Saving Sight: An ASRS Member’s Look at Life as a Retina Specialist and the Heroes of Ophthalmology
Tuesday, September 2, 2014
In 2013, ASRS member Andrew Lam, MD, published Saving Sight—a revealing look at the ups and downs of being a retina specialist working to preserve and restore patients’ sight. Through compelling real-world cases and the stories of innovators who invented the tools ophthalmologists use today, Saving Sight readers will gain a better understanding of the eye and the highly skilled surgeons who treat myriad sight-threatening diseases.
Dr. Lam recently took the time to share what led him to specialize in the retina, why he wrote the book, his thoughts on common retina diseases, and some exciting new approaches to treatments of the future.
1. What led you to become a retina specialist?
After considering all the different disciplines within ophthalmology, I felt I could make the most
difference in patients’ lives as a retina surgeon. The stakes are very high when you go up against serious eye conditions such as macular degeneration, diabetic retinopathy, retinal detachments, and retinopathy of prematurity. I knew I wanted to be someone on the front lines—fighting these diseases every day and trying my best to save my patients’ sight.
2. What is the most fulfilling aspect of your work?
It’s hard to describe the feeling you get when you save someone’s sight, especially if you know that doing so required a high degree of surgical skill or resulted from a deep fund of knowledge gained over many years of study and practice.
As retina specialists, we are able to help people in ways that few others can, and that’s very fulfilling. But it’s also a responsibility and a privilege. A responsibility because of the trust our patients place in us—usually within just a few minutes of meeting for the first time. And it’s a privilege because none of this would be possible without the scores of surgeons who dedicated themselves to training us, or the historical heroes whose inventions allow us to save sight in the first place.
3. What led you to write the book?
Andrew Lam, MD
I wanted the public to better understand what we as retina specialists do—to take readers behind the mask and into the operating room to see what it’s like to save sight, to face a difficult complication, or even to fail.
I also wanted people to know the stories of ophthalmology’s greatest heroes—doctors whose inventions were initially ridiculed but ultimately saved the sight of millions around the world. These are amazing stories of courage, perseverance, defeat, and serendipity. These innovators invented modern cataract and LASIK surgery, discovered how to examine the inside of the eye and repair retinal detachments, and found ways to treat wet macular degeneration and retinopathy of prematurity. These are inspirational tales—and every single one of us will benefit from these discoveries in our lifetimes.
4. What is like, as a retinal specialist, to treat some common retinal conditions?
Age-related macular degeneration (AMD)
When I was a medical student, I watched retina doctors explain to patients that there was no good treatment to prevent wet macular degeneration from inexorably robbing them of their central vision. Sure, there were laser treatments and photodynamic therapy, but neither of those could reliably stop progressive vision loss and certainly did not often improve vision.
Today, we are fortunate to have anti-VEGF medications such as Avastin, Lucentis, and Eylea. These are the closest things to a miracle drug that I have seen in my career—capable of halting the disease in almost all cases and, often, improving patients’ vision.
Much research is being conducted to better understand and treat dry macular degeneration, which is far more prevalent than wet macular degeneration. Although dry AMD does not cause the rapid visual decline that wet AMD does, it does reduce vision over time, and we hope that medications to slow or halt dry AMD will be developed in the near future.
Treating diabetic retinopathy can be one of the most fulfilling—and frustrating—conditions that a retina specialist encounters. Two common eye problems that result from diabetes are vitreous hemorrhage and macular edema.
Vitreous hemorrhages (bleeding in the eye) usually occur from the formation of neovascular blood vessels in the retina. The growth of these vessels is actually the eye’s natural response to the lack of normal blood supply in diabetic eyes, but they are bad because they are apt to leak and bleed. We try to stop the proliferation of neovascular vessels with panretinal photocoagulation laser treatment, and sometimes with injections of a medicine like Avastin.
But when major bleeding in the eye occurs, it can severely affect a patient’s vision—sometimes taking away almost all vision. The good news is that our techniques performing vitrectomy surgery to remove the blood are very good, and some of our most grateful patients are those whose vision has been restored after a vitreous hemorrhage has been cleared.
Diabetic macular edema can be a more frustrating condition to treat. This occurs from leaking blood vessels in the macula—the part of the retina that enables central vision and is, therefore, very important to all of us. The leaking vessels cause swelling in the macula, termed “macular edema.”
If we can reduce or eliminate the edema, the patient’s vision often improves, but this is sometimes hard to do. Our weapons in this battle include eye injections with medicines such as Avastin, Lucentis, or steroids. We can also perform focal laser treatments. The problem is that these treatments don’t always work that well, or for very long.
Sure, some patients respond quickly and do well, but others have persistent macular edema and blurry vision, even after repeated treatments. One of our problems is that we cannot cure the underlying disease: diabetes. Still, we fight diabetic retinopathy as diligently and as well as we can. I tell my patients to consider this a lifelong battle that requires constant vigilance and sometimes many treatments over time. They must also strive to maintain the best blood sugar control they can.
For the retina surgeon, retinal detachments are one of the most important conditions we treat. No other kind of doctor can fix these, which is why we work so hard to perfect our skills in this area.
It’s always a bad day for the patient who discovers that he or she has a retinal detachment. The truth is, there will almost always be some permanent vision loss from a retinal detachment. The good news is that, although retina surgeons cannot restore all the vision lost after a retinal detachment, we can often bring back a lot of sight, and our surgical techniques have become increasingly effective and successful in recent decades.
Fixing macular holes is one of the most gratifying types of surgery retina specialists get to perform. A patient with a macular hole has a black spot in the center of his or her vision—often bad enough to be classified as legally blind in the affected eye.
To do nothing would mean continued poor or worsening vision. So it usually isn’t a difficult decision for the patient to undergo surgery to close the hole. Thankfully, we are almost always successful at closing macular holes and regaining a significant amount of vision for our patients.
Leading-edge treatments and approaches
In the next several years, we anticipate new medicines will be developed that are even more effective at treating wet AMD, and hopefully medicines that last longer so eye injections can be administered less frequently. There is also a lot of research being conducted with drugs that might slow down the progression of dry AMD. Many clinical trials are currently in progress, so the future is bright.
In the long term, I am most excited about the promise of future treatments like gene therapy, stem cells, and even artificial vision. We might one day perform eye injections of tiny, inactivated viruses that transport specially engineered genes into retinal cells. There, these genes can promote the production of proteins that help prevent cell damage or block the proliferation of harmful cell products.
Stem cells have the potential to develop into any cell type in the body. Someday, stem cells might be used to treat any number of degenerative retinal diseases. There are already multiple ongoing clinical trials testing the use of gene therapy and stem cells in patients with eye diseases.
In 2013, the FDA approved the use of the Argus II Retinal Prosthesis System, in which a retinal microchip is inserted into the eyes of blind retinitis pigmentosa patients to restore some sight to them.
The patients wear special glasses fitted with a miniature camera. The images captured by the camera are converted to a series of electrical impulses that are transmitted wirelessly to the microchip inside the eye, which then, in turn, stimulates the eye’s remaining retinal cells to send visual signals to the brain. Now, previously blind patients can distinguish light and dark, detect movement, navigate around large obstacles, and even read large-print words.
We are living in a golden age of ophthalmology, and I consider myself very lucky to be practicing today. Ophthalmologists are a very dedicated and innovative group of people, and I have no doubt that in the course of my career we will see the advent of many more wonderful new treatments that preserve and improve our patients’ sight.