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26 EW NEWS & OPINION August 2012 Insights Ophthalmology's bright future … No kidding by J.C. Noreika, M.D. I f you are a post-doctoral fellow in neuro-bioengineering, just move along—nothing to see here. Or if you regularly attend ARVO, you may want to peruse this offering for its style points. But if you're an ophthalmologist still refracting in plus-cylinder, don't be shy—read on and prepare to be astonished. The Louis J. Fox Center for Vision Restoration at the University of Pittsburgh Medical Center recently sponsored an all-day seminar on cutting edge research devoted to the regeneration of sight. I was among the 150 or so curious souls engrossed by the work of world-class researchers. The U.S. was capably represented, as was Ger- many, Japan, the U.K., and Israel. Presentations were organized around the eye's anatomy. Plenary sessions were supported by shorter but no less interesting offerings. Polls across societies and eco- nomic strata reveal that people are twice as afraid of going blind as they are of dying. The demands of life, both primitive and modern, necessi- tate that vision keeps us informed, safe, productive, reproductive, and alive. Appropriately, as much as 80% of Homo sapiens' brain is somehow related to vision and its significance for survival. Sixty percent of sensory input to the cerebral cortex is de- prived by vision loss. The organism cannot easily compete for necessary resources without sight. Absolute blindness— what J. Lawton Smith once referred to as not being able to see an atomic flash in a coal mine—is not a dis- ability. Absolute blindness is life in the eter- nal darkness of death, as Samuel Taylor Coleridge epically characterized the plight of his Ancient Mariner's ship- mates. The World Health Organization (WHO) estimates that 40 million people suffer some degree of debilitating blindness. Most live in developing countries, the largest being India. Cataract is its leading cause. The number of people Source: Getty Images legally blind in the U.S. exceeds 1.3 million. It is unknown how many suffer absolute vision loss. Most ophthalmologists rarely deal with Lawton Smithsonian blindness. It has been deputed to social service agencies and organizations such as the National Federation of the Blind. Physicians generally don't like to deal with things they can't fix. For ophthalmologists, this may be changing sooner than thought. The seminar began with expos- tulations of technique to restore the cornea from trauma, disease, genet- ics, and age. For example, hybrid corneas with orthogonal lamellae consisting of a purified silk matrix and populated by corneal fibroblasts have the potential to ease the world's ravenous appetite for donor tissue. A separate presentation de- scribed topical therapy applied six times per day for 1 week to restore corneal endothelium in early Fuchs' dystrophy. Regeneration of the optic nerve by applying sophisticated epi- genetic techniques and nanotech- nology might one day revolutionize the tragedy of glaucoma and other neuropathies. Laboratory ganglion cell axons are seen to regenerate and project to appropriate synapses in the lateral geniculate body. In Ger- many and the U.S., photoelectric diode subretinal implantation has shown potential to restore naviga- tional vision. With only 256 channels on a silicone chip, this technology should advance rapidly according to Moore's Law. Human embryonic and induced pleuripoten- tial stem cells may provide a limit- less biologic supply of retinal cell progenitors. One can only wonder what else is in the offering to trans- mute ophthalmology's ability to maintain, enhance, and restore sight. After the seminar, I had the privilege of caring for a woman who has dry age-related macular degener- ation. In her mid 80s, beautiful, immaculately coifed, proud, and independent, she related how she is caring for her older husband who is in his seventh year of chemother- apy. Overcome by the pressure of her responsibility, she began to weep, fearing that her vision would give out before her husband's needs did. It was heart wrenching. I did what I could for someone whose atrophic disease was progressively providing her with a moth-eaten macramé of the world's beauty and threats. Working with magnification and contrast-enhancing tints, edu- cating to the importance of ambient lighting for safe ambulation and the advantages of halogen lighting for reading, her immediate concerns were temporized. The AREDS research was reviewed again and extrapolated to the less-than-certain results of AREDS II. Consultation with low-vision specialists was offered as a future contingency. A modicum of hope was restored, but I lacked the fairy dust to restore what was irrecoverable. I was able to promise that more effective thera- pies, even cures, were likely to be available to her sons, daughters, and grandchildren should they be afflicted by AMD. With the stress draining out of her facial muscles and a hint of a smile lighting her blue eyes, this information provided comfort. Physicians in general and ophthalmologists especially are overwhelmed with demoralizing projections of the oncoming med- ical practice environment. Legisla- tive, regulatory, and economic coercion drain our best clinical and surgical efforts of the gratification that our life-changing efforts render. Of the 154 registrants to the meet- ing, only 27 were ophthalmologists. I hope that more of my colleagues afford themselves of future meetings such as the Louis J. Fox Center's offering. A professional adrenaline rush and a welcome career mood- swing await. Like "a damsel with a dulcimer" in Coleridge's opiate-laced, inter- rupted dream of Kubla Khan, the novel work of these world-class re- searchers unlocking the dark secrets of vision loss can revive within oph- thalmologists the sublime sense of wonder and curiosity that tran- scends workaday tribulation. It is a researcher, physician, and patient win-win-win prospect. It was time well spent. EW Editors' note: Dr. Noreika has no financial interests related to this article. Contact information Noreika: jcnmd@aol.com