The Aging Eye

A Harvard Medical School Special Health Report
The Aging Eye

Preventing and treating eye disease
In this report:
New therapies for
macular degeneration
Insights into glaucoma
Preventing diabetic
retinopathy
Dealing with dry eyes
Special Bonus Section

Choices in cataract
surgery
Price: $26
Copyright Notice
This report is copyrighted by Harvard University and is protected by
U.S. and international copyright. All rights reserved.
Here’s what you CAN do Here’s what you CAN’T do

r1SJOUPVUPOFDPQZBOESPVUFUIJTiPSJHJOBMuUPGBNJMZ (without prior permission)
r:PVBSFQFSNJUUFEUPIBWFPOFDPQZPGUIJTQVCMJDB- r.BLFPSGPSXBSEFNBJMDPQJFTPGBOFOUJSFQVCMJDB-
UJPOPOZPVSDPNQVUFSBUBOZUJNF ZPVDBOUQVUJUPO UJPO5IFMBXQSPWJEFTGPSBWFSZMJNJUFEBNPVOUPG
BOFUXPSLVOMFTTZPVQVSDIBTFEBMJDFOTFUPEPTP
DPQZJOH DPNNPOMZSFGFSSFEUPBTiGBJSVTFu)PX-
*GZPVIBWFQBJEGPSNPSFDPQJFT UIFOZPVNBZIBWF FWFS DPWFSUPDPWFSQIPUPDPQZJOHJTGPSCJEEFO
UIBUNBOZDPQJFTPODPNQVUFSTBUBOZUJNF
r&MFDUSPOJDUSBOTNJTTJPOPGBDPQZSJHIUFEXPSLJTUIF
r$PQZ POBOPDDBTJPOBMCBTJT BDPVQMFPGQBHFTUP MFHBMFRVJWBMFOUPGQIPUPDPQZJOHJU BOETPJTQPTU-
HJWFUPGSJFOET GBNJMZNFNCFST PSDPMMFBHVFT JOHJUPOUIF*OUFSOFUPSJOBOFMFDUSPOJDEBUBCBTF

BOEJTUIFSFGPSFOPUBMMPXFE
r8FBSFSFHJTUFSFEXJUIUIF$PQZSJHIU$MFBSBODF$FOUFS
$$$
:PVDBODPNQMZXJUIUIFDPQZSJHIUMBXTCZQBZ- r3PVUJOFMZDPQZBOEEJTUSJCVUFQPSUJPOT
JOHBSPZBMUZPODPQJFTZPVNBLFPGQBTTBHFT#VUOPU
r3FQVCMJTIPSSFQBDLBHFUIFDPOUFOUT
FWFOUIF$$$DBOBVUIPSJ[FDPWFSUPDPWFSQIPUPDPQZ-
JOHPSXIPMFTBMFFMFDUSPOJDGPSXBSEJOH 4PNFQVCMJTIFSTNVTUSFTPSUUPMBXTVJUTUPQSPUFDU
UIFJSQVCMJDBUJPOT)BSWBSE)FBMUI1VCMJDBUJPOTXPVME
r*GZPVXBOUUPEJTUSJCVUFDPQJFTPGUIJTQVCMJDBUJPO
MJLFUPFMJNJOBUFUIFOFFEGPSTVDITVJUTCZIFMQJOHUP
FJUIFSJOQSJOUPSFMFDUSPOJDGPSN UPPUIFSTPOB
FEVDBUFDVTUPNFST8FIPQFUIJTPVUMJOFIBTIFMQFE
SFHVMBSCBTJT BTLVTBCPVUCVMLEJTDPVOUTPSMJDFOT-
explain what is legal and what is not.
JOHPQQPSUVOJUJFT:PVNBZCFBCMFUPOFHPUJBUFBO
BHSFFNFOU GPSBTJOHMFGFF UIBUXPVMEFOBCMFZPV
UPMFHBMMZEJTUSJCVUFQIPUPDPQJFTPSFMFDUSPOJDDPQJFT
to others. For more information
Copyright Clearance Center (CCC)
1I
XXXDPQZSJHIUDPN
Permissions Requests
/BUBMJF3BNN )BSWBSE)FBMUI1VCMJDBUJPOT
1I
OBUBMJF@SBNN!INTIBSWBSEFEV
Licensing, Bulk, and Corporate Sales

5POZB1IJMMJQT #FMWPJS.FEJB(SPVQ
1I
UQIJMMJQT!CFMWPJSDPN
Harvard Health Publications

)BSWBSE.FEJDBM4DIPPM
4IBUUVDL4USFFU OE'MPPS
#PTUPO ."
XXXIFBMUIIBSWBSEFEV
Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
the aging eye
SPECIAL HEALTH REPORT
Contents
Medical Editor How the eye works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Laura C. Fine, M.D. Eyeball engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Clinical Instructor in Ophthalmology,
Harvard Medical School The art of seeing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Ophthalmic
Ophthalmic Consultants
Consultants of
of Boston
Boston Why aging may cause problems. . . . . . . . . . . . . . . . . . . . . . . . . 4
Jeffrey
Jeffrey S.
S. Heier,
Heier, M.D.
M.D.
Clinical
Clinical Instructor
Instructor in
in Ophthalmology,
Ophthalmology,
The eye examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Harvard
Harvard Medical
Medical School
School Testing your vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Assistant Professor, Tufts Medical School
Assistant Professor, Tufts Medical School Examining the external eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Ophthalmic Consultants of Boston
Ophthalmic Consultants of Boston Examining the internal eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Writer
Writer
Julie Corliss
Julie Corliss Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Editor What causes cataract?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Editor
Annmarie Dadoly
Annmarie Dadoly Diagnosing cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Editor, Special Health Reports Preventing cataract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Editor, Special Health Reports
Kathleen Cahill Allison
Kathleen Cahill Allison
Art Director SPECIAL BONUS SECTION:
Art Director
Heather Derocher
Heather Derocher Choices in cataract surgery. . . . . . . . . . . . . . . . . . . . . . . . 12
Production Editors
Production Editors
Mary Kenda Allen
Mary Kenda Allen Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Melissa Rico
Melissa Rico What causes glaucoma?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Illustrators
Illustrators Types of glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Harriet Greenfield
Harriet Greenfield Diagnosing glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Scott Leighton
Scott Leighton Treating glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Published by Harvard Medical School
Published by Harvard Medical School
Anthony L. Komaroff, M.D., Editor in Chief Age-related macular degeneration. . . . . . . . . . . . . . . . . . 28
Anthony L. Komaroff, M.D., Editor in Chief
Edward Coburn, Publishing Director
Edward Coburn, Publishing Director Types of AMD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Copyright ©2012 by Harvard University. Written permission is
Copyrightto©22012
required by Harvard
reproduce, University.
in any manner, Written
in whole or permission
in part, the is Causes and risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
required to reproduce,
material contained in any
herein. manner,
Submit in whole
reprint or ininpart,
requests the to:
writing
material contained herein. Submit reprint requests in writing to: Diagnosing AMD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Harvard Health Publications Treating AMD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Harvard Health
10 Shattuck St.,Publications
2nd Floor, Boston, MA 02115
10 Shattuck St., 2nd Floor, Boston, MA 02115 Self-care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
617-432-1485 Fax: 617-432-4719
617-432-1485 Fax: 617-432-4719
Website
Preventing and slowing AMD. . . . . . . . . . . . . . . . . . . . . . . . . . 34
Web
For theSite
latest information and most up-to-date publication
For
list, the
visitlatest information
us online and most up-to-date publication
at www.health.harvard.edu. Diabetic retinopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
list, visit us online at www.health.harvard.edu.
Customer Service Preventing diabetic retinopathy . . . . . . . . . . . . . . . . . . . . . . . . 37
Customer Service
For all subscription questions or problems (rates, subscrib- Progression of diabetic retinopathy . . . . . . . . . . . . . . . . . . . . . 37
For
ing, all subscription
address changes,questions or problems
billing problems), call(rates, subscrib-
877-649-9457,
ing, address changes, billing problems), call 877-649-9457, Detecting diabetic retinopathy. . . . . . . . . . . . . . . . . . . . . . . . . 37
send an e-mail to HarvardProd@StrategicFulfillment.com,
send an toe-mail
or write to HarvardProd@StrategicFulfillment.com,
Harvard Health Publications, P.O. Box 9308, Treating diabetic retinopathy. . . . . . . . . . . . . . . . . . . . . . . . . . 37
or write to Harvard Health Publications, P.O. Box 9308,
Big Sandy, TX 75755-9308.
Big Sandy, TX 75755-9308.
Ordering Special Health Reports
Other common eye diseases of later life . . . . . . . . . . . . . 39
Ordering Special
Harvard Medical SchoolHealth Reports
publishes Special Health Reports Presbyopia: Ready for reading glasses?. . . . . . . . . . . . . . . . . . 39
Harvard
on a wideMedical
range ofSchool
topics.publishes
To order Special
copies ofHealth
this orReports
other
on a wideplease
rangesee
of topics. To order copies Eyelid problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
reports, the instructions at the of thisoforthis
back other
reports, please see the instructions at the back
report, or go to our website: www.health.harvard.edu. of this Dry eye syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
report, or go to our website: www.health.harvard.edu.
For bulk rates, corporate sales and licensing:  Watery eyes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
For bulkMedia
Belvoir rates, Group,
corporate sales and licensing: Belvoir Media
Group Attn: Floaters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Attn: HarvardHarvard
HealthHealth Publications P.O. Box
Publications,
5656 Norwalk, CT 06856-5656 email:
P.O. Box 5656, Norwalk, CT, 06856-5656; licensing@belvoir.com. Flashes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
ISBN 978-1-61401-005-0
email: licensing@belvoir.com. Retinal tear or detachment. . . . . . . . . . . . . . . . . . . . . . . . . . . 44
The goal
ISBN of materials provided by Harvard Health Publications
978-1-61401-011-1
is to interpret medicalprovided
The goal of materials information for the Health
by Harvard generalPublications
reader. This Safeguarding sight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
report is not intended
is to interpret as a substitute
medical information for theforgeneral
personal medical
reader. This
advice, which should be obtained directly from a physician.
report is not intended as a substitute for personal medical
Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
advice, which should be obtained directly from a physician.
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Dear Reader,
Of your five senses, which one are you most afraid of losing? If you’re like most people, the
answer is your ability to see. Despite this, many people are not conscientious about caring for
their eyes and often neglect to visit an ophthalmologist for routine eye exams as they get older.
Like the rest of your body, your eyes naturally change throughout your life. These changes
occur gradually and become apparent in later years, as the structures in and around your eyes
become less efficient. For most people, the first sign is presbyopia, deterioration of close-up
vision. Luckily, this problem can be treated with reading glasses or bifocals.
However, more serious age-related eye problems can cause vision loss or visual distortion that
glasses can’t fix. More than one million Americans older than 40 are considered legally blind,
which means their vision is 20/200 or worse in their best eye, even with corrective lenses or
surgery. Another 2.4 million have significantly reduced vision. The risk of developing vision
problems increases as you get older, especially after age 65. One dramatic example: people ages
80 or older make up about 8% of the U.S. population, but account for 69% of people who are
blind.
This report focuses on four disorders that pose the greatest threats to vision after age 40: cata-
ract, glaucoma, age-related macular degeneration, and diabetic retinopathy. It will help you
determine your risk of developing these disorders, describe their symptoms, and discuss diag-
nosis and treatment. This report also describes other common eye disorders, including pres-
byopia, dry eye, floaters and flashes, retinal detachment, and eyelid problems such as drooping
upper or lower lids.
In this report, you’ll learn why you should have regular eye exams, especially if you have diabe-
tes or a family history of glaucoma; how to recognize the risk factors and symptoms of specific
eye diseases; and what steps you can take to prevent or treat them before your vision deterio-
rates further. You’ll learn about the latest advances in cataract surgery, as well as new ways to
screen for and treat age-related macular degeneration. This report also provides specific infor-
mation about what you can do to protect your eyes—and your vision.
Sincerely,
Laura Fine, M.D. Jeffery Heier, M.D.

Medical Editor Medical Editor
Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
How the eye works
T he eye is often compared to a camera, but in truth,

the organ of sight is far more complex and effi-
cient. Not only does the eye focus and snap pictures,
Eyelids and eyelashes act like windshield wip-
ers, constantly brushing and blinking away dust and
other debris that might otherwise blow into the eye.
but it also works continuously with the brain and ner- The lacrimal gland, located behind the upper lid, pro-
vous system to process ever-changing images, produces tears that course over the eye surface and keep
viding you with the visual information you need for it lubricated, nourished, and clear of foreign matter.
doing everything from hitting a golf ball to preparing Tears drain off into the nose through ducts at the eye’s
your taxes. innermost corner.
The conjunctiva is a thin, colorless membrane that
lines the inner surfaces of the eyelids and the front
Eyeball engineering portion of the sclera, the eye’s white outer surface. The
Despite its reputation as a delicate organ, the eye is conjunctiva is so sensitive that when it becomes aware
remarkably resilient and hardy, engineered by nature of a foreign body, it automatically triggers a protective
to last from infancy through old age. Shaped like a reaction, such as tearing or blinking.
sphere, the eyeball is about an inch in diameter, with Six extraocular muscles regulate each eye’s up-
a slight protrusion in front. It sits in a bony, protective and-down, side-to-side, diagonal, and rotational
socket of the skull, called the orbit, and is surrounded motions. The muscles come in pairs and run from the
by a cushiony layer of fibrous tissue, fat, and muscles. back of the orbit to the sides of the eyeball, beneath
the conjunctival membrane (see Figure 1).
Three distinct layers of tissue surround the eye
and form its wall (see Figure 2). The surface layer
(approximately 1 millimeter thick) is made of tough
collagen. You see it in the visible part of the eyeball as
both the sclera (the white part) and the cornea, a clear,
dome-like window at the front of the eye.
The middle layer, called the uveal tract, comprises
the iris, ciliary body, and choroid. The iris—the pig-
mented segment, which might be blue, green, brown,
or another color—forms a ring around the pupil, a
black hole in the center of the iris. Basically a circular
curtain of muscle fibers, the iris controls how much
light enters the eye. As with an automatic camera,
The National Eye Institute created a series of photos to demon- which adjusts the size of its aperture (opening) to the
strate how different eye problems affect vision. The photo above available light, the involuntary muscles of the iris open
shows how a person with normal vision would see those two boys
to allow more light to enter the pupil in dim light, and
while standing 20 feet away from them. In this report, you’ll find
examples of how people with cataract, glaucoma, age-related
close to make the pupil smaller in bright light. A good
macular degeneration, and diabetic retinopathy would see the example of the eye’s adaptation is the mildly painful
same boys. change that occurs when you walk into sunlight after
Photograph courtesy of the National Eye Institute. sitting in a dark movie theater. Even subtle alterations
2 The Aging Eye w w w.h ealt h .ha r va r d.e du

in light prompt a response from the eye, and the iris Within the retina are about 150 million rods and
muscles are continually adjusting to the environment. seven million cones—specialized cells made up of chem-
Just behind the pupil and iris lies the crystalline icals that react to different wavelengths in light. Located
lens, which is connected at its outer rim to the cili- mainly in the periphery of the retina, the rods do not
ary body by ligaments called zonules. The lens focuses perceive color. The cones, which do perceive color, are
light rays on the retina, the thin, light-sensitive inner responsible for fine detail in the center of vision. They
layer at the rear of the eye. Muscles in the ciliary body enable us to read words on a page and recognize a famil-
enable the flexible lens to alter its shape and allow the iar face from across the room. Cones are most active in
eye to focus on objects at varying distances. When bright light, while rods are most sensitive in the dark;
you look at a tree far away, for instance, the muscles this is why it is hard to detect colors and fine details in
relax and stretch the zonule ligaments, which in turn the dark. The cones are located primarily in the macula,
pull on the lens, causing it to flatten and assume a thin a remarkably small part of the retina that gives us sharp
contour. But shift your gaze to something close, such central vision. The best vision—for reading or detailed
as a computer screen, and the muscles contract and work—comes from the fovea, at the center of the mac-
loosen the zonules, which makes the lens thicker and ula. The rest of the retina delivers peripheral vision (side
curved more in the middle. The ability of the lens to vision), which is less sharply focused.
focus from far to near is called accommodation.
The ciliary body also produces aqueous humor,
a watery fluid that provides nutrients to the lens. The art of seeing
The aqueous humor is found principally in the space Sight is not fully developed at birth; the brain and
between the iris and the cornea, known as the anterior eyes have to learn to work together in the first months
chamber. The fluid flows to this region from the poste- of life. Once sight is well developed, the eyes and
rior chamber—the area between the iris and the lens—
and then carries waste products from the eye through
the trabecular meshwork and Schlemm’s canal, a cir-
Figure 1 Eye anatomy
cular drainage system located where the clear cornea,
Orbital bone
white sclera, and colored iris meet. In a healthy eye,
this circulation constantly drains and resupplies the
aqueous humor, maintaining a balance of fluid in the Extraocular
muscles
two chambers. Eyelid
Behind the lens is the vitreous humor. This clear,
stable gel, which looks like raw egg white, supports Eyeball
and fills the rear two-thirds of the eyeball. This gel Cornea
provides a pathway for light coming through the lens. Iris
The choroid is sandwiched between the sclera
Sclera
and retina in the rear of the eye. This membrane is
packed with blood vessels that carry oxygen and
other nourishment to the adjacent outer portion of
the retina. Orbital bone
The retina, the innermost layer, is where images
are captured and recorded. This mass of unique nerve
The eyeball is surrounded by ligaments, fat, and muscles and
cells and fibers sends the brain visual messages about rests in a protective, bony socket called the orbit. Six extraocular
the size, shape, color, and distance of the objects you muscles control the eyeball’s movement. The cornea, a tough,
see. The images travel along the optic nerve, which transparent dome that helps focus light, and the sclera, the white
carries the signals to the brain. portion of the eye, protect the interior of the eye.
ww w. h ealt h . h ar v ar d . e du The Aging Eye 3

