AUG 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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August 2013 EW NEWS & OPINION 15 Insights Communiqué from the front: the third annual international Vision Restoration Conference by J.C. Noreika, MD, MBA J.C. Noreika, MD, MBA A recent newspaper article related the story of two 43-year-old Belgian men. Identical twins and totally deaf, they were inseparable, "talked" vigorously through language of their hands, even drove a car. They enjoyed gossip magazines. Having learned that they were incurably losing their sight, both petitioned doctors that they be euthanized. Belgium, the Netherlands, and Luxembourg have legalized euthanasia. Other countries such as France have legislation pending to sanction the practice. In December 2012, these otherwise healthy men bid goodbye to loved ones and each other, pointed upward from their hospital beds "and were gone." Ophthalmologists don't witness the finality of Marc and Eddy Verbessem's decision. But, they do contend with the drama of vision loss as it plays out in the lives of patients with corneal disease, retinal degeneration, optic nerve destruction, and ischemic insult. The third annual international Vision Restoration Conference sponsored by the UPMC Eye Center, the Louis J. Fox Center for Vision Restoration, and the McGowan Institute for Regenerative Medicine was held on June 10-11 in Pittsburgh. This unique meeting showcases presentations on the most advanced regenerative research performed in laboratories worldwide. Breakthroughs on the threshold of practical vision restoration no longer require implausible extrapolation from laboratory bench to exam lane. Regrettably, few practicing clinical ophthalmologists attend. The two-day meeting's organization follows the path of photons and neuronal excitation through the cornea, to the retina and macula, along the ganglion cell pathway terminating in the occipital visual cortex. The speakers hail from around the world. The United States is well represented by researchers from the Massachusetts Institute of Technology, Cal Tech, the Carnegie Institute of Technology, Rensselaer Polytechnic Institute, and prominent Departments of Ophthalmology in Miami, Michigan, Boston, Indiana, San Diego, Manhattan and, of course, Pittsburgh. Teleconferencing permitted live presentations on synthetic corneal grafts for high risk patients from Stockholm and on the latest Argus II epiretinal digital bioprosthesis (Second Sight Medical Products, Sylmar, Calif.) from Los Angeles. It facilitated the symposium's viewing at the LV Prasad Eye Institute in India. Topics on molecular genetics, biochemistry and zebra fish as a model for retinal regeneration were discussed. These papers provided the framework for hypotheses on the clinical potential of stem cell therapy in the repair of opaque and scarred corneas, retinal pigment epithelium, retinal ganglion cells, and photoreceptors. The progress of both digital bioprosthetic systems emanating from centers in Los Angeles and Boston was reviewed as the quest advances to improve the outcomes of the blind with retinitis pigmentosa. University of Pittsburgh researchers updated their results on artificial vision provided by microdiodal stimulation of the tongue. The overall effect of these nascent technologies is promising. Presentations on embryonic and induced pluripotential stem cell therapy were particularly compelling. In regard to the cornea, this treatment approach offers the millions of third-world victims of scarring, many of whom are children, the possibility of regaining useful, life-saving visual function. The application of discrete packets of conjunctival stem cells over an amniotic membrane has been found to restore scarred corneas. This work on simple limbal epithelial transplantation (SLET) will continue in India where the problem is particularly acute. Elsewhere in the eye, differentiated retinal pigment epithelial cells can be regenerated in the laboratory as a sheetlike functional structure that can be potentially transplanted to preserve the photoreceptors in diseases such as macular degeneration and Stargardt's disease. Likewise, retinal ganglion cells have been shown to regenerate in laboratory mammals as far as the lateral geniculate nucleus following a crush injury to the optic nerve. Using nanotechnology, silicone sleeves aid the development of individual units of the multicellular retinal receptor complex to permit gene manipulation, disease replication, and pharmacologic research. Small molecule drug development research explored the biochemical pathways of lipofuscin in drusen formation. In one instance, by using beta-cyclodextrins, lipofuscin bisretinoids, which are the toxic components of retinal lipofuscin, were efficiently removed "from cultured RPE cells and from RPE cells ex vivo obtained from mice having mutations that cause Stargardt's disease in humans." Some cyclodextrins are already approved by the FDA for use in Niemann-Pick disease. The two-day meeting drew to a close with the staging of a panel discussion led by a UPMC hand transplant surgeon addressing the feasibility and challenges of whole eye transplantation. That this fantas- tic topic was incorporated in the final program of a serious academic meeting speaks to the far-reaching effects of the various research platforms presented. To the non-academic clinician, the symposium can be intimidating with the near-casual expostulation of genetic signaling, up and down regulation and synthesis of induction proteins. Yet, it all holds together providing a Cliffs Notes overview of ophthalmology's future. Regardless of one's moralistic orientation to the Verbessems' decision to end their lives rather than lose their vision, the work of these world-class researchers may hopefully render the choice moot. I have attended the last two UPMC's Vision Restoration Conferences and will return to marvel at the progress being made in the fight for those, like the poet John Milton, "who only stand and waite." EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com

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