whole body.