Figure 2 The inside story down on the retina, the brain automatically turns it
right side up.
Extraocular
muscle
Although it is possible to see with only one eye,
Trabecular Sclera you generally rely on binocular vision—vision with
meshwork
Choroid
both eyes—for depth perception. You get a three-
Anterior dimensional view of your vehicle because the brain
chamber Retina interprets what is seen from your two eyes (each
Cornea with a slightly different perspective) as a single
image.
Lens Vitreous Macula
Pupil humor If a flashy car nearby catches your attention, you
instantly shift your gaze without a thought. The exter-
Iris nal muscles of the eyes are synchronized to keep the
eyes aligned and to coordinate their movement.
Posterior Optic nerve
chamber
Ciliary body
Why aging may cause problems
Just as hair turns gray and skin sags with age, the eyes,
Rays of light pass through the cornea, the anterior chamber, and
too, undergo a metamorphosis as you grow older.
then through the lens, which focuses images. The lens is nourished
by the aqueous humor, a clear, watery solution that circulates Although many of these changes are part of nor-
from the posterior chamber into the anterior chamber and helps mal aging, some set the stage for more serious eye
maintain normal pressure. Light reaches the retina after it passes problems.
from the lens through the vitreous humor, a clear gel that fills As eyes age, eyelid muscles weaken, and skin
most of the eyeball. The retina has light-sensitive cells that capture becomes thinner and more flaccid. This can cause
images, which are then sent to the brain via the optic nerve. At the
the upper lid to droop or the lower lid to sag. Eye-
retina’s center is the macula, a small region that provides sharp,
central vision. lashes and eyebrows may lose their lushness and thin
out considerably.
the brain team up to provide virtually instantaneous Tear production also drops off, and the oily film
visual information. that tears provide decreases as lubricating glands
Consider what happens when you walk through in the conjunctiva and lids fail. These changes can
a parking lot and spot your car. First, you are actually lead to a buildup of mucus, resulting in stickiness, or
seeing the light reflected off the car that enters your make the cornea dry, causing irritation or an uncom-
eye; some light must be present in order to see. fortable, gritty sensation in the eye.
If the image is clear, it means that light thrown off The conjunctiva turns thinner and more frag-
the surfaces of the automobile hits your cornea, where ile with age and takes on a yellowish tinge from
it is refracted, or bent, inward and is then sent through an increase in elastic fibers. The white of your eye
the aqueous fluid until it reaches the lens. The light (sclera) also assumes a yellow hue from a collection
rays are then bent further, passed through the vitreous of lipid, or fat, deposits. Calcium may deposit in the
fluid, and projected onto the retina as a flat, upside- sclera, leading to patches of grayish translucency.
down image. The exposed conjunctiva between the lids begins to
The light is absorbed by the retina and turns into degenerate, and the cornea can develop an opaque
electrical energy, which the optic nerve then conveys white ring around its edge.
to the visual area of the brain. Data about your car— With time, the crystalline lens hardens and loses
its size, shape, color, and position—are sent along the its elasticity. This makes it more difficult to focus on
optic nerve as impulses, a sort of neurologic code that near objects, a common condition called presbyopia.
the brain deciphers. Although the image is upside You might also find that your night vision grows

poorer. These changes usually occur simultaneously
Warning signs that warrant a doctor visit
in both eyes.
Aging can also cause the lens to darken, grow See an ophthalmologist if you experience any of the fol-
lowing symptoms or problems with your eyes:
opaque, and in some cases thicken, causing nearsight-
edness. Clouding of the lens, which is called cataract, • Change in iris color • Halos (colored circles
usually develops slowly over many years. It may go • Crossed eyes around lights) or glare
unnoticed until the cloudiness blocks the central line • Dark spot in the center of • Hazy or blurred vision
of sight and impairs vision (see “Cataract,” page 9). your field of vision • Inability to close eyelid
Over time, the anterior chamber in each eye may • Difficulty focusing on • Loss of peripheral vision
become shallower in some susceptible people—those near or distant objects • Redness of or around the
who have small eyes and are farsighted, for example. • Double vision eye
This raises the risk for blockage of the aqueous humor • Dry eyes with itching or • Spots in your field of
burning vision
drainage system near the iris. The resulting fluid
• Episodes of cloudy vision • Sudden loss of vision
backup may lead to higher pressure inside the eye that
• Excess discharge or • Trouble adjusting to dark
damages the optic nerve, a condition known as closed-
tearing rooms
angle glaucoma. Left untreated, it can cause blind-
• Eye pain • Unusual sensitivity to
ness. Another form of glaucoma, called open-angle
• Floaters or flashes light or glare
glaucoma, occurs when pressure builds up in the eye
• Growing bump on the • Veil obstructing vision
because of a different problem: the aqueous humor is
eyelid • Wavy or crooked appear-
less able to flow out through the trabecular meshwork ance to straight lines
and Schlemm’s canal. Because glaucoma can silently
steal sight before symptoms develop, it is important
to have routine eye exams (see “Glaucoma,” page 20). Although age-related changes affect everyone, your
The aging retina thins and may grow less sen- race affects your risk for specific types of eye disease. In
sitive because of cell loss, a reduced blood supply, Americans older than 40, the leading cause of blindness
or degeneration. Especially prone to deterioration in white people is age-related macular degeneration,
is the macula; age-related macular degeneration is while in black people it is cataract, and in Hispanic peo-
a serious disease that can steal a person’s central ple it is glaucoma (see Figure 3). This probably results
vision (see “Age-related macular degeneration,” from a combination of factors such as genetics, dietary
page 28). patterns, and access to medical care.
Figure 3 Causes of blindness by race

White persons Black persons Hispanic persons
8.7% 4.4%
6.4% 14.3% 14.3%
36.8%
54.4% 5.4% 25.6%
7.3% 28.6% 28.6%

25.0%
26.0% 14.3%
The leading causes of blindness vary by race and ethnicity. AMD Glaucoma Other
Adapted with permission from Archives of Ophthalmology. Cataract Diabetic retinopathy

The eye examination
R egular, comprehensive eye exams are the best way

to detect eye disease early, when treatment (if
available) is most effective. (For guidelines on how
vision as your eye’s “vital sign,” much like blood pres-
sure and heart rate are the heart’s vital signs. If you
wear corrective lenses, the doctor tests your vision
often to be examined, see Table 1.) A thorough eye while you wear your glasses or contact lenses and also
exam involves a series of evaluations—some done looks at your glasses through a device called a lensom-
in the dark, some in the light, and some with special eter to determine their exact prescription.
instruments. People who feel their eyes are too sensi- Your exam score indicates how well you see com-
tive or who fear an eye exam should be assured it is pared with someone whose vision is normal. For
not painful. instance, if you have 20/20 vision—considered the
Because some eye disorders are inherited and oth- standard for normal—that means you can see at a dis-
ers develop after an illness, the doctor will ask about tance of 20 feet what another individual with normal
your family and personal health history. Diabetes, for vision sees at 20 feet. However, if your vision is 20/40,
example, can affect vision and always deserves careful you see at a distance of 20 feet what a person with
attention (see “Diabetic retinopathy,” page 36). normal vision would be able to see at 40 feet; in other
words, you need to stand closer to the object to see it
as clearly. In general, the higher the second number,
Testing your vision the worse your vision.
That familiar chart with rows of letters and numbers If the test indicates a need for corrective lenses or
that diminish in size is the Snellen chart. A doctor or a prescription adjustment, the doctor measures the
technician uses this chart to test the sharpness of your eye’s refraction, or focusing accuracy, using instru-
central vision, known as visual acuity. Think of central ments that contain a combination of corrective lenses.
Table 1 When to see an eye doctor

Otherwise healthy people
Younger than 40 After initial examination, only when visual changes, eye injury, or ocular symptoms occur
Ages 40–64 Every two to four years
Ages 65 and older Every one to two years
People with diabetes
Type 1 diabetes diagnosed before age 30 Five years after diagnosis; at least annually thereafter
Type 1 diabetes diagnosed at age 30 or older At time of diagnosis and at least annually thereafter
Type 2 diabetes At time of diagnosis and at least annually thereafter
Special considerations
• People at greater risk for specific eye conditions because of age, family history, or other factors will need to schedule certain parts of the eye
exam more frequently.
• People with certain illnesses, or those taking certain medications, may need to schedule more frequent exams; ask your doctor for guidance.
• Women who are pregnant and have diabetes may need more frequent eye exams.
Source: American Academy of Ophthalmology.

To confirm that reading, you will be asked to look Checking the coordination of the six muscles in
through a variety of lenses to ascertain which one each eye is an important part of the exam. Tests vary,
gives you the best sight. but the goal is to ensure that your eyes function prop-
The doctor will also evaluate your peripheral erly together.
vision. Typically you’ll be asked to cover one eye and
fix the other eye on a point straight ahead. The doctor
will shift an object, such as a pen, back and forth at Examining the internal eye
the outer edges of your visual field and ask you to note Using a slit lamp, a diagnostic tool with a powerful
when you see it moving. microscope and a narrow slit of light, the doctor can
In certain circumstances, your color vision may explore different levels of the eye’s transparent tissue
also be measured with special color pictures. In addi- and assess the inner workings of the eye. As you keep
tion, depth perception can be determined with a series your head steady on a chin rest, beams of light are pro-
of three-dimensional images. This is especially impor- jected onto and into your eye. The instrument’s use of
tant if anyone in your family has had strabismus (eye narrow light beams and high magnification provides
muscle imbalance). a cross-sectional picture of eye tissue. This gives the
doctor a close-up view of the cornea, anterior cham-
ber, lens, vitreous humor, and retina. The doctor will
Examining the external eye check for many things, including degeneration or the
The doctor examines the outer eye—the lids, lashes, presence of foreign particles in the cornea, inflamma-
and orbit—and looks for signs of any underlying prob- tion within the anterior chamber, cataract, floaters,
lems, such as infections, sties, cysts, tumors, or lid mus- and tumors or abnormal blood vessels in the iris.
cle weakness. The doctor then checks your eyeball’s ■ Testing pupil dilation. The doctor applies spe-
appearance (including the sclera and conjunctiva) and cial eye drops to dilate your pupils, allowing a better
notes whether the pupil reacts normally to light. examination of the eye’s interior. The drops take time
Your eye professionals

If you’ve ever been confused about whether you need to see Ocuplastic specialist. This is an ophthalmologist who has
an ophthalmologist, optometrist, or optician, you’re not received advanced training in plastic and reconstructive
alone. Although the names of these specialists sound similar, surgery of the eye and surrounding structures. Oculoplastic
each plays a distinct role in eye care. Because the training specialists are often consulted for problems with the eyelids,
and experience of each specialist varies, it is important to tear drainage, and skin cancer around the eyes.
seek the services of the appropriate professional for your eye Optometrist. An optometrist, or doctor of optometry, is a
care needs. health service provider who deals with vision problems.
Ophthalmologist. An ophthalmologist is a physician— Optometrists must complete a four-year course at an
either a doctor of medicine (M.D.) or doctor of osteopathy accredited college of optometry, but they do not attend
(D.O.)—who specializes in medical and surgical care of the medical school and are not trained to perform surgery. They
eyes and visual system, as well as in prevention of eye dis- are licensed by the state to examine the eyes, determine the
ease. Licensed ophthalmologists must complete four or more presence of vision problems (including eye diseases),
years of medical school, one year of internship, and three recommend eye exercises, and prescribe eyeglasses and
or more years of specialized medical, surgical, and refrac- contact lenses. In many states, optometrists are permitted to
tive training. Ophthalmologists are qualified to diagnose treat certain eye conditions with medications. Normally, if an
and treat (medically and surgically) diseases, disorders, and optometrist diagnoses a serious eye disorder in a patient, he
injuries of the eyes and visual system. In addition, they can or she will refer that person to an ophthalmologist.
provide more basic eye care, including prescribing eyeglasses Optician. An optician is a technician who makes and fits
and contact lenses. eyeglasses, contact lenses, or other optical devices after they
have been prescribed by an ophthalmologist or optometrist.

to wear off, so people often experience light sensitivity glaucoma, including anyone who is over age 40 or who
and difficulty focusing on close tasks for several hours has a borderline result with the air-puff test, should
afterward. Be aware that it is often difficult to drive be given a more accurate test, known as applanation
while your eyes are dilated. Some ophthalmologists tonometry. After the eye is numbed with anesthetic
offer drops to reverse the dilation of your eyes after drops, the doctor gently touches the cornea with an
the exam. These typically reduce the time it takes to instrument to measure the eye’s internal pressure.
recover from the dilation and help your vision return ■ Viewing the retina and optic nerve. Finally, the doc-
to normal more quickly. tor will use a hand-held ophthalmoscope or focusing
■ Measuring eye pressure (tonometry). This painless lenses with a light source (mounted on the doctor’s
test to measure eye pressure can detect possible signs head or on the slit lamp) to look more deeply into
of glaucoma and is also used to monitor glaucoma your eye to evaluate the clarity of the lens and vitre-
treatment. The simplest version, known as air-puff or ous humor and the health of the retina, macula, optic
noncontact tonometry, uses an instrument called a nerve, and their blood vessels. In special circum-
tonometer that emits a puff of air to determine what stances, the doctor will use different lenses to view the
force it takes to flatten the cornea. Anyone at risk for far periphery of the retina.

Cataract
A cataract is a clouding of the normally clear lens of

the eye. The term was apparently coined because
the resulting whiteness of the lens resembles the
Age is the factor most likely to cause cataract. But
other factors such as family history, eye injuries, use
of some medications (particularly corticosteroids such
churned-up water of a cataract, or large waterfall. It as prednisone), and certain health problems (such as
takes years for the lens to become foggy, but the opac- diabetes) can contribute to cataract as well (see “Are
ity can eventually cause a disabling loss of vision, you at risk for cataracts?” below). Several studies have
either by distorting light rays or keeping them from linked cataract with alcohol consumption and smok-
reaching the retina at all. About half of all people ing. Even if you have smoked for many years, quitting
ages 65 to 74 have cataracts; after age 75, about 70% now will help lower the chances of cataracts form-
do. Over all, more than 22 million Americans have ing in the future. Long-term exposure to high levels
cataracts. of ultraviolet-B (UVB) rays from the sun is another
Most people develop some degree of lens opacity hazard, and studies have found a greater prevalence
by age 60. Despite surgical advances, the lack of access of cataract in people who live in areas with abundant
to health care in developing countries makes cata- sunlight. Wearing sunglasses can help protect eyesight
ract the leading preventable cause of blindness in the and minimize cataract formation.
world today.
Diagnosing cataract
What causes cataract? Cataracts are painless and progress slowly. Vision usu-
Contrary to what some people believe, cataract is not ally turns blurry, hazy, or dim, and glare from lights
caused by a film blanketing the eye, nor is it related to and the sun can be especially distressing. In the early
overuse of the eyes. It does not spread from one eye
to the other—although the condition may develop in
both eyes. Are you at risk for cataracts?
Aging and accompanying changes in the chemi- Age is the most common risk factor for cataracts: after age
cal composition of the lens are the most common 75, more than 70% of Americans either have a cataract or
have had cataract surgery. You are at higher risk for this
causes. Many cataracts develop as an exaggeration of common eye problem if you
a normal aging process known as sclerosis or hard- • smoke
ening. The lens becomes less resilient, less transpar-
• use corticosteroid medications (commonly prescribed for
ent, and often thicker. Fibers in the lens compress, asthma, inflammatory bowel disease, rheumatoid arthri-
and the lens stiffens. Clarity fades as proteins clump tis, and other illnesses)
together, creating tiny specks or wheel-like spokes in • have suffered an eye injury
the outer edges of the lens. In later stages, the milki- • have diabetes
ness becomes denser and occurs in the center, making • have spent considerable time in the sun
it truly difficult to see. The change in the lens is similar • are obese
to what happens when you cook an egg white; it goes • are an alcoholic
from clear to opaque. Early on, before cataracts blur • have a family history of cataract.
vision, they can cause nearsightedness, double vision, Source: American Academy of Ophthalmology.
or distorted vision.

Investing in the right sunglasses
Ultraviolet (UV) radiation has been linked to eye damage— General purpose. Medium to dark lenses, fine for most out-
particularly cataract and age-related macular degeneration. The door recreation. Block 95% of UVB, 60% of UVA, and 60% to
easiest way to protect your eyes from the hazardous radiation of 90% of visible light. Most sunglasses fall into this category.
the sun is to wear sunglasses. It’s also a good idea to request UV Special purpose. Extremely dark lenses with UV blockers,
protection (an invisible coating) for any prescription glasses you recommended for places with very bright conditions such as
own. Sunglasses need not bear a designer label or cost hundreds beaches and ski slopes. Block 99% of UVB, 60% of UVA, and
of dollars to do their job properly. 97% of visible light.
UV light has three wavelengths: Just because a lens appears darker doesn’t mean its ability
UVA is long, looks almost blue in the visible spectrum, and is to block out UV radiation is any greater than a lighter lens.
responsible for skin tanning and aging. Look for the ANSI label; even inexpensive sunglasses can be
UVB is shorter, more active, and linked to sunburn and skin effective.
cancer; a large portion is absorbed by the atmosphere’s ozone There is some evidence that blue light from the sun may con-
layer. tribute to the development of age-related macular degenera-
UVC is short and completely absorbed by the ozone layer. tion. Lenses with a red, amber, or orange tint may provide
better protection against this light. You may find less distor-
Sunglasses are labeled according to guidelines for UV protec-
tion, however, with gray or green lenses.
tion established by the American National Standards Institute
(ANSI). There are three categories: If you aren’t sure what kind of sunglasses to buy or think
you may be at high risk for eye disease, consult an eye care
Cosmetic. Lightly tinted lenses, good for daily wear. Block
professional.
70% of UVB rays, 20% of UVA, and 60% of visible light.
stages, the eye may become more nearsighted because Anyone who experiences blurring or eye discom-
the denser the lens, the greater its refracting power. fort should visit an ophthalmologist immediately for a
Night vision worsens, and colors appear duller. Because full examination, because cataract is only one of several
most cataracts develop very slowly, many people don’t important diseases that affect vision (see “Warning signs
realize what is wrong until the decline in visual acu- that warrant a doctor visit,” page 5). The doctor will test
ity forces them to seek frequent changes in their eye- the sharpness of your vision with a Snellen chart (see
glass or contact lens prescription. These efforts become “Testing your vision,” page 6) and will probably dilate
fruitless, however, because corrective lenses don’t help your pupils with drops. By painlessly examining the inte-
once the cataract becomes fairly dense. rior of the eye with a slit lamp, the doctor can see any
cataract and assess just how extensive the cloudy patches
are. Additional examinations and tests help rule out other
eye disorders, such as glaucoma or retinal degeneration.
Preventing cataract
There is no sure way to avoid developing cataract.
However, because of the link between cataract and
the sun’s ultraviolet radiation, make sure to wear
sunglasses as well as a hat or visor whenever you are
outdoors. Smoking also appear to raise the risk of cat-
aract, so if you smoke, quit.
Eating plenty of fruits and vegetables, which con-
tain an abundance of antioxidant vitamins, seems to
As cataracts progress, your vision gradually blurs or dims. make people less likely to develop cataracts. Studies
Photograph courtesy of the National Eye Institute. show that people who ate the most foods rich in the

antioxidants lutein and zeaxanthin, such as spinach
and other dark green vegetables, were less likely to Symptoms of
develop cataract than those who ate the least. cataract
Any of these symptoms in one or both eyes may be a sign
of cataract:
Coping with early cataracts • Blurry or dim vision
In the early stages of cataract formation, you might • Glare from bright lights
notice a slight decline in your vision, but not so much • Double vision
that it affects your day-to-day activities. In some cases, • Distorted images
the lens simply thickens, causing nearsightedness, • Increasing nearsightedness
rather than becoming opaque. In these instances, the • Declining night vision
following tips can help:
• Get a new eyeglass prescription if it improves your
distance vision. These measures help many people successfully
delay cataract surgery for years—and some never
• Increase lighting at home, particularly for close work.
end up needing it. To help you decide whether you
• Reduce glare by positioning lights directly behind
need cataract surgery, see the Cataract question-
you, focused on the task at hand, and by shielding
naire on the following page, and read the special
your eyes from direct light.
section, “Choices in cataract surgery,” beginning
• Get antireflective coating on your lenses. on page 12.

Specia l S ecti on
Choices in cataract surgery

S
urgical removal of the clouded lens is the only effective until you feel that you need better
vision.
cure for cataract. No drugs, eye drops, diets, exercises,
However, when safety becomes
or glasses can reverse the problem. For most people, the a concern, such as when you are
only choice is when to undergo the procedure. But some people driving a car or maneuvering
will also face a second choice: which replacement lens to re- stairs, it’s time to consider cataract
surgery. A 2008 review article in
ceive (see “Specialized replacement lenses,” page 16).
the journal Injury Prevention that
pooled data from a dozen different
The Cataract questionnaire eyes for detailed work—such as studies found that cataract surgery
below can help you determine architects, dentists, and jewel- reduced the risk of driving-related
how much your vision loss is ers—are likely to require sur- difficulties by 88%. And a study
affecting your daily activities gery sooner than others. Keep in published in the Journal of the
and when you should consider mind that cataract surgery can American Medical Association
surgery. Those who rely on their almost always be safely delayed found that people with cataracts
who underwent surgery were half
as likely to get into a motor vehi-
Cataract questionnaire cle accident as those who did not
have surgery. (For driving tips, see
■ Do you have difficulty, even with glasses, with any of the following “Driving safely into the golden
activities:
years,” right.)
• Reading a newspaper or book?
If your doctor determines
• Seeing steps or curbs?
that you have cataracts in both
• Reading traffic signs, street signs, or store signs? eyes, he or she may recommend
• Taking part in sports such as bowling, handball, tennis, or golf? operating first on the eye with
• Watching television? the denser cataract (and poorer
• Seeing well in poor or dim light? vision). If surgery is successful
■ Do you experience glare from headlights or bright sunlight? and your vision improves sub-
■ Do you avoid (or have you stopped) driving because of your vision? stantially, you may elect to forgo
surgery on your other eye. How-
If you answered “yes” to more than a few of these questions, consider a
consultation with an ophthalmologist. ever, most patients note signifi-
cant benefits from having the
12 The Ag in g E ye w w w.h ealt h .ha r va r d.e du

Choices in cataract surgery | Special Section
second eye operation, includ- formed in the United States, with one who is. Ask around to find an
ing better depth perception and nearly 3.1 million Americans experienced surgeon to guide you
improvements in their ability to undergoing the procedure each through the preparatory, opera-
drive and to read. Many people year. Once an inpatient procedure tive, and postoperative stages.
choose to have the second sur- requiring up to a week of hospi- The vast majority of people
gery once the first eye has healed talization, today cataract surgery have an artificial intraocular lens
and vision is stable. If you are is performed under local anesthe- (IOL) implanted to replace the
extremely farsighted or near- sia on an outpatient basis and is clouded lens that is removed dur-
sighted and need cataract sur- considered one of the safest of all ing surgery (see “Replacement
gery in both eyes, you may want surgeries. Most ophthalmologists lenses,” page 15). In rare cases,
to plan to have the second sur- are trained to perform cataract people have conditions that pre-
gery within about one month of surgery or will refer you to some- vent the use of a replacement
the first surgery. Otherwise, you
might have problems with dou-
ble vision and depth perception
Driving safely into the golden years
because of the difference in the
eyeglasses prescription between Good driving is a total-body experience involving motor coordination as well
as the senses. But vision is key to staying safe behind the wheel. Aging can
your two eyes. These problems
increase your challenges as a driver, especially if you suffer from an eye
will resolve once you’ve had sur- condition such as macular degeneration, presbyopia, glaucoma, or cataracts.
gery in both eyes. Stay safe by getting annual eye exams, checking in with your ophthalmolo-
Some people have cataract gist, and taking necessary precautions.
along with another eye prob- Invest in new, more powerful glasses to compensate for any vision loss.
lem. In some cases, your doctor Consider adding antiglare coating to your eyeglasses to reduce the tempo-
may recommend cataract surgery rary blindness caused by oncoming headlights at night.
because the cataract makes it dif- You can adjust your car to suit your needs, as well. Consider installing
ficult to examine and manage broader side-view and rear-view mirrors to provide greater peripheral vision,
the other problem. Whatever the or choose a car with bigger and brighter gauges to help you stay in control.
situation, you and your doctor Simple lifestyle adjustments may also be in order. Perhaps driving in heavy
should discuss the rationale for rain or at night is no longer a good idea. For instance, cataracts, which cloud
the lens, make night driving particularly difficult. Fortunately, cataract surgery
the operation as well as benefits
is one of the safest, most common procedures performed in the United
and risks. But with an uncom- States.
plicated cataract, the ophthal-
To help stay on top of your driving skills, you may want to take one of the
mologist’s role is to help patients courses offered for older drivers by the AARP (www.aarp.org/families/
reach their own decisions about driver_safety) or AAA (www.seniordrivers.org). These courses cover every-
surgery. You’re the best judge of thing from loss of vision, hearing, cognitive function, and motor function to
how much your cataract inter- the side effects of common medications.
feres with your safety and daily Elderly drivers do have one advantage: experience. All those years behind the
activities. wheel are invaluable when it comes to making sound driving decisions. Older
drivers buckle up more frequently—and are far less likely to use cell phones
or drive intoxicated—than people under 50, according to National Highway
Surgery: What’s involved
Traffic Safety Administration polls and other sources. Still, it’s up to the older
Cataract surgery is the most com- driver to identify his or her limits and develop a suitable safe-driving plan.
mon type of eye operation per-
ww w. h ealt h . h ar v ar d . e du T he A g in g E ye 13
Special Section | Choices in cataract surgery
lens. Or the implant may need to use lasers, except in some follow- left behind to support the artifi-
be removed if it dislocates or is up procedures. To remove the cial lens implant (see Figure 4).
displaced by injury. In such cases, original lens, the surgeon makes The doctor usually replaces
the doctor will prescribe eye- a tiny incision in the eye, a deli- the clouded lens with a clear
glasses or contact lenses to cor- cate procedure done with the aid artificial lens made of silicone
rect postoperative vision. of special surgical microscopes. or acrylic, smaller than a dime,
Most often, surgeons place The doctor may choose from sev- which folds to fit through the inci-
the new lens behind the iris, eral procedures for extracting the sion. Once inside the lens capsule,
within the portion of the lens lens. the folded lens opens up again.
capsule that remains after surgery. ■ Phacoemulsification. This In some cases, the surgeon uses
Occasionally, the lens implant is procedure—the most commonly a rigid plastic lens instead, which
inserted in front of the iris, espe- used technique for cataract sur- requires a slightly larger incision
cially if the capsule is faulty. In gery—requires only a tiny inci- that may need stitches.
either case, plastic loops (called sion that often needs no stitches Phacoemulsification offers
haptics) hold the implant in place. and heals rapidly. The outer lin- good long-term results, and 97%
Unlike some other eye sur- ing of the lens capsule (the mem- to 98% of all cases done by an
geries, cataract surgery does not brane that surrounds the lens) is experienced surgeon are success-
ful and free of complications.
Figure 4 Cataract surgery ■ Extracapsular surgery. This
older technique is typically used
1. 2. Phacoemulsifier
for very dense or hard cataracts
Incision and in other special circum-
stances. It involves an incision of
about three-eighths of an inch in
the sclera (the white of the eye)
Clouded lens
under the upper eyelid, above
where the sclera and cornea join.
The ophthalmologist makes a small incision Using a small, needle-like probe called a The surgeon then opens the lens
about an eighth of an inch long in the side phacoemulsifier, the doctor directs high-
capsule and removes the harder,
of the cornea. frequency sound waves through the lens to
break it into small pieces, which are then
central portion of the clouded
gently suctioned out through the probe. lens, usually in one piece, and
then gently vacuums out the softer
part of the lens. The outer part
3. 4.
of the lens capsule is left undis-
turbed, providing support for a
replacement. After putting in the
new lens, the surgeon stitches up
New artificial lens the incision.
(folded) Haptics The main difference between
The artificial lens, which is folded to fit The new lens unfolds inside the lens extracapsular surgery and phaco-
inside the probe, is inserted through the capsule and is held in place by tiny loops emulsification is that with “phaco,”
same incision. called haptics. most patients can resume their

normal routine sooner because a preoperative evaluation. People for distance and near. But that’s a
the smaller incision heals faster. who receive monofocal IOLs typi- less popular option, because you
Over all, either procedure restores cally find their vision restored to then need two different sets of
vision to 20/40 or better in more what it was before the cataract glasses.
than 90% of all cases. developed. However, most of Many factors will affect which
■ Intracapsular surgery. In this these people need to wear glasses IOLs are the right choice for you.
procedure, which is rarely used for reading or distance vision, Here are some questions your
today, both the lens and the cap- because the standard monofocal surgeon might ask:
sule are removed. Intracapsular IOLs lack the capacity for accom- • How do you feel about con-
surgery is generally reserved for modation—the ability to change tinuing to wear glasses or con-
cases in which the lens has dis- focus from near to far and back tact lenses after your cataract
located because of either injury again. surgery?
or an accompanying disease. In Many people who choose a
• How important is good night
this surgery, the replacement monofocal IOL opt for clear dis-
vision to your lifestyle?
lens generally rests in front of the tance vision and use reading
•In general, how well do you
pupil or is secured with stitches to glasses for close vision. Those
adjust to changes and learn new
the eye wall. who are accustomed to taking
skills?
glasses off to read (namely, people
Replacement lenses who are naturally nearsighted) •W
hat activities or tasks are part
Although the first intraocular lens may choose instead to wear of your daily life, both for work
(IOL) was implanted in England glasses for distance and mid- and pleasure?
in the 1950s, artificial replace- range vision. Another option is to • During which activities would
ment lenses weren’t widely used in choose an IOL designed for mid- you find glasses the most incon-
the United States until the 1980s. range vision and to wear glasses venient or aggravating?
Until then, people who’d under-
gone cataract surgery had to wear Figure 5 Zones of vision
thick magnifying glasses called
aphakic spectacles, or use con-
tact lenses for visual correction. Near Far
With the advent of IOLs, patients
no longer need those tools and
recover their vision much more ZONE 1 ZONE 2 ZONE 3
quickly. The lens implants require (12–20 in.) (2– 4 ft.) (20–100 ft.)
no particular care. Newsprint Cooking TV
Most people—nearly 95%— Phone book Computer Driving
Maps Price tags Golf
who have cataract surgery receive Sewing Cleaning Road signs
monofocal IOLs. As the name
suggests, these lenses are designed Ophthalmologists divide vision into three broad zones based on the approximate
distance between your eyes and the object you’re viewing. If you’re considering a spe-
to focus at one set distance (far,
cialized replacement lens during cataract surgery, knowing which zone is most important
intermediate, or near). The lens to you can be helpful when deciding which type of lens would be most appropriate.
power varies from patient to
Adapted from materials provided by Bradford J. Shingleton, M.D., Associate Clinical Professor of Ophthalmology,
patient and is determined during Harvard Medical School.
Specialized replacement lenses

Starting around age 40, the lens in your eye becomes less flexi- option for you if you want to reduce
ble—a normal part of aging that makes near vision more dif- your dependence on glasses or contacts
ficult, especially in low light. Eventually, everyone develops this as much as possible, do not have
problem, known as presbyopia, and most people (even those astigmatism or are willing to address
without cataracts) need reading glasses to see well close-up. your astigmatism by additional surgery, Staar Surgical Company
But several types of intraocular lenses (IOLs) may reduce or are less comfortable adapting to
eliminate the need for glasses after cataract surgery for people change and learning new skills, and are willing to risk some
who have presbyopia, as well as those with astigmatism (see night vision symptoms.
Figure 11, page 40).
Toric. These are specialized monofocal IOLs that have been
Accommodating. When you switch altered to correct for astigmatism. Instead of making limbal
from gazing at something far away to relaxing incisions, the surgeon may implant this IOL. One
something nearby (or vice versa), the drawback to these IOLs is the risk that they will rotate out of
tiny ciliary muscles in your eye tug on position, which may require further surgery to reposition or
your lenses so they change shape ever replace the lens. Toric lenses give focused vision at a single
so slightly, enabling you to focus near, distance and also correct your astigmatism, so you may not
far, or in-between. This capability, called need distance glasses after surgery. As with standard monofo-
accommodation, diminishes as the lens cal lenses, you will still need reading glasses to see up close.
stiffens with age. But the ciliary muscles Toric lenses may be a good option for you if you have astigma-
retain their ability to contract and relax. tism as well as cataracts and don’t mind wearing glasses or
Accommodating IOLs have hinges on Eyeonics, Inc.
contacts for some activities, such as reading or driving.
the sides, enabling them to change
New advances. Companies that make IOLs are refining
focus, similar to the natural lens in a younger eye. These IOLs
several other modifications designed to enhance vision. One
offer excellent distance and middle vision, but aren’t as
category is aspheric IOLs. Unlike traditional IOLs, which are
reliable for near vision. Eye exercises can help people get used
spherical (meaning the front surface is uniformly curved),
to them, but about half of people who receive them still end
aspheric IOLs are slightly flatter around the edges. These
up needing reading glasses. Accommodating lenses may be an
lenses are supposed to improve the ability to distinguish an
option for you if you want to reduce your dependence on
object from its background and to reduce glare and halos. One
glasses or contacts, do not have astigmatism, or are willing to
aspheric IOL, the Tecnis Z9000, is advertised as improving the
address your astigmatism by having additional surgeries such
ability to see in varying light conditions, such as rain, snow,
as LASIK or limbal relaxing incisions (see page 17).
fog, twilight, and nighttime darkness.
Multifocal. Like bifocals or progressive lenses used in glasses,
Many IOLs include filters that block ultraviolet (UV) light,
these IOLs include different areas designed for distance,
which is known to increase the risk of cataracts and other
intermediate, and near vision (see Figure 5). But unlike the
vision problems.
lenses in glasses, the areas are organized in concentric circles,
rather than from top to bottom. The brain and eye figure out What to consider
which part of the lens to use. One example,
the Restor IOL, uses a type of refractive These options aren’t right for everyone; for instance, people
technology to provide focus for multiple with severe macular degeneration, glaucoma, or diabetic
distances. The lens has small, concentric retinopathy are not the best candidates.
circular ridges that permit the eye to change Another consideration is cost: Medicaid and most insurance
its range of focus. Another lens, called the plans do not cover these lenses. For multifocal or accommoda-
ReZoom, has five broad zones to provide tive IOLs, typical costs range from $1,900 to $3,000 per eye.
distance, intermediate, and near vision. The For astigmatism-correcting toric IOLs, the cost ranges between
main drawback of multifocal lenses is $800 and $2,000 per eye. Because there are so many different
difficulty in seeing well at night. The tiny lenses on the market, it’s difficult to find comprehensive, reli-
ridges can distort bright light, creating more able data about the benefits and risks associated with each.
glare and halos. Multifocal lenses may be an Discuss your options with your cataract surgeon.
Alcon Laboratories, Inc.

Several different companies irregularity in the curve of the high risk of developing a blood
have developed specialized, non- cornea; see Figure 11, page 40), clot. In these cases, your eye sur-
monofocal IOLs designed to the surgeon can make a few small geon should discuss the surgery
reduce the need for glasses after incisions in the cornea during with your primary care physician
cataract surgery (see “Specialized cataract surgery, known as lim- or cardiologist and may require
replacement lenses,” at left). For bal relaxing incisions, to improve you to undergo blood testing
people who choose the far more the problem. This technique, also before your operation. Don’t stop
common monofocal IOLs but known as a limbal astigmatic ker- taking any medications on your
also hope to be less dependent atotomy, has the effect of reshap- own without consulting your
on glasses, there are two options: ing the curvature of the cornea, doctor.
a technique called monovision making it less like a football and Inform your eye surgeon if
and a procedure known as limbal more like a basketball. While this you take or have ever taken an
relaxing incisions. technique still doesn’t achieve alpha blocker. Alpha blockers,
■ Monovision. This technique accommodation (the ability to which include alfuzosin (Uroxa-
involves implanting one eye with focus at a range of distances), it tral), doxazosin (Cardura), silo-
an intraocular lens to provide may enable the person to see well dosin (Rapaflo), tamsulosin
near vision and the other eye with without glasses for distance. (Flomax), and terazosin (Hytrin),
a lens to provide far vision. This are used mainly to treat enlarged
technique works well for peo- Preparing for cataract surgery prostate in men, but they may be
ple who previously used contact Before surgery, the ophthalmolo- prescribed for high blood pres-
lenses in the same manner. But gist measures the curvature of sure or urinary retention in
many people find the adjustment your cornea and the length of women. These drugs, along with
quite challenging (if not impos- your eye to calculate the power tolterodine (Detrol) and the herb
sible), because of the change in of the implant you need. Your saw palmetto (both used to treat
depth perception that occurs with doctor performs a general medi- enlarged prostates), can interfere
reduced binocular vision. If you cal exam and may request tests to with the medications used to keep
are considering this option, your assess your overall health. the pupils dilated during cataract
eye surgeon may recommend He or she may also ask about surgery, raising the risk of com-
that you try out monovision (one any medications you take on a plications. If the surgeon knows
eye for near vision, the other eye regular basis, because certain ahead of time, special steps can
for distance) with contact lenses drugs may need to be avoided be taken before or during surgery
before your cataract surgery to before surgery. For example, your to avoid these complications.
see how well you can adjust to the doctor may ask you to avoid aspi- Depending on your medical situ-
change. Typically the dominant rin and other drugs that have an ation, your doctor may prescribe
eye is chosen for distance. Mono- anticoagulant (blood-thinning) antibiotic eye drops, anti-inflam-
vision is usually not an ideal effect, especially if the surgery matory eye drops, or both before
option for people who require involves larger incisions, because the surgery.
crisp, detailed vision. these drugs increase the risk of
■ Limbal relaxing incisions. bleeding during surgery. Note During and after surgery
For people with pronounced that some people cannot under Local anesthesia (given directly
astigmatism (a common vision any circumstances stop taking on the eye or by injection) keeps
impairment that results from an blood thinners, because of their the eye comfortable and immobile
during surgery. The entire proce- to have a bluish glow. Spending the eye is sensitive after surgery,
dure usually lasts less than half an time in bright sunlight may give avoid rubbing or touching your
hour, during which you may see objects a reddish afterimage when eye, and guard against any sud-
light, hear noises, and be aware of you come indoors. den movement that could jar your
the presence of the surgical team. Sticky eyelids, itching, sen- head. To avoid accidental rubbing
However, you probably will not sitivity to light, and mild tearing of your eye while you are sleep-
see formed images, and you may are perfectly normal after sur- ing, you may need to wear a pro-
not be able to tell whether your gery, but severe pain and sudden tective metal eye shield at night
eye is open or closed. Most peo- changes in vision are unusual and for a few days or weeks.
ple do not have pain of any sort warrant an immediate call to your Your doctor or health profes-
during the procedure. doctor. Patients who suffer minor sional will show you how to clean
Afterward, the surgeon may discomfort can take a non-aspirin your eyelids, which may become
cover the eye with a bandage or pain reliever such as acetamino- crusted from discharge. Many
shield, which may be removed phen (Tylenol) every four to six people prefer to wear medium-
later that day or the following hours. Any discomfort should density sunglasses when outdoors
day. Typically you will be dis- subside on its own within a day to screen out the glare, even
charged after you rest for a while or two. though most implants have ultra-
in the recovery area, but you will The ophthalmologist will violet blockers (see “Investing in
need someone to drive you home. schedule several postoperative the right sunglasses,” page 10).
Reading and watching television visits: the day after surgery, after Make sure you understand
are permitted almost immedi- about a week, at three to four all of your doctor’s postoperative
ately. Although it’s a good idea weeks, and then usually six to care instructions. It’s important
to take it easy, most people can eight weeks later. The doctor will that you follow these instructions
resume normal activities within a examine your eye, test your visual carefully to help ensure a full and
few days. Check with your doctor, acuity, and measure eye pres- rapid recovery. Discuss any ques-
however, before doing anything sure. Corrections for eyeglasses tions you have with your doctor.
strenuous. will probably not be prescribed
Vision usually improves soon until three to six weeks following Possible complications
after following cataract surgery. surgery. More than 98% of people who
For some, vision may be excellent undergo cataract surgery have
within hours. For others, it may Self-care improved vision afterward,
take several days or even a few Once at home, you will use anti- assuming they have no other
weeks to return to normal. This biotic and cortisone drops or limiting eye disease, and most
longer interval does not neces- ointment, as well as a nonste- have an uneventful recuperation.
sarily indicate any complication roidal anti-inflammatory drug, Complications, mild or severe,
or failure of the surgery. During to prevent infection and reduce are extremely rare, occurring only
the healing process, you may be inflammation. To prevent infec- once in several thousand opera-
surprised by changes in color: tions, wash your hands thor- tions, but they need immediate
because the clouded lens, which oughly before applying the drops, medical attention.
commonly filters out some colors, and avoid touching the bottle tip If a person develops an infec-
has been removed, colors may to your eye (see “How to apply tion inside the eye, vision—and
appear more luminous or seem eye drops,” page 26). Because even the eye—could be lost. Most

ophthalmologists use antibiotics cornea, in front of the blood ves- neal transplants in the United
before, during, and after surgery sels, and no blood vessels are States. With the advent of bet-
to minimize this risk. Surface cut inside the eye. Even bleeding ter cataract surgery techniques
inflammations or infections usu- caused by larger incisions may and implantable lenses, the like-
ally respond well to medication. stop automatically without caus- lihood of experiencing corneal
Inflammation inside the eye with- ing any damage. Hemorrhaging edema after cataract surgery has
out infection, which may occur from the choroid in the back of fallen dramatically—only one
in response to surgery, is usually the eye is a rare but serious cause in every 1,000 people who have
minor and can be treated with of vision loss. cataracts removed develops this
postoperative steroids. Inflammation, bleeding, adhe- complication.
Although uncommon, a slight sions, or other factors that increase In rare cases, the implant may
leak in the incision may occur, pressure inside the eye can cause become displaced. If this happens,
creating a greater risk for infec- secondary glaucoma, which is usu- you might notice blurred vision,
tion inside the eye. The doc- ally temporary. Glaucoma medi- glare, double vision, or fluctuat-
tor may apply a contact lens or a cations can usually control the ing vision. Your ophthalmolo-
pressure bandage over the eye to pressure, but this complication gist can reposition the implant or
promote healing. In rare cases, sometimes requires laser or other replace it with another one if your
the wound has to be reclosed with surgery. vision is severely impeded.
a stitch. Retinal detachment occurs In 30% of all cataract oper-
Pronounced astigmatism, infrequently and requires surgical ations, the outer covering of
which causes blurred vision, repair. On occasion, tissues of the the lens capsule that was left in
develops in some individuals macula—the central part of the the eye to support the implant
after surgery because of swell- retina—may swell for one to three becomes cloudy sometime after
ing of the tissue or tight stitches months after cataract removal. surgery, again causing blurred
(if stitches are used) that pull on One symptom of this condition, vision. This problem does not
the cornea and distort its shape. called cystoid macular edema, mean the whole cataract has
After the eye has healed from the is blurring of central vision. An grown back; the cloudiness affects
operation, swelling diminishes ophthalmologist can usually diag- only a tissue membrane, not the
and any stitches may be cut. This nose it with special testing and replacement lens. If the condi-
usually corrects the astigmatism. can often treat it successfully with tion inhibits clear vision, it can
In some people, cataract removal medication. be treated with a technique called
can relieve existing astigmatism, Another rare complication is YAG laser capsulotomy. (YAG
as incisions may be designed to pseudophakic bullous keratopa- stands for yttrium-aluminum-
adjust the cornea’s shape (see thy, the development of corneal garnet, a type of laser.) In this
“Limbal relaxing incisions,” page edema (fluid buildup, leading procedure, the ophthalmologist
17). to clouding of vision). This may uses a laser to create an opening
Bleeding within the eye is occur months to years after cat- in the center of the opaque cap-
another potential problem. This aract surgery and sometimes sule to allow passage of light. This
rarely occurs in phacoemulsifi- requires a corneal transplant. In procedure is quick and painless,
cation procedures because the fact, corneal edema following and it requires no incision; it can
smaller incision used with this cataract surgery once accounted be done in an ophthalmologist’s
technique is placed in the clear for about one-third of all cor- office or outpatient clinic.
Glaucoma
M ore than 2.3 million Americans ages 40 and

older have been diagnosed with glaucoma, and
an additional two million have the disease but don’t
Figure 6 What happens in glaucoma
Posterior
know it because the early stages usually progress with- chamber
Anterior Lens
out symptoms. Glaucoma is a major cause of blind- chamber
ness and threatens 2% of people over 40, becoming
Iris
even more common as people age. Yet early diagnosis
and treatment can almost always save vision. Trabecular Aqueous
meshwork humor
Sclemm’s canal flow
What causes glaucoma? Posterior chamber

Glaucoma is a group of eye diseases that cause vision
Ciliary body
loss through damage to the optic nerve. Doctors used
to think that high pressure within the eye, called intra- In a healthy person, the ciliary body continuously produces aque-
ocular pressure, was the primary cause of this damage, ous humor, a clear liquid that circulates from the posterior chamber
into the anterior chamber of the eye and helps maintain its shape
but we now know that other factors besides pressure
and pressure. The fluid (see arrows) bathes and nourishes the inte-
must be involved, because some susceptible people rior of the eye, then drains through the trabecular meshwork into
with “normal” intraocular pressure can experience small blood vessels. If this sieve-like meshwork is blocked, aqueous
vision loss from glaucoma. humor accumulates, and pressure inside the eye increases.
Normally, the aqueous humor—the liquid that fills
the area behind the iris—circulates through the pupil through a circular, sieve-like system of tissues called
into the front compartment of the eye, nourishing the trabecular meshwork and drains out of the eye
the lens and the cells lining the cornea. It then passes through Schlemm’s canal. From there, it is absorbed
into surrounding blood vessels. The process works
continuously as more aqueous humor is produced
and excess fluid is eliminated through the trabecular
meshwork to keep a healthy balance of pressure in the
eye (see Figure 6).
In glaucoma, this drainage system breaks down,
slowing or blocking the outflow of fluid. The fluid
backs up in the eye, much like water in a clogged sink,
and internal pressure rises. This, in turn, puts stress
on the optic nerve, which provides the eye’s wiring to
the brain. If the pressure continues unabated, nerve
fibers that carry the optical messages begin to die off,
and vision starts to fade. Loss of vision may also result
As glaucoma progresses, you may notice that your peripheral from the obstruction of tiny blood vessels that feed
vision diminishes. the retina and optic nerve. Nerve fibers on the outer
Photograph courtesy of the National Eye Institute. edge are typically affected first, so vision loss begins

with peripheral vision and gradually closes in until the • a thin cornea (see “Corneal thickness explained,”
cells supplying central vision are lost. The damage that below).
occurs in glaucoma is irreversible.
While pressure plays an important role in most
glaucoma cases, other mechanisms also appear to Types of glaucoma
cause cell death in nerve fibers. Scientists are now Although 25 to 30 types of glaucoma exist, the follow-
investigating ways to prevent this cell death through ing are among the more common:
several different strategies, collectively known as neu- ■ Open-angle glaucoma. This is the most common
roprotection. However, these studies are preliminary, form of the disease, accounting for more than 90% of
and drugs to lower intraocular pressure remain the all cases. It strikes black and Hispanic people far more
mainstay of treatment for glaucoma (see “Treating frequently than whites, is most prevalent in people
glaucoma,” page 23). over 60, and tends to run in families.
The name comes from the fact that the angle
Who gets glaucoma? through which fluid drains from the anterior chamber
No one is immune to glaucoma, but some people are of the eye remains open, yet the aqueous humor drains
more likely than others to develop the disease. Those out too slowly, leading to fluid backup and a gradual
who face a higher risk include the following groups: but persistent elevation in pressure. Ultimately this
■ People ages 60 and older. Like other bodily pro- damages the optic nerve and causes vision loss if not
cesses that wind down with age, the eye’s drainage treated in time and controlled by medication. Because
system also seems to become less efficient as people the condition is generally asymptomatic in its early
grow older. stages, regular eye exams are important, especially for
■ People who have family members with glaucoma. The anyone at increased risk.
most common type of glaucoma, open-angle glau- ■ Closed-angle glaucoma. In closed-angle glaucoma,
coma, is hereditary. People whose immediate fam- the pressure in the eye rises rapidly as the angle between
ily members have this form of the disease face a far the iris and cornea narrows and the iris suddenly blocks
higher risk than the general population. the trabecular meshwork, preventing fluid from flow-
■ People of African American or Hispanic ancestry. ing out. When this form of the disorder occurs, the eye-
Glaucoma is six to eight times more common in Afri- ball quickly hardens and the pressure causes pain and
can Americans than in Caucasians. Hispanics also blurred vision. Also, people often see halos—colored
appear to be more prone to the disease than people of
European ancestry.
The following conditions may also increase your Corneal thickness explained
chances of developing glaucoma: Several years ago, researchers discovered that the thickness
of your cornea (the clear part of the eye’s protective covering)
• diabetes
plays a role in the accuracy of your eye pressure reading.
• high blood pressure Many times, people with thin corneas (less than 540
micrometers) show artificially low intraocular pressure
• routine use of corticosteroid drugs (such as high readings, which can be dangerous if your actual pressure
doses of steroids to control asthma, rheumatoid reading is higher, putting you at risk for glaucoma. On the
arthritis, inflammatory bowel disease, and other other hand, people with thick corneas may show an
illnesses) artificially high pressure reading, which could lead to
unnecessary treatment. Fortunately, there is a quick, painless
• past eye injuries (most commonly a blunt trauma to test, called a pachymetry test, to measure corneal thickness.
the eye, usually while boxing or playing baseball) The measurement (done routinely with pressure screenings)
• a history of severe anemia and shock enables your doctor to better understand your intraocular
pressure reading and develop an appropriate treatment plan.
• severe nearsightedness or farsightedness

rings around lights. This condition is a medical emer- dark. However, these symptoms generally occur later
gency and should be treated as soon as possible. in the disease. The good news is that vision loss from
■ Low-tension or normal-tension glaucoma. In this less glaucoma can be prevented if the condition is discov-
common condition, the optic nerve suffers damage typi- ered before the nerve is damaged. This makes regu-
cal of glaucoma, but at normal eye pressures. The diag- lar screening for glaucoma beginning at age 40 very
nosis is often made after there has been some vision important.
damage, but more sensitive diagnostic techniques are Symptoms are much more obvious in closed-angle
making it possible to detect this disease earlier, before glaucoma. Most people experience blurred vision, con-
peripheral vision is lost. After other possible causes of the siderable eye pain, rainbow halos around lights, head-
optic nerve damage and visual loss have been eliminated, aches, nausea, and vomiting. This is a serious condition
lowering the pressure even further with medication, sur- and can cause blindness in a relatively short time. Go to
gery, or both will usually stabilize the condition. an emergency room if you can’t get through to your oph-
■ Congenital glaucoma. This is a rare condition thalmologist right away. Left untreated, glaucoma can
present at birth and often inherited. It is attributed lead to limited tunnel vision and eventual blindness.
to a structural defect in the drainage angle and is fre-
quently found in both eyes.
■ Secondary glaucoma. Secondary glaucoma may Diagnosing glaucoma
develop as a result of some other eye problem—such Most doctors agree that a regular eye exam should
as longstanding inflammation, injury, cataract, diabe- include glaucoma screening beginning at age 40, and
tes, or blood vessel blockage in the eye—or as an effect people who are at higher risk should be screened
of some medications (most typically, corticosteroids). annually. These include people with a family history of
the disease, people of African American ancestry, and
Progression of glaucoma people with diabetes.
Except in the case of closed-angle glaucoma (which During your exam, the ophthalmologist evaluates
can appear suddenly with pain and blurred vision), pressure in the eye through tonometry (see “Measur-
glaucoma often has no symptoms in its early stages. ing eye pressure,” page 8). Normal pressure is 8 to 21
Even blind spots or diminishing peripheral vision millimeters of mercury (mm Hg), but people with eye
may not be noticeable until the disease is already pressure in this range may still develop the disease.
quite advanced. Occasionally, people realize some- Likewise, those who have slightly elevated pressure
thing is awry when they repeatedly need new eye- may not be destined to get glaucoma; how much stress
glass prescriptions or have trouble adjusting to the the optic nerve can withstand differs for each person
and each eye.
The doctor will use both a slit lamp and an oph-
Symptoms of thalmoscope to look for any deterioration of your
open-angle glaucoma optic nerve. If the front surface of the nerve, called the
• Few or no symptoms in early stages optic disc, is affected by glaucoma, the doctor may see
• Blind spots and diminishing peripheral vision in later stages a characteristic called cupping: the disc may appear
closed-angle glaucoma indented, and its color—normally pinkish yellow—
(This is a medical emergency: call your doctor immediately.) may turn pale and more yellow because the advancing
• Severe pain disease has hindered blood flow to the area.
• Nausea If your eye pressure is not in the normal range or
• Colored halos around lights if your optic nerve looks unusual, the doctor will per-
• Eye redness form one or two specialized glaucoma tests:
• Blurry vision or rapid vision loss ■ Perimetry. Also called a visual field test, this
test requires you to look straight ahead and indicate

whether you see lights flashing on and off in different
locations within your peripheral (side) vision.
Home testing for glaucoma
You can buy a device to check your eye pressure at home,
■ Gonioscopy. This procedure involves placing
but a regular professional eye exam is far more reliable
a special contact lens on the surface of an anesthe- and less likely to produce false readings that could result
tized eye. The lens has mirrors and facets that, when in needless worry or unwarranted reassurances.
studied through the slit lamp, give a detailed view of One home device, called the Proview Eye Pressure Moni-
the corner of the eye and show whether the drainage tor, measures pressure through the eyelid on the basis
angle is open, narrowed, or closed. of phosphene—a sensation of light produced in the eye
by something other than light. To see a phosphene, close
To confirm the presence of the disease, the doc-
your eye and gently press your finger on your eyelid where
tor may repeat the tonometry test (see “Measuring it meets the nose. The phosphene appears as a bright cen-
eye pressure,” page 8), particularly because pressure tral area surrounded by a dark ring with an outer bright
in the eye may vary at different times of the day. halo. The eye pressure monitor works by gently applying
If you have glaucoma, your ophthalmologist may pressure with a pencil-like probe on the eyelid until the
patient sees the phosphene ring. The device then converts
use a technique called fundus photography to pro- the input to a pressure measurement.
duce three-dimensional pictures of the optic disc,
Further studies are under way to evaluate the device’s
which serve as a baseline for later comparisons of the accuracy. There are also several online tools to check your
disc. If the disc changes over time, that means your peripheral vision, but experts typically don’t recommend
pressure hasn’t been well controlled and you need these tests because the results haven’t been fully vali-
more aggressive treatment. Several newer techniques dated and could therefore lead to unnecessary concern (or
worse, misguided complacency). If you choose to use the
to create computer-generated images that analyze
device or an online test, it is important to see an ophthal-
fiber layers of the optic nerve are also available. Over mologist to discuss its use.
time, they can detect the loss of optic nerve fibers,
allowing the doctor to track the progression of the
disease. at risk of developing glaucoma. OHTS investigators
found that early treatment with eye drops to reduce
Monitoring and treating pressure intraocular pressure reduced by half the chance of
Most types of glaucoma—including open-angle glau- developing optic nerve damage or visual field loss
coma, the most common type—can be controlled but due to glaucoma. Two other trials, the Advanced
not cured. No treatment can restore vision lost to the Glaucoma Intervention Study and the Collabora-
damage of glaucoma, but it is possible to stop the tive Initial Glaucoma Treatment Study, further con-
progression of the disease. firmed the benefits of lowering intraocular pressure,
Each year, glaucoma patients typically undergo whether through various types of surgery or through
two to four examinations that measure visual acuity, medication.
the optic disc, and eye pressure. The visual field test
and other tests are done at selected intervals to estab-
lish the stability of the disease or to note deteriora- Treating glaucoma
tion, which requires more effective treatment. This In some respects, treatment of glaucoma is similar
ongoing monitoring is important in order to pre- to that of heart disease. Both conditions have mul-
serve vision in people with glaucoma. tiple causes and may require multiple medications.
Several large trials have demonstrated the ben- And in both cases, therapy represents a lifetime com-
efits of reducing intraocular pressure—whether mitment. It’s important to adhere to your treatment
through medications (see Table 2), surgery, or some plan even when you may not feel any benefit, because
combination. The Ocular Hypertension Treatment quite often benefits are not immediately obvious.
Study (OHTS), for example, involved more than Take eye pressure, for example. Like blood pres-
1,600 people recruited across the country who were sure, intraocular eye pressure varies over the course

Table 2 Glaucoma medications
These drugs are all taken topically as eye drops, unless otherwise noted.
Generic name (brand name) Doses per day Side effects/comments
Adrenergics
dipivefrin* (AKPro, Propine) Headache, stinging, redness, burning, transient blurring of vision.
2–3
May cause pounding heart and fast heartbeat in some people.
Alpha agonists
apraclonidine* (Iopidine) Stinging, burning, redness of eyes, dry mouth, blurred vision, fatigue.
2–3
brimonidine* (Alphagan) Minimal effect on lungs and cardiovascular system.
Beta blockers
betaxolol* (Betoptic, others) Stinging, irritation, blurred vision, tearing, allergic reaction. Elderly
carteolol (Cartrol, Ocupress, generic) people are especially prone to side effects. May cause breathing
levobetaxolol (Betaxon) problems for people with asthma. Can slow heart rate for those with
1–2
levobunolol* (AKBeta, Betagan) heart disease. May cause mental and physical lethargy. Men may
metipranolol* (OptiPranolol) experience a decrease in libido.
timolol* (Betimol, Timoptic, others)
Carbonic anhydrase inhibitors

Oral
acetazolamide* (Diamox) Dizziness, diarrhea, loss of appetite, metallic taste in the mouth,
methazolamide* (Neptazane) numbness or tingling in hands and feet, weight loss, fatigue,
2–3
excessive urination, anemia. Can lead to loss of potassium; eat
potassium-rich foods, such as bananas and citrus fruit.
Topical
brinzolamide (Azopt) Burning, stinging, bitter taste in mouth, corneal inflammation,
dorzolamide hydrochloride* (Trusopt) 2–3 allergy. Dorzolamide is also available in oral form; drops have fewer
side effects for most people.
Miotics
carbachol* (Carbastat, Miostat) Eye pain, stinging, blurred vision, change in near or distance vision,
reduced night vision.
echothiophate (Phospholine Iodide) Blurred vision, change in near or distance vision, reduced night
3– 4
vision, headache, eyelid twitching, tearing, sweating, diarrhea.
Pilocarpine* (Betoptic Pilo, Ocusert Pilo, others) Blurred vision, change in near or distance vision, reduced night
vision.
Prostaglandins
bimatoprost (Lumigan) Burning, stinging, itching, redness, blurred vision. Used only once a
latanoprost* (Xalatan) 1 day; some people report growth of lashes or change in eye color due
travoprost (Travatan) to increase in brown pigment in the iris.
Combination medications
timolol plus dorzolamide hydrochloride (Cosopt) A more convenient option for people who need more than one type
2
timolol plus brimonidine (Combigan) of medication.
Another class of glaucoma medications known as hyperosmotics are used only to control sudden elevations in eye pressure. They are given
orally or by injection; examples include glycerin (Osmoglyn) and isosorbide (Ismotic).
*These medications are available in generic versions.

of the day. Because an important goal of glaucoma individual needs. Depending on such factors as the
treatment is to control eye pressure and stop the severity of your glaucoma and your medical history,
progression of the disease, your physician may tai- your doctor may prescribe these drugs in a differ-
lor your medication schedule to address such fluc- ent order or use two or more drugs in combination.
tuations in eye pressure. Taking your medications The more commonly used medications tend to have
on a regular schedule and not skipping any doses is fewer and less severe side effects than those less
important for keeping eye pressure under control commonly prescribed (see Table 2).
throughout the day. ■ Prostaglandins. These eye drops are commonly
Regular exams are equally important because used because they require only one application
without an exam, you don’t know whether fluid per day. This medication lowers eye pressure by
pressure in your eye is in a safe range or whether increasing the flow of aqueous humor through the
your visual field is slowly deteriorating. People who uveal and scleral tissues.
have questions about their drugs, trouble follow- ■ Beta blockers. These eye drops contain medica-
ing their treatment plans, or difficulty using their tion similar to the beta blockers used to treat some
medicine should ask their doctors for advice and types of heart disease. Beta blockers lower pres-
solutions. sure in the eye by reducing the amount of aqueous
For open-angle glaucoma, treatment usually humor produced by the ciliary body. This class of
begins with topical medications—eye drops or medication is usually well tolerated, but side effects
sometimes ointments—administered one to several may occur. You may use topical beta blockers even
times a day (see Table 2, left). Depending on the if you are also taking beta blockers in pill form for
severity of the condition, multiple drops and some- heart disease, but you should notify both your oph-
times pills may be required. Most ophthalmologists thalmologist and physician that you are doing so.
begin with the lowest effective dose to minimize ■ Carbonic anhydrase inhibitors . Medications in
cost and potential side effects. this class, also known as CAIs, can be used either
You can apply drops more easily by pulling your orally or topically to decrease eye pressure by
lower lid out to create a small pouch for the medi- reducing the amount of aqueous humor produced
cine (see “How to apply eye drops,” page 26). Gently in the eye.
closing your eye will ensure the medicine spreads ■ Alpha agonists. These eye drops lower pressure
over its surface. Generally, drops should be used in the eye by both decreasing production of aque-
every 12 hours if prescribed twice a day, every eight ous humor and increasing the fluid outflow.
hours if prescribed three times a day, and so forth. ■ Adrenergics. These drugs reduce the amount
Although eye drops help control pressure in the of aqueous humor and increase its outflow through
eye, they may have side effects that can keep you the trabecular meshwork.
from using them. These may affect just the eye or ■ Miotics. These are the oldest of the glaucoma
your whole body, as the drops can enter your blood- medications in use. Applied as eye drops, they
stream through your nose and throat. To minimize improve the capacity of the drainage system. Miot-
that problem, press your fingertip against the inner ics are used infrequently because their side effects
corner of the eye after adding the drops. This com- on vision are more common and troublesome than
presses the tear duct and prevents the medicine those of many other glaucoma medications.
from entering the drainage pathway into the nose. ■ Hyperosmotics. For closed-angle glaucoma,
hyperosmotic medication may be taken orally or
Glaucoma medications injected intravenously. The medication quickly
The following classes of drugs are listed in the order reduces the pressure in the eye by pulling fluid from
an ophthalmologist is most likely to prescribe them. the eyeball into the internal eye blood vessels, so it
However, the doctor will adjust treatment to your can pass out of the eye with the normal blood flow.

glaucoma (see Figure 7). There are two versions: argon
How to apply eye drops laser trabeculoplasty and selective laser trabeculo-
1. Wash your hands. A plasty. Both treatments effectively lower eye pressure
2. Tilt your head back while standing, more than 75% of the time.
sitting, or lying down. Pull your The procedure, done in an ophthalmologist’s
lower lid away from the eye to form office, usually takes less than 10 minutes. After you
a pocket with your index finger (A). receive anesthetic drops to numb your eye, the doc-
3. Let the drop fall into the pocket tor puts a temporary contact lens on your eye, then
B
without touching the bottle to your focuses and applies the laser. You may see flashes of
eye or eyelid. Slowly let go of the
lower lid. green or red light during the procedure, but you won’t
feel any pain. The doctor then checks your eye pres-
4. Close your eyes, but try not to blink,
squint, or shut them too tightly, sure and prescribes anti-inflammatory eye drops for
which could push the drops out of use at home. You may experience blurred vision and
your eyes. C sensitivity to light for a day or two after the operation,
5.Gently press on the inside corner but real discomfort is rare. And you’ll probably still
of your eye where the lids meet the need to keep taking your regular glaucoma medicines.
nose (B) for two to three minutes. Laser trabeculoplasty is often helpful, but the ben-
(This step can be omitted when ap-
plying artificial tear drops.) efits aren’t permanent. As the treatment effect wanes
(usually within two to three years), you may need
6. Wipe unabsorbed drops and tears from the closed lids
with a tissue (C). additional medicines or more surgery.
■ Laser iridotomy. Doctors use this procedure to
7. If you are putting in more than one drop or more than
one type of eye drop, wait at least five minutes before treat people who have closed-angle glaucoma and
putting in the next drop. those at risk for the problem. Like trabeculoplasty,
this procedure is done in an ophthalmologist’s office.
A few additional suggestions:
• If you have a strong blink reflex, try lying flat on your
After numbing your eye and applying a temporary
back and putting a drop outside the lid of your closed contact lens to guide the laser, the doctor creates a
eye and near your nose. Then open your eye and the tiny hole—no bigger than the head of a pin—in your
drop will roll in. iris. The new drainage hole allows fluid to drain from
• If your hands are shaky, try approaching your eye from your eye. This restores the balance between fluid
the side so you can rest your hand on your face to entering and leaving your eye and stabilizes eye pres-
help steady your hand. You can also try putting a wrist
weight of 1 to 2 pounds on the hand you’re using, sure. The actual procedure takes only a few minutes.
which can reduce mild shaking. Laser iridotomy often cures closed-angle glaucoma.
• If the dropper is attached directly to the bottle (as Occasionally, people who have this procedure need
opposed to a separate dropper) and you have trouble additional treatment with medications or incisional
holding on to it, wrap something (such as a paper surgery.
towel) around it. ■ Incisional glaucoma surgery . If medications
• You can also purchase an assistive device (available at
or laser treatment fail to lower your eye pressure
medical supply stores) to help you put in eye drops.
enough, you may need incisional surgery. Glaucoma
filtration surgery, also called trabeculectomy, is the
Glaucoma surgery most common. This delicate microsurgical proce-
Should medication fail to control the eye pressure, dure is done in an operating room under local anes-
your ophthalmologist may recommend either laser or thesia. The eye surgeon makes a small flap in the
incisional glaucoma surgery. white of the eye, called the sclera. This creates a res-
■ Laser trabeculoplasty. This procedure uses very ervoir called a filtration bleb under the conjunctiva,
focused light energy from lasers to treat open-angle the thin, clear coating covering the sclera. The aque-

ous humor inside the eye can then drain through Figure 7 Laser trabeculoplasty for glaucoma
the flap to collect in the bleb, where it is absorbed
by blood vessels and other nearby tissues. The doctor
then closes the flap with tiny stitches. Some of these
stitches may be removed after surgery to increase
fluid drainage and lower the pressure inside your eye. Laser
You will likely receive medications that help reduce
scarring in your eye both during and after surgery.
If your doctor is concerned that a trabeculec-
tomy will not be successful, he or she may recom-
mend an aqueous shunt. This is a small valve with a
tube. The doctor places the valve under the conjunc-
tiva and sews it to the sclera, then inserts the tube Lens
into the anterior chamber. The shunt drains excess

fluid into a small reservoir, or filtration bleb, between Iris
the conjunctiva and sclera.
Incisional surgery helps to reduce eye pressure in
many people, allowing them to reduce or even stop
their glaucoma medications. However, up to 20% of Small burns on the
people need a second surgery. The filtering blebs cre- trabecular meshwork
ated by this surgery may leak, become infected, or fail
to form. Incisional surgery may also lead to blurred or
reduced vision or the development of cataract.
■ Cyclophotocoagulation. Doctors use cyclopho-
tocoagulation when other treatments fail to remove In this procedure, the surgeon uses a high-energy beam of light
excess fluid from the eye. It is generally reserved for (laser) to produce small burns on the trabecular meshwork. The
advanced or aggressive open-angle glaucoma. The procedure improves the flow of aqueous humor out of the eye.
A slit-lamp microscope and a special contact lens allow the oph-
procedure uses a laser on the ciliary body, the struc-
thalmologist to get a detailed view of the angle where the iris,
ture behind the iris that produces aqueous humor. cornea, and sclera meet, and to focus the laser on the tissue.
This helps lower the amount of fluid entering the eye,
which in turn lowers eye pressure. Although serious called the Trabectome, and the Express mini glau-
complications are uncommon, this surgery can cause coma shunt. These surgical procedures are under
inflammation and may increase the risk of cataract. long-term evaluation for safety and efficacy. So far,
■ Newer surgical options. Several newer glaucoma it appears that these procedures do not reduce eye
surgical procedures currently performed include pressure quite as much as trabeculectomy, but they
canaloplasty, ab interno trabeculotomy with a device may offer advantages in certain patients.

Age-related macular degeneration
Types of AMD
U nlike glaucoma, which first affects periph-
eral vision, age-related macular degeneration
(AMD) strikes at the macula, the heart of the eye’s
The disease occurs in two main forms: dry and wet.
While this discussion focuses on the age-related
vision center. This small part of the retina, which forms, younger people may develop other kinds of
measures only about 3 by 5 millimeters (less than macular degeneration, some inherited and some
one-quarter-inch square), is responsible for sharp, acquired, which may have similarities to age-related
central vision (see Figure 8). People with AMD macular degeneration.
often develop blurred or distorted vision and cannot ■ Dry AMD. The vast majority (90%) of people
clearly see objects directly in front of them. Eventu- with AMD have the dry or atrophic type. Although
ally they may develop a blind spot in the middle of some people have no symptoms and are completely
their field of vision that increases in size as the dis- unaware that they have the disease, others com-
ease progresses. pletely lose their central vision. The disease is caused
Although the disorder eventually can become by a breakdown or thinning of retinal tissue and, in
debilitating, in the earliest stages of AMD there often advanced stages, loss of photoreceptor (light-sensi-
are no warning symptoms. If the condition pro- tive) cells in the macular area of the retina. Dry AMD
gresses to intermediate AMD, some people begin to may affect only one eye at first, causing gradual dis-
notice blurring in the center of their vision. At the tortion of the visual field and blurring of the central
advanced stage, the blurred area increases, making sight. It is likely that the second eye is also involved,
it hard to read or even recognize people. About eight but with no symptoms. However, the second eye may
million Americans have early or intermediate AMD, progress and show symptoms over time. Some cases
and more than two million people ages 50 and older of dry AMD progress to the more serious wet form of
have an advanced form that is characterized by severe the disease.
vision problems. ■ Wet AMD. All people with wet AMD start out
with the dry form. Although wet AMD is less com-
mon, it is the most common cause of severe vision
loss. It progresses more rapidly, and vision loss can
occur suddenly. It results when abnormal blood ves-
sels develop in the layer of cells beneath the retina
(the choroid layer) and extend like tentacles under
and into the retina, toward the macula. These new
vessels are prone to leaking fluid and blood, which
injure tissue and photoreceptor cells. The outcome is
scarring and marked loss of vision, usually in the cen-
ter of the macula.
As age-related macular degeneration progresses, you may notice Causes and risk factors
a blind spot develop in your central vision. The causes of AMD are not well understood. Scien-
Photograph courtesy of the National Eye Institute. tists don’t know exactly why the macula deteriorates.

But they do know that certain factors can increase centrated in the eye; and lutein and zeaxanthin, sub-
your risk of developing AMD. Aging itself is a major stances known as carotenoids that are found in green
risk factor: people in their 50s have only a 2% chance vegetables and fruits and are also the dominant pig-
of developing any form of AMD, yet that risk jumps ments in the macula.
to 30% in those older than 75. Women (who tend to A diet high in refined carbohydrates and sugary
live longer than men) get the disorder more often, foods such as cakes, cookies, and white bread may
as do people with a family history of the disease. also raise the risk of AMD. People whose diets con-
Smoking is another risk factor—smokers have up to tained more of these so-called high–glycemic index
four times the risk of developing the later stages of foods were more likely to develop AMD than those
macular degeneration. But quitting lowers your risk, who ate fewer of those foods, according to one study
with benefits becoming evident after a year of being in the American Journal of Clinical Nutrition. Other
smoke-free. evidence hints that a diet high in saturated fat may
Other factors that may increase risk include increase the risk of AMD.
exposure to bright sunlight and ultraviolet radiation, Ongoing research continues to focus on causes—
light-colored eyes, farsightedness, obesity, hyperten- such as genes, diet, and environmental condi-
sion, high cholesterol, and coronary artery disease. tions—with the hope of ultimately preventing AMD.
Research suggests that diet may play a role in Researchers have identified three gene variants that
the development of AMD. For example, studies have are strongly linked to a higher risk of developing
found that AMD is more common in people whose AMD, and several genetic tests for AMD are com-
diets are deficient in several nutrients. These include mercially available. However, the value of this infor-
the antioxidant vitamins C and E; the mineral zinc, mation to date is unclear, because the findings would
which exists in trace amounts in the body but is con- not change how a doctor would monitor or treat
Figure 8 When central vision is damaged
Degeneration
around macula
What the eye looks at
What the brain perceives
Amsler grid
Optic
nerve
©Harriet Greenfield
When the macula is damaged, people may first experience blurred or distorted vision and see straight lines as wavy. As the condition
progresses, they may notice a black or dark space at the center of their visual field. An ophthalmologist may ask the patient to focus on
a dot on a visual grid (Amsler grid). If the lines near the dot appear wavy, macular degeneration may be responsible.

patients. As a result, most eye doctors advise people A doctor may suspect dry AMD if the view
not to spend their money on such tests. Still, many through an ophthalmoscope reveals clumps of pig-
experts in the field believe this type of information ment or clusters of drusen (small yellow deposits that
may be valuable in the future as new treatments build up under the macula). Although these lesions
options arise. can indicate early or intermediate stages of AMD,
drusen alone are not conclusive evidence.
An Amsler grid test (see Figure 8) can help to
Diagnosing AMD identify the distorted vision typical of AMD. You
Although symptoms vary, people with the dry form focus your eyes on a central dot on a grid that resem-
of AMD will probably first experience blurred bles graph paper. If the lines near the dot appear wavy
vision and difficulty reading or distinguishing faces. or are missing, AMD may be to blame. (You can sim-
These can also be symptoms of early stages of wet ulate this test on your own by looking at window-
AMD. Wet AMD typically progresses swiftly if left panes, floor tiles, or ceiling tiles. See if the straight
untreated, causing a blind spot at the center of the edges look wavy.) Distortion that appears on the grid
visual field. Over time, this area may enlarge and hin- may be a sign of the wet form of AMD and should
der sight. However, some people who have AMD in be evaluated, especially if it represents a change from
only one eye often do not realize they have any vision previous observations. If you already show evidence
loss because their healthy eye compensates so well. of dry AMD, it’s a good idea to perform this test regu-
Distorted vision is another early sign of wet larly to check for signs of disease progression to the
AMD. Leaking blood vessels raise the position of the wet form of the disease. This is important because the
macula and cause straight lines to suddenly appear earlier the disease is detected, the greater the likeli-
wavy and shapes to look deformed. Colors may hood of successful treatment.
seem faded. While AMD can severely damage cen- In late 2009, the FDA approved a device called
tral vision, it does not affect peripheral vision, and ForeseeHome that allows people to monitor their
patients do not go totally blind from even the most AMD from home. The device resembles equipment
severe forms of the disease. your doctor uses but is much smaller—about the size
A routine eye examination can often detect signs of a tabletop microscope. To use ForeseeHome, you
of AMD before sight is affected and before perma- must pay a rental fee and a monthly monitoring fee
nent visual loss occurs. The eye exam includes an (as of 2012, those costs were $250 and $60, respec-
acuity test to measure how well you see at different tively). The daily test takes a few minutes per eye,
distances (with glasses, if needed). A complete eye and the results are automatically sent via phone to a
exam will rule out or identify coexisting eye diseases, monitoring center. If the monitoring detects a change
such as cataract or glaucoma. in your test results, the company alerts you and your
doctor to schedule an appointment. The $60 monthly
fee, which is not covered by most insurance plans, has
Symptoms of prevented many people from signing on to the pro-
AMD gram. A large, government-sponsored trial is under
Report any of the following symptoms to your doctor: way to better understand the potential benefits of
• Blurred vision the device. For now, experts say the system probably
• Distorted vision makes sense only for people at high risk of advanced
• Faded colors AMD.
• Difficulty reading If the doctor suspects wet AMD, you will prob-
• Difficulty distinguishing faces ably also undergo fluorescein angiography. In this
• Blind spot in the center of the visual field
test, a special dye is injected into your arm. As the
dye travels through the blood vessels in the retina,

your doctor takes multiple photographs with a special Anti-VEGF drugs
camera; these images reveal whether the blood vessels Vascular endothelial growth factor (VEGF) has been
in your eyes are leaking and where any abnormalities linked to abnormal blood vessel growth and vascular
are located. The procedure helps the ophthalmologist leakage in AMD and other common retinal diseases,
determine the best course of treatment. such as diabetic retinopathy (see page 36) and reti-
nal venous occlusive disease. Anti-VEGF drugs block
the effects of VEGF (see Figure 9), thus inhibiting the
Treating AMD growth of abnormal new blood vessels and leakage
Currently, the only treatment for dry AMD is vitamin associated with increased VEGF stimulation.
supplementation combined with a well-balanced diet For these treatments, the doctor first numbs your
that includes leafy green vegetables and several serv- eye, then injects the drug into your eyeball with a very
ings of fish per week. However, success in the treat- fine needle. People say the injection doesn’t hurt and
ment of wet AMD has led to increased efforts in the feels a bit like touching their eye in search of a lost con-
prevention and treatment of dry AMD. Several inno-
vative approaches are being evaluated, and while the
Figure 9 Targets for anti-VEGF therapy
results won’t be available for several years, there is
hope for the future. You can search online for a listing Normal
of clinical trials evaluating such treatments at www. A
clinicaltrials.gov, or ask your doctor.
Photoreceptor
The federally funded Age-Related Eye Disease cells
Study (AREDS) found that high doses of particular
supplements can slow (and sometimes even prevent) Area of
progression from intermediate to advanced AMD, detail
Healthy
thereby preserving vision in many people (see “Pre- blood
venting and slowing AMD,” page 34). A follow-up vessels
study, AREDS2, will determine whether adding addi-
AMD
tional supplements—lutein and zeaxanthin (found
B
naturally in plants) and the omega-3 fatty acids DHA
and EPA (found in fatty fish)—will further slow the Abnormal
progression to advanced AMD. blood vessel
growth
Because dry AMD progresses very slowly, people
usually manage quite well in their daily routines even VEGF
with some central vision loss. If the condition worsens, molecules
special low-vision aids—such as magnifying lenses or
closed-circuit televisions that “read” regular print and
then enlarge it on a monitor—can help maintain qual- The wet form of age-related macular degeneration injures healthy
ity of life (see “Living with low vision,” page 34). tissue in the retina. The blood vessels and photoreceptor cells
The development of anti-vascular endothelial of a healthy eye are seen in the top illustration (A). When VEGF
growth factor drugs, or anti-VEGF drugs (see at right), molecules stimulate abnormal blood vessel development, healthy
has revolutionized the treatment of wet AMD. Less blood vessels sprout tentacles that extend under and into the
often, laser surgery may be used. Another treatment retina, often involving the macula (B). These new vessels are
fragile, often leaking blood and other fluids, which injure tissue
that may help certain people with severe, end-stage
and photoreceptor cells. Anti-VEGF drugs counteract the action of
AMD is a device called the implantable miniature tele- VEGF molecules, thereby inhibiting blood vessel proliferation. They
scope (see “A tiny telescope inside the eye,” page 32). also appear to reduce vascular permeability, which decreases the
amount of leakage from abnormal blood vessels.

tact lens. You will need injections at regular intervals In 2008, the National Eye Institute launched
for anywhere from several months to several years. a trial comparing bevacizumab and ranibizumab.
Possible side effects include short-term eye pain, irrita- Both drugs, when administered monthly, worked
tion, discharge, and seeing spots or floaters, but when equally well for stabilizing or improving visual acu-
they occur, they are often mild in nature. More serious ity, according to the first-year results, which were
side effects, including infections that can lead to vision published in the New England Journal of Medicine in
loss, occur in less than one in 1,000 injections. 2011. The study tested two dosing regimens: once a
Three anti-VEGF drugs are FDA-approved for month or on an “as needed” basis, meaning the drug
treating wet AMD. Doctors rarely prescribe the old- was given when people showed signs of active dis-
est one, pegaptanib (Macugen) because the newer ease. For both dosing schedules, boosts in visual acu-
drugs—ranibizumab (Lucentis) and aflibercept ity were nearly identical between the two drugs. The
(Eylea)—are far more effective. A fourth drug, beva- visual gains were slightly lower in the “as needed”
cizumab (Avastin), is FDA-approved only for treating group, but those participants had four to five fewer
several types of cancer but has long been used “off- injections per year than those in the monthly treat-
label” to treat AMD, after short-term studies demon- ment group. In addition, people who used ranibi-
strated its effectiveness. zumab as needed improved slightly more and with
one fewer injection than people who used bevaci-
zumab. Results from the second year of the trial will
help clarify any meaningful differences between the
A tiny telescope inside the eye
two drugs and the two dosing regimens.
A telescopic lens the size of a pea that is surgically placed
within the eye may help older people with severe AMD
The major difference between the two drugs is
see more clearly. The implantable miniature telescope the cost: about $50 per dose for bevacizumab ver-
(IMT) functions like a telephoto lens on a camera, sus about $2,000 per dose for ranibizumab. In 2011,
magnifying images by two to three times. The telephoto reports of eye infections following bevacizumab
effect allows images in the central visual field (so-called
injections sparked concern about the drug’s safety.
straight-ahead vision) to focus not on the damaged
macula but instead on other, healthier areas of the retina. But investigations traced the problem to improper
By reducing the “blind spot” that results from severe compounding practices by a limited number of
AMD, the implant enables people to recognize images pharmacies.
that had been either difficult or impossible to see. The FDA approved aflibercept in 2011, after two
In a study of 206 people who received the IMT, 67% of the large studies showed the drug was as effective as
treated eyes had an improvement of three lines or greater ranibizumab. Aflibercept is slightly less expensive
on the eye chart, compared with 13% of the non-implanted
control eyes. The IMT is designed to go in one eye only, for than ranibizumab—about $100 less per injection—
jobs like reading and recognizing faces, while the other eye and may require fewer injections.
is used for peripheral vision during other activities such as Because the drugs are expensive, check your
walking. People who receive the IMT must participate in a insurance plan or Medicare coverage to see how
structured vision rehabilitation program to learn to use and
much of the cost you will need to shoulder (if any) if
maximize the different abilities of their eyes.
you choose this therapy.
The device, which was approved by the FDA in 2010, isn’t
appropriate for most people with AMD. To be considered for
the implant, you must be at least 75 years old, have end- Laser treatments
stage AMD, and be legally blind (that is, your best corrected Because anti-VEGF drugs have fast become the treat-
distance vision is between 20/160 and 20/800). People with ment of choice for many people with wet AMD, laser
better vision would not benefit from the enlarged image the
treatments are used less frequently. Once the only
device provides. As of early 2012, the surgery to implant the
device is done only by cornea surgeons at selected centers option for treating wet AMD, laser surgery has been
in the United States. supplanted in part because the procedure often does
not prevent the growth of new blood vessels, and

because it destroys both diseased sections of the ret-
ina and adjacent healthy ones. Moreover, laser sur-
What is a macular hole?
A macular hole is different from and less common than macu-
gery does nothing to correct or slow the underlying
lar degeneration. It results when the vitreous humor, the gel-
disease process in wet AMD. like substance that fills the back of the eye, pulls away from
In general, lasers are used only in situations where the surface of the retina, creating traction that may cause a
the leaking blood vessels are relatively small and hole to develop in the macula. In severe cases, a person with
this condition will lose much of his or her central vision.
located far from the central portion of the macula,
or when someone cannot have intraocular injections Ophthalmologists use a procedure called vitrectomy and
membrane stripping with gas injection to close the hole
because of an eye infection or advanced glaucoma. and possibly restore vision. The doctor removes the vitreous
Few people fall into these categories. humor to prevent it from pulling on the retina, along with
■ Laser photocoagulation. In this procedure, the any visible scar tissue, and fills the resulting space with a gas
doctor aims a laser beam at leaky blood vessels to seal bubble. The patient must spend a few days to a week (but
sometimes as long as two to three weeks) in a face-down
them and prevent further seepage. People reap the
position, to allow the gas bubble to exert pressure upward,
most benefits when the procedure is done on newly pushing against the hole at the back of the eye, and gradually
formed vessels that haven’t yet encroached on the sealing the hole. This procedure is more than 90% effective in
fovea. In such cases, sealing off the leaking blood ves- closing the hole, but the degree of vision improvement varies
sels may restore vision. Laser photocoagulation can widely from person to person.
be done in a doctor’s office and takes only a few min-
utes, although the entire office visit may take signifi- decline in vision. To preserve vision, patients usually
cantly longer, and sometimes multiple treatments are need more than one Visudyne treatment per year.
necessary. You may experience some mild discomfort For people who don’t get good results from anti-
and sensitivity to light afterward. Frequent check- VEGF drugs, doctors sometimes add photodynamic
ups will be scheduled, during which the doctor may therapy and steroid injections to the anti-VEGF drug
repeat the fluorescein angiography test (see “Diagnos- regimen. Still, studies have not found that this com-
ing AMD,” page 30) to assess the status of the blood bination treatment is any more effective than anti-
vessels. The surgery is often helpful, but in about half VEGF drugs alone.
the cases, the condition recurs and may require more If you undergo Visudyne therapy, you’ll need to
laser treatments. avoid exposing your skin or eyes to direct sunlight or
■ Photodynamic therapy. Another option is photo- bright light for two to five days after treatment. Your
dynamic therapy, which uses a laser in combination eyes may be especially sensitive to light. Speak to
with a light-activated drug, verteporfin (Visudyne), your eye doctor about other steps you’ll need to take
to treat various medical conditions, including wet following this therapy.
AMD. The procedure is a two-step, 15-minute process
that can be done in a doctor’s office. First, the drug is
injected into a vein in the arm through an intrave- Self-care
nous line over a 10-minute period. During the next Although AMD cannot be cured, early detection is
five minutes, the drug travels through the body and important to prevent further deterioration of the ret-
accumulates in the abnormal blood vessels in the eye. ina. For this reason, it’s crucial that older people have
The doctor then activates the drug by shining a low- regular eye exams and contact their doctors about
intensity laser into the eye for about 90 seconds. This any changes in their eye health and vision. Because
produces a highly energized form of oxygen that kills all the available treatments for wet AMD work best in
abnormally growing cells, closing off the abnormal the disease’s early stages, consult an ophthalmologist
blood vessels without damaging surrounding healthy immediately if you notice symptoms.
eye tissue. Visudyne therapy alone rarely restores ■ Home monitoring. People already diagnosed with
vision; more often, it simply slows retinal damage and AMD can monitor their condition by testing them-

selves at home with an Amsler grid (see Figure 8, Preventing and slowing AMD
page 29) or the ForeseeHome monitor (see “Diag- While there is no surefire way to prevent AMD, you
nosing AMD,” page 30). Keep the Amsler grid on the can take steps that may delay onset of the disease or
refrigerator door or another convenient spot. By rou- reduce its severity. Because smoking can accelerate
tinely testing each eye, someone with dry AMD may AMD damage, quitting smoking is an important pre-
be warned that wet AMD is beginning, while people ventive step. Wearing hats and sunglasses that block
who have already had laser surgery for AMD may be the sun’s blue wavelengths—which are thought to pos-
alerted to recurrent leakage or bleeding. sibly promote AMD—may also provide protection.
If you have already lost some of your vision to Some evidence suggests that using statins, a group
AMD, low-vision aids can help maximize the sight of drugs usually prescribed to lower cholesterol, reduces
you have left (see “Living with low vision,” below). the risk of AMD. Heart disease is usually identified with
Specialists in low vision can prescribe appropriate an increased risk of AMD, so the statin connection is not
aids and provide referrals to agencies that offer sup- surprising. Nevertheless, much more research is needed
port and assistance to the visually impaired. before doctors begin prescribing statins to prevent AMD.
Living with low vision

Many people must live with vision that limits their daily specialized text-to-speech conversion
activities, a condition known as low vision. Low vision may programs that read text aloud. Special
involve blurry vision, poor central vision, loss of peripheral keyboards, magnifiers for monitors, and
vision, or even double vision. Whatever the symptom, the other devices are also available. Most
immediate consequences are often the same—difficulty major computer supply stores carry
performing day-to-day activities such as reading a newspa- these products.
per, using a computer, watching television, cooking a meal, or Other aids. Electronic “talking”
crossing the street. Still, low vision is like many complicated watches, alarm clocks, and calculators let
medical conditions: while there may not be a cure, there people rely on their hearing rather than Stand-mounted
often are ways to cope. their vision. Listening to audiobooks is magnifier
Optical aids. The magnifying lens another popular option.
remains one of the most common A simple desk lamp with a metal shade is one of the easiest
tools to help compensate for low ways to improve vision if you use it properly. Position the lamp
vision. Most magnifying lenses are so that the light shines directly onto the materials in front of
made to be held, but some can be you, rather than over your shoulder or high above you.
incorporated into the lens of a pair
of prescription glasses and used Other inexpensive, low-tech vision aids include large-print ver-
for reading or detail work. Special sions of playing cards, bingo cards, and push-button telephone
Hands-free binoculars lenses that work like miniature and cell phone pads. And, of course, many books and newspa-
telescopes can be mounted on pers come in large-print versions.
a pair of glasses and used for driving or watching a movie. Rehabilitation. In addition to using various gadgets, people
Glasses with special filters or stand-mounted magnifiers with low vision can learn a few simple tactics to compensate
containing a light source may help with excessive glare or for their diminished sight. Ophthalmologists, optometrists,
reduced contrast (less distinction between light and dark). and occupational therapists can offer such advice. For ex-
An expensive option is a device similar to something once ample, dark coffee is easier to see when poured into a white
featured in Star Trek: goggles that consist of two tiny high- mug, and a fried egg is more visible when served on a dark
definition television sets that display images recorded and plate. You can rearrange furniture for easier navigation, and
enhanced by a digital camcorder. label your foods and medications with large print to make
Computer aids. Many software programs can make the them easier to identify.
text on a computer monitor larger or more legible to people You can order low-vision devices through several organiza-
with vision problems. Options range from programs that tions, including the Low Vision Center in Bethesda, Md. (see
enable you to change font size and background displays to “Resources,” page 48).

Evidence also suggests that certain nutrients help pre-
vent macular degeneration. Middle-aged and older people
Will vitamins help?
AREDS found that the following combination of anti-
may benefit from diets rich in fresh fruits and dark green
oxidants and zinc may help protect against advanced
leafy vegetables such as spinach or collard greens. AREDS age-related macular degeneration. (Copper is added to
reported in 2001 that for people at high risk of developing the mix because high levels of zinc may cause copper
advanced stages of wet AMD, high-dose combinations of deficiency.)
antioxidant vitamins and minerals lowered risk by about • Vitamin C: 500 milligrams (mg)
25% (see at right). The supplements provided no appar- • Vitamin E: 400 international units (IU)
ent benefit for people who had either no AMD or early • Beta carotene: 15 mg
AMD. Ask your doctor about taking such supplements if • Zinc: 80 mg
you have intermediate or advanced dry or wet AMD. • Copper (cupric oxide): 2 mg

Diabetic retinopathy
W ith cases of diabetes escalating, the eye problem

known as diabetic retinopathy—which can cause
vision loss and blindness—is becoming a serious pub-
Diabetic retinopathy occurs in two stages.
First, the walls of the small blood vessels become
abnormal and weaken. They leak fluid into the
lic health issue. More than 4.4 million people ages 40 surrounding tissue, often leaving deposits of pro-
and older currently suffer from diabetic retinopathy. tein and fat called hard exudates. The vessels also
Diabetes comes in two main forms: type 1 and develop microaneurysms, tiny bulges or balloons
type 2. In type 1 diabetes, the pancreas is unable to in their walls that tend to leak red blood cells into
produce insulin, the hormone that enables sugar and the retina. As the condition progresses, the abnor-
other nutrients to enter cells for energy and growth. mal vessels begin to close, robbing the retina of its
Type 2 diabetes occurs when the body becomes resis- blood supply. Nerve fibers die off because of poor
tant to the effects of insulin and not enough insulin is circulation and lack of oxygen, creating white cot-
produced to overcome the resistance. Both disorders tony patches known as soft exudates (see Figure
lead to high blood sugar levels that, left untreated, 10).
have serious long-term consequences throughout the These changes may not necessarily alter your
body, including the eyes. vision. But if the fluid or blood leakage occurs near
People with diabetes are at greater risk of develop- the macula—the part of the retina responsible for
ing cataracts and glaucoma, but a third problem—dia- sharp, central vision—your sight will be impaired.
betic retinopathy—is most likely to cause severe vision When fluid leaks into the center of the macula, the
loss and even blindness. Diabetic retinopathy occurs macula can swell, blurring vision. This condition is
when abnormal blood sugar levels damage small called macular edema, and it can range from mini-
blood vessels in the retina. Damage to the retina can mal to severe.
lead to vision problems, including permanent vision As retinopathy advances, the decreased blood
loss. flow causes the damaged retina to try to repair
itself by sprouting new blood vessels. However,
these new vessels grow abnormally and extend into
the vitreous humor, the gel-filled compartment of
the eye in front of the retina. The fragile new ves-
sels are prone to leak blood and break. When they
bleed into the vitreous humor, they can block the
passage of light and cause a sudden loss of vision.
The blood is usually reabsorbed, but scar tissue may
form. The scar tissue tugs on the retina, pulling it
away from the back of the eye, which can lead to
permanent vision loss (see “Retinal tear or detach-
ment,” page 44). In some cases, the blood does not
reabsorb, and surgery may be required to remove
As diabetic retinopathy progresses, you may notice spots and the blood and treat the underlying retinopathy.
floaters in your vision. Central vision may become distorted.
Photograph courtesy of the National Eye Institute.

Preventing diabetic retinopathy Figure 10 Diabetic retinopathy
One of the best ways to protect your vision if you
have diabetes is to control your blood glucose lev- Abnormal blood
Retina
els carefully. The Diabetes Control and Compli- vessel growth
cations Trial, and a long-term study following it,
found that people with diabetes who keep their Vitreous
blood sugar at near-normal levels cut their risk humor Cotton-
wool
of developing eye diseases and macular edema by spots
75%. If you have diabetes, also pay careful atten-
Macula
tion to your blood pressure and cholesterol levels.
Lens
Levels above normal increase the likelihood that
diabetic retinopathy will occur and that it will sig-
Microaneurysms Hard exudates
nificantly affect your vision.
Ongoing high blood sugar levels that result from poorly managed
Progression of diabetic retinopathy diabetes can cause the tiny blood vessels in the retina to break
down and leak fluid into surrounding tissues, leaving deposits of
In the early stages of diabetic retinopathy, there may protein and fat called hard exudates. The vessel walls can also
be no symptoms. But as the problem becomes more develop tiny bulges called microaneurysms. Eventually, the dam-
severe, macular edema may develop. This can cause a age blocks the retina’s blood supply. Nerve fibers die, creating
noticeable decline in central vision, especially as the white fluffy patches known as cotton-wool spots.
swelling increases.
An eye exam can detect even the earliest changes, may become more severe, and vision loss and blind-
such as ness can occur. The sooner you get help, the better, as
• leaking blood vessels earlier treatment is more likely to be effective.
• retinal swelling (macular edema)
• fatty deposits on the retina
Detecting diabetic retinopathy
• damaged nerve tissue Unfortunately, diabetic retinopathy has no early warn-
• s mall, balloon-like abnormalities known as ing signs. The best way to protect yourself is to under-
microaneurysms. stand your risk and receive vision testing as necessary.
As diabetic retinopathy progresses to its later Anyone with diabetes—either type 1 or type 2—
stage, symptoms become more dramatic. You might should get a comprehensive dilated eye exam at least
notice spots that are really specks of blood floating once a year.
in your vision. Although sometimes the specks will Comprehensive eye exams can detect macular
clear without treatment, hemorrhaging can occur edema and diabetic retinopathy in the earliest stages.
repeatedly, often during sleep. Seek treatment imme- Prompt treatment can help prevent severe vision loss
diately from an eye care professional if you notice and blindness.
specks obscuring your vision. Otherwise, bleeding
Treating diabetic retinopathy

Symptoms of There is no cure for diabetic retinopathy. But you can
diabetic retinopathy take steps to prevent vision loss—or at least to slow its
• Blurred vision • Distorted vision progression. Treatments include laser therapies, anti-
• Fluctuating vision • Floating spots VEGF drugs, and steroids. The choice depends on the
type and extent of your disorder.

Laser treatments is clouded with blood) with a salt solution. Your eye
So-called focal laser treatments are used for macular will be red and sensitive, and you’ll need to used med-
edema. In one type, the doctor identifies individual icated eye drops and wear an eye patch while it heals.
blood vessels and seals them off with the laser. This
slows leakage and decreases fluid around the retina. Anti-VEGF drugs
Local anesthetics prevent any discomfort during the Although laser treatments have been the standard of
procedure, which typically involves 20 to 50 laser care for diabetic retinopathy for nearly 30 years, recent
burns per eye. If macular edema affects both eyes, a research has shown that anti-VEGF drugs—either
second session—usually a week or so later—will be alone or in combination with laser therapy—may be
needed for the other eye. The procedure can cut the the best way to prevent vision loss. These drugs, which
risk of further vision loss in half, and in a small num- block a chemical signal that stimulates blood vessel
ber of people, it actually restores vision. growth, are used to treat advanced AMD (see “Anti-
Another version, known as scatter laser treat- VEGF drugs,” page 31).
ment, is used for advanced retinopathy. The doctor A 2010 report in Ophthalmology found that
makes 1,000 to 1,500 laser burns in the outer edges nearly 50% of people who received the anti-VEGF
of the retina, away from the centrally located macula. drug ranibizumab (Lucentis) in combination with
Because so many laser burns are needed, treatment immediate or delayed laser treatment had substantial
typically requires at least a couple of sessions. This improvements in their vision, compared with 28% of
laser treatment may be uncomfortable, so ask your those who got laser treatment alone.
doctor about the possibility of a shot to numb the
eye. Scatter laser therapy helps prevent new blood Steroids
vessel growth, causing the vessels to stop proliferat- Steroid injections have also been used to treat
ing or even to regress, which lowers the risk of hem- advanced diabetic retinopathy. Steroids can reduce
orrhage or detachment. The treatment may slightly retinal swelling and often improve vision, at least for
impair your peripheral vision, color vision, and night a while. The benefits often disappear after one to two
vision. years, according to one large study. And the long-term
If the bleeding in your eye is severe, the doctor risks of steroid use, which include an increased risk of
may need to perform a vitrectomy before perform- developing cataract or glaucoma, are concerning. But
ing laser surgery. The doctor makes a tiny incision research continues on ways to increase the duration of
in your eye and replaces the vitreous humor (which effectiveness and minimize side effects.

Other common eye diseases of later life
M any people will never be affected by serious eye

diseases. But nearly everyone will eventually
experience some changes in vision, or the less serious
■ Corrective lenses. The most common remedy for
presbyopia is optical correction—reading glasses. If
you already wear corrective lenses, you might consider
eye problems described in this section. Although oph- bifocals, trifocals, or progressive lenses, which com-
thalmologists are able to treat many of these problems, bine several levels of adjustment to correct both dis-
in some situations you may be referred to a an oculo- tance and close-up vision problems. Some people use
plastic specialist or other expert (see “Your eye profes- two pairs of glasses—one for distance and one for close
sionals,” page 7). work. Many drugstores and supermarkets carry magni-
fying reading glasses that may help. You should consult
your ophthalmologist about an appropriate strength
Presbyopia: Ready for before purchasing a pair, and you should never buy
reading glasses? reading glasses in lieu of having an eye examination.
One of the truest signs of aging is discovering that you You can also get prescription contact lenses that
need to hold menus and newspapers at arm’s length correct the vision in one eye for reading and the other
in order to read them. Presbyopia—coined from the for distance—a technique called monovision. Multifo-
Greek words for “old sight”—is a loss in the eye’s focus- cal contact lenses (combining several levels of adjust-
ing ability that may start as early as the late 30s, but ment, as found in bifocal, trifocal, or progressive
typically develops in the 40s and 50s, eventually affect- lenses) are also available. Whichever type of lens you
ing everyone. It occurs when the aging lens becomes choose, you may need frequent changes in prescrip-
more rigid and less efficient in bending to accommo- tion, because presbyopia becomes progressively worse
date changes in near and distant focus. An accompa- until about age 60 to 65, when it stabilizes.
nying lag in the function of the ciliary eye muscles Another possible option is a novel type of eye-
contributes to the difficulty in seeing small print. wear called Superfocus (formerly known as Trufo-
Blurred close vision that leaves eyes tired and cals), which are adjustable focusing eyeglasses. Each
strained is an early hint of presbyopia’s arrival. After lens features a flexible lens with a transparent mem-
reading or doing other detail work, you may find it brane attached to a rigid surface, with a pocket of clear
hard to see distant objects clearly; the problem may fluid in between. If the wearer moves a tiny slider on
be more pronounced after reading in poor light, or in the bridge of the glasses, the fluid shifts and alters the
the evening when you are tired. The condition occurs shape of the flexible lens, thereby changing the visual
regardless of whether you are nearsighted, farsighted, correction. That allows the wearer to focus at a range
or astigmatic. However, presbyopia often affects far- of distances, from near to far, without zones or lines.
sighted people at a younger age than those who are They can be purchased online, custom-made to your
myopic (nearsighted). If you’re nearsighted (see Figure prescription, for about $700, which is usually covered
11), you may be able to overcome presbyopia when it by vision insurance plans, according to the company’s
first develops simply by taking off your glasses to read. website. You may want to ask your ophthalmologist
Eventually, however, as your presbyopia worsens and about his or her experience with these glasses before
the lens of your eye becomes stiffer, you may need new purchasing them.
corrective lenses or other measures to cope with this ■ Surgical monovision. One option for people 40 to
common condition. 60 years old with presbyopia but otherwise healthy

eyes is surgical correction to produce monovision, in stances.) If you choose laser surgery and never had
which one eye is corrected for close-up vision, leaving focusing problems until presbyopia developed, the
the other for distance vision. This approach doesn’t fix surgeon will correct one eye so you can see up close,
the stiffened lenses that are the underlying cause of leaving the other eye with your natural ability to see
presbyopia, but it can eliminate the need for bifocals far. If you’re both myopic and presbyopic, the doc-
or multiple sets of glasses, and it may even enable you tor can correct your nondominant eye for near vision
to read without glasses. and your dominant eye for distance. It may take sev-
Doctors use various procedures to make the eral surgeries to get the desired result, and the results
correction. Laser surgery techniques include may not be lasting.
laser-assisted in situ keratomileusis (LASIK), pho- Another technique used for monovision is con-
torefractive keratectomy (PRK), and laser thermal ductive keratoplasty (CK). This method is similar to
keratoplasty (LTK), each of which reshapes the cor- laser surgery but doesn’t actually use a laser. Instead,
nea or the area around it to provide correction. (The CK uses short bursts of radio waves to shrink and
technique used depends on your particular circum- reshape the cornea. One limitation is that it can take
Figure 11 Faulty optics: When your vision isn’t perfect

When the eye sees normally, light focuses directly on the retina,
producing a clear image. But in some people, the optics are NORMAL
Focal point
faulty, and images appear blurred because the eye focuses the on retina
image either in front of or behind the retina. These problems are
not eye diseases but common conditions known as refractive er-
rors of the eye. Although laser surgery procedures such as LASIK
have become increasingly popular as a way to correct refractive
Retina
errors, such techniques are usually appropriate only for people
younger than 50. For that reason, refractive errors in older adults
NEARSIGHTED Focal point in
are most often corrected with eyeglasses and contact lenses.
(Myopia) front of the retina
Myopia (nearsightedness). A nearsighted person has difficulty
seeing objects at a distance because the light rays converge
and focus before reaching the retina. The cause is usually an
elongated eyeball (which requires light rays to travel farther
than they would in a normal eye) or a lens or cornea that is too
strong, bending the light rays so they focus before getting to
the retina.
FARSIGHTED Focal point
Hyperopia (farsightedness). People with this defect see ob-
(Hyperopia) behind the
jects better at a distance than up close. In this case, the eyeball is
retina
usually too short, and light rays reach the retina before they are
focused. Hyperopia can also be caused by weaknesses in the re-
fractive power of the lens and cornea. While farsightedness may
go unnoticed for years, the eye’s corrective ability diminishes
with age, and a person will probably need glasses by midlife.
Astigmatism. In this condition, irregularities in the curvature
of the cornea’s surface cause distorted vision. Light rays do not astigmatism
meet at a single point. For some people, vertical lines appear Multiple
focal points
blurry; for others, horizontal or diagonal lines may look out of
focus. Astigmatism develops early and is usually well established
after the first few years of life. The defect often occurs together
with nearsightedness or farsightedness.
©Harriet Greenfield

a few months before the full benefits are apparent. CK Eyelid problems
may also carry a slight risk of causing astigmatism. Age, certain diseases, and certain cosmetic treatments
Monovision isn’t for everyone. It is vital that your can affect the muscles and skin of the upper and lower
eyes be healthy, even if you have presbyopia: no other eyelids in several ways. Often the problem is sim-
eye defects, such as cataract, glaucoma, or corneal ply cosmetic, but in other cases it may interfere with
problems, can be present. Some people may find it too vision or cause eye irritation, leading to watery eyes
difficult to adjust to having different focusing abilities and other difficulties.
in each eye. If you’re considering having this surgery, ■ Ptosis. Like other parts of the anatomy that
the FDA advises you to try monovision with contact respond to gravity over time, the upper eyelids may
lenses first, to find out whether you can adjust to hav- start to sag as muscles lose their strength. Eye injury,
ing each eye focus differently. neurologic problems, and disease (such as diabetes or
■ Refractive lens exchange (clear lens extraction). the neuromuscular disorder myasthenia gravis) can
Improvements in the lenses used for cataract surgery also bring on this condition. One popular cosmetic
(see “Specialized replacement lenses,” page 16) have procedure, Botox injections to eliminate wrinkles at the
also provided another surgical option for people who brow and forehead, may also cause temporary drooping
are nearsighted. Some ophthalmologists use these (although the problem can last as long as three months,
lenses to replace the natural lenses in people who are so it may not feel temporary to the person affected).
middle-aged or older who have the beginnings of cat- Although drooping of the upper lid often is a cos-
aracts that aren’t yet affecting their vision and who rely metic concern, it can interfere with sight if the lid is so
on glasses or contact lenses for presbyopia. lax that it covers or partially covers the pupil. Before
But keep two things in mind before undergoing trying any treatment, you will need a medical exam
this surgery for presbyopia. First, it is not approved by to identify the underlying cause. Ptosis resulting from
the FDA and will not be covered by insurance unless disease usually responds to treatment of the disease.
you have cataracts, and the cost can be as high as If the problem is caused by Botox injections, it’s best
$5,000 for each eye. Second, many ophthalmologists to wait until the injections wear off, in about three to
are reluctant to perform this procedure in people with- four months.
out cataracts because of the risks and lack of informa- If a droopy eyelid is unattractive or interferes with
tion about long-term safety and effectiveness. The FDA vision and is not caused by a treatable disease, you
has noted that the chances of retinal detachment are may want to consider surgical repair. The ptosis repair
slightly higher in people who have undergone refrac- procedure removes excess tissue and lifts the lid. It can
tive lens exchange, compared with the general popu- be performed under local or general anesthesia on an
lation, but otherwise, the risks are similar to those outpatient basis. Many health insurers will cover this
associated with cataract surgery. operation only if the ptosis is affecting your vision.
■ Phakic intraocular lenses. These are surgically Your ophthalmologist or oculoplastic specialist can
implanted lenses that for some people may be an determine whether this is the case.
alternative to LASIK for correcting nearsightedness. ■ Blepharochalasis. In a different but related condi-
In contrast to cataract surgery, which replaces your tion, just the skin of the lid begins to droop, not the
natural lens, phakic lenses are placed either between entire lid as in ptosis. This happens when the skin
the cornea and the iris or just behind the iris, without loses elasticity and sags, creating new skin folds that
removing your lens. As of 2012, two FDA-approved can actually droop over the lashes and block the upper
phakic lenses are available. However, the FDA lists a field of sight by covering the pupil. This condition,
number of risks associated with these lenses, including blepharochalasis, may be surgically corrected with a
possible vision loss or other vision problems, including procedure called blepharoplasty. As with ptosis, most
halos, glare, or double vision, and the lenses may also health insurers will pay for this repair only if your
increase your risk of developing glaucoma or cataract. condition interferes with vision.

■ Ectropion. This condition occurs when the lower ■ Skin cancer. It’s a good idea to periodically check
lid sags and turns outward. The muscles of the lower your eyelids for any unusual growths that change
lid weaken, and the lid no longer comes in contact color or shape, and alert your ophthalmologist if
with the eyeball. As a result, the margin of the lid you notice anything unusual. The doctor can then
may thicken, the upper and lower lids no longer meet examine the lesion and decide whether it should be
when the eye is closed, and the eye may tear exces- biopsied. If a lesion proves to be cancerous, an ocu-
sively. The constantly exposed cornea and conjunctiva loplastic specialist will remove it and reconstruct the
may become red and irritated. eyelid as necessary.
In mild cases, no treatment is needed except the
regular use of artificial tears, which may be purchased
over the counter, and perhaps the use of a plastic eye Dry eye syndrome
shield at night to help retain moisture. If the symp- As people age, tear production declines, producing
toms or appearance are more bothersome, surgery irritation, burning, or a slightly painful, scratchy feel-
designed to tighten the lower eyelid and surrounding ing in the eye. Sometimes mucus accumulates, caus-
muscles can correct it. The goal of the procedure is to ing a sticky sensation. You may become sensitive to
secure the lower lid so that it rests more closely against light, have trouble wearing contact lenses, or even find
the eyeball. After the surgery, you may need to wear it difficult to cry.
an eye patch and apply antibiotic ointment for a few This syndrome, called dry eye, is often mild and
days. doesn’t require treatment beyond the regular use of
■ Entropion. In this condition, the lower lid rolls artificial tears you can buy at the drugstore. When the
in, toward the eye. Because the lashes constantly rub problem is severe, it may feel like you have sand in
against the cornea, entropion may produce irritation, your eyes.
a feeling of something in the eye, tearing, and blur- Dry eye syndrome affects more than eight mil-
ring. Sometimes, in mild cases, it helps to tape the lion people in the United States. It is more common
lower lid to the cheek every night so the edge of the in women and usually starts in middle age. People
lid and the lashes are in the proper position. Ask your with allergies are more susceptible; the condition
doctor if this approach might work for you and how to may accompany systemic disease such as lupus or
do it properly. If not, a surgeon can correct this disor- rheumatoid arthritis. A shortage of tears is also one
der with a relatively simple surgical procedure. of the symptoms of Sjögren’s syndrome, a disorder of
Table 3 Over-the-counter options for dry eye syndrome

Known as artificial tears or ophthalmic lubricants, these products relieve dryness and discomfort by adding moisture and lubrication to the eyes.
People who find they need to use them more than four times a day should use a preservative-free version, which many brands offer. However, be
aware that multiple-use containers may contain ingredients that cause irritation if the drops are used frequently. Single-dispense vials are truly
free of preservatives and provide the best option for people who use these remedies frequently or who have extremely sensitive eyes. The thicker
gel formulations and ointments are best used just before bedtime, as they tend to blur vision during the day.
Active ingredient Brand names

carboxymethylcellulose Refresh Optive, Refresh Tears, Refresh Liquigel, Refresh Celluvisc, Refresh Plus, TheraTears
glycerin Soothe Lubricant Eye Drops, Moisture Eyes
hydroxypropyl methylcellulose Bion Tears, Tears Naturale, Genteal Mild, Genteal Gel
oil-based emulsion Soothe XP
polyethylene glycol Systane, Systane Ultra, Blink
polyvinyl alcohol Tears Again, Akwa Tears, Murine Tears

your ophthalmologist may advise you to apply warm
Symptoms of compresses to your eyelids and massage them periodi-
dry eye syndrome cally to free oil from the glands.
• Persistent sensation of grittiness in the eyes In severe cases, an ophthalmologist may need to
• Difficulty wearing contact lenses insert plugs into the tear drainage ducts. The plugs
• Inability to shed tears help natural and artificial tears stay on the eye longer
• Burning sensation in low humidity or polluted air by preventing them from draining out of the opening
in the inner corner of the eyelid. Alternatively, your
doctor may prescribe special soft contact lenses that
the immune system that causes dryness of the mouth, help hold in moisture. You may also be advised to
eyes, and mucous membranes. wear goggles at night to retain moisture, especially if
Dry eye syndrome may also develop in people the eye does not fully close in sleep.
with posterior blepharitis, an inflammation of the
inner eyelid that is common in people with allergies
or in those with the skin disorders rosacea or sebor- Watery eyes
rheic dermatitis. In people with blepharitis, the oil Although some people suffer from dry eyes as they
glands in the eyelid become inflamed and clog. As a grow older, others suffer from the opposite problem—
result, the eyes are not bathed in the usual fine sheen watery eyes. It may seem counterintuitive, but often
of oil, and water from tears evaporates more rapidly this problem develops because of dry eye syndrome:
than normal. because dry eyes are uncomfortable, the eyes reflex-
One study found that women who ate plenty of ively produce more tears. At other times, watery eyes
omega-3 fats (a healthy fat found in tuna, salmon, and result from tear drainage problems. Normally tears
other fatty fish, as well as in flaxseed) were less likely drain from the surface of your eyes, flow under the
to develop dry eye syndrome than women who rarely eyelids, and pass down into the nasal passages. But
ate such fats. Tuna in particular seemed to be the most if this drainage system becomes obstructed for some
beneficial. reason, tears build up in the eyes until they spill over
An ophthalmologist can diagnose dry eye syn- the lids. At other times, an eyelid problem or an infec-
drome with a slit lamp and can test the amount of tear tion leads to watery eyes.
production. Treatment usually involves some type Your doctor may analyze tear samples to see if an
of topical medication, with most preparations avail- infection is to blame, or do a test to gauge tear produc-
able over the counter (see Table 3). If the problem tion. Another test involves irrigating the tear drainage
is caused by a reduction in natural tear production, system to check for possible blockages.
artificial tears may provide some relief. Another alter- Treatment for watery eyes depends on the cause. If
native offered by some doctors are tears made from dry eye syndrome is causing excessive reflexive tearing,
your own serum, which is the clear liquid separated then the solution is to remedy the dry eyes (see pre-
from clotted blood. For blepharitis, oil-based emul- vious section). When an infection is responsible, your
sion drops are helpful, or the prescription medication doctor will most likely prescribe antibiotics. Surgery
cyclosporine (Restasis) is an option. Although dry eye may help repair an obstruction in the drainage system.
may be sporadic, longtime sufferers often need to use
these drugs repeatedly.
To minimize evaporation of tears, avoid exposure
Symptoms of
to dust, pollen, cigarette smoke, and other pollutants watery eyes
• Persistent tearing • Tenderness of eyes
and stay out of the wind and away from hair dryers
• Redness or sinuses
and air conditioner currents. Humidifiers may help by
• Discomfort
adding moisture to indoor air. If you have blepharitis,

Floaters If floaters become a nuisance to central vision, mov-
Older people often notice occasional spots or opaque ing the eye up and down or left and right may shift the
flecks drifting across their line of vision, particularly floaters and provide temporary relief.
when they are looking at a page of a book, a computer
screen, or a solid, light background. These floaters are
tiny clusters of cells or gel in the vitreous cavity, where Flashes
the clear jelly-like substance called vitreous humor Seeing shooting stars—a phenomenon called pho-
fills your eyeball. What you actually see is the shadow topsia—is not unusual as people age. Solitary flashes
these little clumps cast on the retina. In some cases, appear as sparks or minuscule strands of light, almost
the vitreous gel may detach from the retina, suddenly like streaks of lightning across the sky. They occur
causing more floaters, an event called posterior vitre- when the vitreous gel bumps, rubs, or tugs against
ous detachment. the retina. Generally harmless, they require no treat-
About 25% of people have these vitreous detachment. In rare cases, they may be a sign of more severe
ments and floaters by their 60s, and 65% by their 80s. retinal complications. If their appearance is sudden
Floaters also appear more often in people who are or accompanied by a shower of floaters or a loss of
nearsighted or have had cataract surgery. These phe- peripheral vision, see your ophthalmologist. Photop-
nomena are usually nothing more than an annoyance sia differs from the flashing or zigzag lights that may
and often dissipate on their own. If they occur sud- precede migraine headache, which some people expe-
denly, however, consult an ophthalmologist. Certain rience simultaneously in both eyes, typically for as
eye diseases or injuries can cause them. Floaters can long as 20 minutes, but sometimes for an hour or even
also be small drops of blood from a torn retinal vessel. longer.
Less commonly, new floaters are the sign of a retinal
tear, which should be evaluated (see “Retinal tear or
detachment,” right). Retinal tear or detachment
Once floaters have been checked and declared Occasionally, floaters and flashes can be a sign of
harmless, one of three things may happen. The floater something more serious: a retinal tear or retinal
may disappear as it breaks apart or settles; the floater detachment. In a retinal tear, the vitreous gel pulls on
may become less noticeable with time; or it may stay the retina with enough force to tear the retina. Fluid
and become bothersome. Floaters can be removed, but from inside the eye may enter through this tear and
the surgical risk is greater than that of the floater itself. separate the retina from underlying tissues that nour-
ish it. Separation of the retina from the back of the eye
is called a retinal detachment.
Symptoms of
People who are middle-aged and older are the
retinal detachment most likely to experience this problem. Nearsighted-
Contact your ophthalmologist immediately if you notice any
ness increases the chances for detachment, as do cata-
of these early warning symptoms of retinal detachment,
because the condition may be a medical emergency. Some ract removal and eye injuries.
retinal detachments must be treated immediately to pre- Retinal detachment is a serious condition and can
vent vision loss, although only a doctor can make this lead to a permanent loss of vision. If you suspect one,
determination. contact your ophthalmologist immediately; if you can-
• Flashing lights not reach your own doctor, go to an emergency room for
• New floaters evaluation. If a tear is caught early, treatment may pre-
• Gradual shading of vision from one side (much like a cur- vent a retinal detachment. When not treated, the condi-
tain being drawn) tion may worsen until the retina separates completely
• Quick deterioration of sharp, central vision (this occurs from the inner wall of the eye, remaining connected
when the macula detaches)
only at the optic nerve in the back of the eye and the cili-

ary body in the front of the eye. The worst cases cause Figure 12 Laser photocoagulation
blindness.
Because the underlying disorder that causes retinal
Laser burns
tears may occur in both eyes, your ophthalmologist will
want to examine both eyes thoroughly. Your other eye
may also have retinal deterioration or other problems
that require treatment.
Examination with dilated pupils and an indirect
ophthalmoscope (a device that is mounted on special Vitreous cavity
headgear) enables the doctor to determine the extent of
Retinal tear
the detachment, the location of any holes or tears, and Laser
the best way to treat the problem. Some retinal tears don’t Retina
require treatment, especially if they are old. But most

cases of retinal detachment call for surgery to reposition
the separated retina against the back wall of the eye.
■ Laser photocoagulation. In this procedure, done Retinal tear
on an outpatient basis with topical anesthesia, the
doctor uses pinpoints of laser light to create tiny burns
In this procedure, which is usually done in an office, the ophthal-
around any small holes or tears in the retina. The mologist uses a laser to make a series of tiny burns around the
resulting scar tissue forms a barrier, essentially weld- retinal tear. This creates a barrier of scar tissue that stops the tear
ing the retina to the back wall of the eye so that it is from progressing.
less likely to detach (see Figure 12).
■ Cryopexy. An ophthalmologist may also repair over the next few days, it reattaches the retina. Even-
tears that have not yet caused detachment by applying tually the gas bubble dissipates, and is replaced with
a freezing treatment called cryopexy. Like laser pho- fluid in the eye.
tocoagulation, this approach functions as spot weld- The most challenging aspect of this procedure may
ing for the eye: it induces an adhesion that reduces the be the recovery. To ensure that the retina reattaches
likelihood of the tear leading to a detachment. This properly, and depending on the location of the reti-
procedure is performed on an outpatient basis using nal tears, you may have to spend a significant amount
local anesthesia and may be used when the location of of time each day in a face-down position to keep the
a tear makes laser surgery too difficult. bubble in the correct position. (If necessary, you can
■ Pneumatic retinopexy. This approach is frequently rent special equipment to achieve the right position.)
used as the initial treatment for repairing a detached Until the gas bubble disappears, you should also posi-
retina, because it can be done on an outpatient basis tion pillows in your bed in a way that keeps you from
without the need for the operating room and involves lying on your back. Your physician can provide more
the fastest visual recovery. However, the decision specific advice.
whether to use this method or opt for scleral buck- ■ Scleral buckling. If the retina has already started
ling or vitrectomy depends on the location of the reti- to pull away from the choroid and the gap has filled
nal tear or tears, and what type of retinal detachment with fluid, the situation may call for scleral buckling.
(if any) has occurred. For this procedure, you receive This procedure, done in an operating room and under
local anesthesia to numb the eye. The ophthalmolo- local or general anesthesia, involves draining the fluid
gist first uses cryopexy (or, less frequently, laser pho- so the retina falls back against the choroid, then seal-
tocoagulation; see above) to create a barrier with scar ing the hole. Then a silicone buckle is sutured around
tissue. The ophthalmologist then injects a gas bubble the outside of the eyeball, slightly indenting the sclera
into the vitreous cavity. As the gas bubble expands (the white outer layer of the eyeball) so that it makes

better contact with the retina. In addition to this pro- cate procedure, usually performed under local anes-
cedure, you will also undergo cryotherapy or laser thesia, the surgeon uses microsurgery to remove the
therapy, and a gas bubble may be injected to keep the vitreous gel that might be causing traction or tugging
retina in place. on the retina. Following cryotherapy or laser treat-
■ Vitrectomy. This surgery involves the removal of ment, the vitreous humor is then replaced with a saline
the vitreous humor, which reduces the traction on the solution or a gas bubble, which will dissipate on its
retina (typically the cause of retinal tears). In this deli- own.

Safeguarding sight
A lthough aging puts people at greater risk for seri-

ous eye disease and other eye problems, loss of
sight need not go hand in hand with growing older.
eye disorders, including age-related macular degen-
eration. Next, take a look at your diet. Maintaining a
nutritious diet, with lots of fruits and vegetables and
Practical, preventive measures can help protect minimal saturated fats and hydrogenated oils, pro-
against devastating impairment. An estimated 40% to motes sound health and may boost your resistance to
50% of all blindness can be avoided or treated, mainly eye disease. Wearing sunglasses and hats is important
through regular visits to a vision specialist. for people of any age. Taking the time to learn about
Regular eye exams are the cornerstone of visual the aging eye and recognizing risks and symptoms can
health as people age (see Table 1, page 6). Individuals alert you to the warning signs of vision problems.
who have a family history of eye disease or other risk Although eyestrain, spending many hours in front
factors should have more frequent exams. Don’t wait of a television or computer screen, or working in poor
until your vision deteriorates to have an eye exam. light does not cause harmful medical conditions (see
One eye can often compensate for the other while an “Common eye myths dispelled,” below), they can
eye condition progresses. Frequently, only an exam tire the eyes and, ultimately, their owner. The eyes
can detect eye disease in its earliest stages. are priceless and deserve to be treated with care and
You can take other steps on your own. First, if respect—and that is as true for the adult of 80 as it is
you smoke, stop. Smoking increases the risk of several for the teenager of 18.
Common eye myths dispelled

Myth: Doing eye exercises will delay the need for glasses. But eating any vegetables or supplements containing these
Fact: Eye exercises will not improve or preserve vision or vitamins or substances will not prevent or correct basic vision
reduce the need for glasses. Your vision depends on many problems such as nearsightedness or farsightedness.
factors, including the shape of your eye and the health of the Myth: It’s best not to wear glasses all the time. Taking a
eye tissues, none of which can be significantly altered with break from glasses or contact lenses allows your eyes to rest.
eye exercises. Fact: If you need glasses for distance or reading, use them.
Myth: Reading in dim light will worsen your vision. Attempting to read without reading glasses will simply strain
Fact: Although dim lighting will not adversely affect your your eyes and tire them out. Using your glasses won’t worsen
eyesight, it will tire your eyes out more quickly. The best your vision or lead to any eye disease.
way to position a reading light is to have it shine directly Myth: Staring at a computer screen all day is bad for the
onto the page, not over your shoulder. A desk lamp with an eyes.
opaque shade pointing directly at the reading material is Fact: Although using a computer will not harm your eyes,
the best possible arrangement. A light that shines over your staring at a computer screen all day will contribute to eye-
shoulder will cause a glare, making it more difficult to see strain or tired eyes. Adjust lighting so that it does not create
the reading material. a glare or harsh reflection on the screen. Also, when you’re
Myth: Eating carrots is good for the eyes. working on a computer or doing other close work such as
Fact: There is some truth in this one. Carrots, which contain reading or sewing, it’s a good idea to rest your eyes briefly
vitamin A, are one of several vegetables that are good for every hour or so to lessen eye fatigue. Finally, people who
the eyes. But fresh fruits and dark green leafy vegetables, stare at a computer screen for long periods tend not to blink
which contain more antioxidant vitamins such as C and E, as often as usual, which can cause the eyes to feel dry and
are even better. Antioxidant vitamins may help protect the uncomfortable. Make a conscious effort to blink regularly so
eyes against cataract and age-related macular degeneration. that the eyes stay well lubricated and do not dry out.

Resources
Organizations Lighthouse International
111 E. 59th St.
Association for Macular Diseases and
New York, NY 10022
The Macula Foundation
800-829-0500 (toll-free)
210 E. 64th St., 8th Floor www.lighthouse.org
New York, NY 10065
212-605-3719 Provides educational materials on age-related vision problems
www.macula.org and referrals to vision and rehabilitation agencies. Call for a cata-
log of nonoptical aids for daily living.
Provides information and support for people with macular degen-
eration and other macular diseases; publishes a quarterly news- Low Vision Center
letter, Eyes Only. 7701 Woodmont Ave., Suite 604
Bethesda, MD 20814
Eye Care America
301-951-4444
P.O. Box 429098 www.lowvisioninfo.org
San Francisco, CA 94142-9098
877-887-6327 (toll-free) Provides information and sells low-vision devices.
www.eyecareamerica.org
National Eye Institute
Seniors EyeCare Program
Information Office
800-222-3937 (toll-free)
31 Center Drive MSC 2510
A program of the American Academy of Ophthalmology; seeks to
Bethesda, MD 20892
raise awareness about eye disease and ensure access to medical
eye care. The Seniors EyeCare Program helps seniors get medical 301-496-5248
eye care. The website offers a search tool for finding ophthalmol- www.nei.nih.gov
ogists by location or subspecialty. Part of the National Institutes of Health; provides up-to-date
information on eye disease and research.
Eye Surgery Education Council
4000 Legato Road, Suite 700 Prevent Blindness America
Fairfax, VA 22033 211 W. Wacker Drive, Suite 1700
703-591-2220 Chicago, IL 60606
www.eyesurgeryeducation.com 800-331-2020 (toll-free)
Established by the American Society of Cataract and Refractive www.preventblindness.org
Surgery; provides information on a variety of common vision Provides fact sheets, brochures, and other informational material
problems and therapies as well as an online search tool for eye on eye safety, eye care, vision screening, and eye ailments.
surgeons.
Glaucoma Research Foundation

251 Post St., Suite 600
San Francisco, CA 94108
800-826-6693 (toll-free)
www.glaucoma.org
Provides educational materials on glaucoma and publishes a free
newsletter, Gleams, three times a year.

Glossary
accommodation: The ability of the eye’s lens to focus at a miotic: A type of eye drop that constricts the pupil; used to
range of distances. treat glaucoma by improving the capacity of the eye’s drain-
age system.
anterior chamber: The space behind the cornea and in front
of the iris; it is filled with aqueous humor. mydriatic: A type of drug that dilates the pupil.
aqueous humor: The watery fluid that nourishes the eye and myopia: An optical error in which light rays meet and focus
fills the anterior and posterior chambers. before reaching the retina; also known as nearsightedness.
astigmatism: A refractive error characterized by irregular cur- ophthalmoscope: An instrument with a light and mirrors for
vature of the cornea, causing distorted images. examining the deep interior of the eye.
cones: Specialized cells in the retina that are sensitive to color optic nerve: A “cable” that emanates from the back of the
and light; they are more active in light than in the dark, pro- eye, consisting of specialized nerve fibers that transmit visual
vide sharp vision, and are abundant in the macular area of the impulses to the brain.
retina
orbit: The bony socket that surrounds the eyeball.
conjunctiva: The transparent membrane that lines the eyelid
and covers the front portion of the sclera. peripheral vision: Side vision, or what the eye perceives out-
side the direct line of vision.
cornea: The curved, transparent dome of tissue at the front
of the eye, through which light first passes on its way into the posterior chamber: The area behind the iris and in front of
eye. the lens that is filled with aqueous humor.
drusen: Tiny yellow deposits that form beneath the mac- retina: The innermost layer of the eye, consisting of special-
ula and may indicate early stages of age-related macular ized cells and lining nearly three-quarters of the back of the
degeneration. eye; it converts light energy to electrical energy and sends
visual images to the brain via the optic nerve.
fluorescein angiography: A diagnostic test that photographs
blood vessels in the retina after the intravenous injection of a rods: Light-sensitive cells in the retina that respond best in
special dye. darkness and dim light.
fovea: A pitlike area in the middle of the macula that provides sclera: The white of the eye; a tough, protective coating of
the clearest vision. collagen and elastic tissue that, with the cornea, makes up the
outer layer of the eyeball.
hyperopia: An optical error in which light rays reach the ret-
ina before converging at a focus point; commonly known as slit lamp: An instrument that magnifies internal structures
farsightedness. of the eye with the aid of a slit beam of light. Also called a
biomicroscope.
intraocular lens: A small artificial lens permanently fixed
inside the eye to replace the natural lens during cataract tonometry: A glaucoma screening test that measures pressure
surgery. inside the eye.
iris: The colored ring in front of the lens that controls the size visual acuity: The eye’s ability to see sharply, usually mea-
of the pupil and how much light enters the eye. sured in comparison with what a normal eye would see from
20 feet.
lacrimal gland: The gland that produces tears; located in the
upper, outer section of the eye’s orbit. visual field: The scope of what the eye sees; includes central
and peripheral vision.
lens: A flexible, transparent structure directly behind the iris
that focuses rays of light onto the retina. vitreous humor: The clear, gel-like substance that fills the
space behind the lens and supports the shape of the rear por-
macula: The area of the retina packed with cones, responsible tion of the eye.
for sharp central vision.

Receive HEALTHbeat, Harvard Health Other publications from Harvard Medical School
Publications’ free email newsletter Special Health Reports Harvard Medical School publishes in-depth reports on a
Go to: www.health.harvard.edu to subscribe to HEALTHbeat. wide range of health topics, including:
This free weekly email newsletter brings you health tips, advice, Addiction Exercise Your Joints Nutrition
and information on a wide range of topics. Alcohol Eye Disease Osteoporosis
You can also join in discussion with experts from Harvard Health Allergies Foot Care Pain Relief
Publications and folks like you on a variety of health topics, Alzheimer’s Disease Grief & Loss Positive Psychology
medical news, and views by reading the Harvard Health Blog Anxiety & Phobias Hair Loss (women’s) Prostate Disease
(www.health.harvard.edu/blog). Arthritis Hands Sensitive Gut
Sexuality
Back Pain Headache
Six-Week Eating Plan
Balance Hearing Loss
Skin Care
Order this report and other publications Caregivers Heart Disease
Sleep
Change Made Easy Heart Disease & Diet
from Harvard Medical School Strength Training
Cholesterol High Blood Pressure Stress Management
online | www.health.harvard.edu Core Workout Immune System Stroke
phone | 877-649-9457 (toll free) Depression Incontinence Thyroid Disease
Diabetes Knees & Hips Virus
mail | Belvoir Media Group Diabetes & Diet Living Longer Vitamins & Minerals
Attn: Harvard Health Publications
Energy/Fatigue Living Wills Weight Loss
P.O. Box 5656
Erectile Dysfunction Memory Women’s Health
Norwalk, CT 06856-5656
Exercise Neck & Shoulder Pain Workout Workbook
b ulk rate | licensing@belvoir.com
Periodicals Monthly Newsletters and annual publications including:
www.health.harvard.edu Harvard Health Letter Harvard Heart Letter Prostate Disease Annual
877-649-9457 (toll free) Harvard Women’s Health Watch Harvard Men’s Health Watch
ISBN 978-1-61401-011-1 AE12

SV20000

The Aging Eye

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

The Aging Eye

Caricato da

Copyright:

Formati disponibili

A Harvard Medical School Special Health Report

The Aging Eye

Special Bonus Section

Here’s what you CAN do Here’s what you CAN’T do

Licensing, Bulk, and Corporate Sales

Harvard Health Publications

Laura Fine, M.D. Jeffery Heier, M.D.

T he eye is often compared to a camera, but in truth,

2 The Aging Eye w w w.h ealt h .ha r va r d.e du

ww w. h ealt h . h ar v ar d . e du The Aging Eye 3

4 The Aging Eye w w w.h ealt h .ha r va r d.e du

Figure 3 Causes of blindness by race

7.3% 28.6% 28.6%

ww w. h ealt h . h ar v ar d . e du The Aging Eye 5

R egular, comprehensive eye exams are the best way

Table 1 When to see an eye doctor

6 The Aging Eye w w w.h ealt h .ha r va r d.e du

Your eye professionals

ww w. h ealt h . h ar v ar d . e du The Aging Eye 7

8 The Aging Eye w w w.h ealt h .ha r va r d.e du

A cataract is a clouding of the normally clear lens of

ww w. h ealt h . h ar v ar d . e du The Aging Eye 9

10 The Aging Eye w w w.h ealt h .ha r va r d.e du

ww w. h ealt h . h ar v ar d . e du The Aging Eye 11

Choices in cataract surgery

12 The Ag in g E ye w w w.h ealt h .ha r va r d.e du

14 The Ag in g E ye w w w.h ealt h .ha r va r d.e du

Specialized replacement lenses

16 The Ag in g E ye w w w.h ealt h .ha r va r d.e du

18 The Ag in g E ye w w w.h ealt h .ha r va r d.e du

M ore than 2.3 million Americans ages 40 and

What causes glaucoma? Posterior chamber

20 The Aging Eye w w w.h ealt h .ha r va r d.e du

ww w. h ealt h . h ar v ar d . e du The Aging Eye 21

22 The Aging Eye w w w.h ealt h .ha r va r d.e du

ww w. h ealt h . h ar v ar d . e du The Aging Eye 23

Carbonic anhydrase inhibitors

24 The Aging Eye w w w.h ealt h .ha r va r d.e du

ww w. h ealt h . h ar v ar d . e du The Aging Eye 25

26 The Aging Eye w w w.h ealt h .ha r va r d.e du

into the anterior chamber. The shunt drains excess

ww w. h ealt h . h ar v ar d . e du The Aging Eye 27

28 The Aging Eye w w w.h ealt h .ha r va r d.e du

Figure 8 When central vision is damaged

What the eye looks at

What the brain perceives

ww w. h ealt h . h ar v ar d . e du The Aging Eye 29

30 The Aging Eye w w w.h ealt h .ha r va r d.e du

ww w. h ealt h . h ar v ar d . e du The Aging Eye 31

32 The Aging Eye w w w.h ealt h .ha r va r d.e du

ww w. h ealt h . h ar v ar d . e du The Aging Eye 33

Living with low vision

34 The Aging Eye w w w.h ealt h .ha r va r d.e du

ww w. h ealt h . h ar v ar d . e du The Aging Eye 35

W ith cases of diabetes escalating, the eye problem

36 The Aging Eye w w w.h ealt h .ha r va r d.e du

Treating diabetic retinopathy

ww w. h ealt h . h ar v ar d . e du The Aging Eye 37

38 The Aging Eye w w w.h ealt h .ha r va r d.e du

M any people will never be affected by serious eye

ww w. h ealt h . h ar v ar d . e du The Aging Eye 39

Figure 11 Faulty optics: When your vision isn’t perfect

40 The Aging Eye w w w.h ealt h .ha r va r d.e du

ww w. h ealt h . h ar v ar d . e du The Aging Eye 41

Figure 11 Faulty optics: When your vision isn’t perfect