Sight, space and liberty

    22 November 2014

    ‘My old chemistry master used to say, “You can’t buy eyes at Harrods any more, so look after yours,”’ says Raja Das-Bhaumik, consultant ophthalmic plastic surgeon at Moorfields. But although blindness — whether through accident or disease — is a top-league concern for everyone, visual loss has far less of the profile that, say, cancer or heart disease does.

    ‘It is essential for people to have regular eye tests, even if their sight is good,’ says Dawn Richards, head of clinical services at VitalityHealth. ‘Each member of VitalityHealth has a personal health fund which can be used to pay for eye tests, an integral part of any general health check-up. The earlier problems are picked up, the easier they are to treat.’ Das-Bhaumik adds, ‘You’d be surprised at the number of people who lose their vision, or part of it, and just wait for it to come back. It doesn’t.’ His advice? ‘If you have loss of vision, pain or redness in the eye, get referred to an ophthalmologist as soon as possible — or failing that see an optician.’

    Because the first symptoms of eye diseases such as glaucoma and wet age-related macular degeneration (or for purposes of abbreviation, wet AMD) are painless, they are known as silent conditions. ‘They creep up on you like a thief in the night,’ says Simon Kelly, chairman of the Quality and Safety Sub-Committee at the Royal College of Ophthalmologists and Consultant Ophthalmic Surgeon at the Royal Bolton Hospital. And these conditions will steal your sight: in the case of glaucoma, it’s the peripheral vision that goes first; with wet AMD it’s the central field.

    So what sort of problems should we be looking for? In the case of wet AMD, crooked verticals are a warning sign. ‘If trees or window bars start appearing distorted or “kinked”, it’s an early signifier,’ says Kelly, adding, ‘although because it only occurs in one eye many people don’t notice they’re affected.’ It’s important to get referred as quickly as possible because these days, unlike a few years ago, this condition can be treated — and in some cases reversed — by injections into the eye of the drugs Lucentis or Eylea.

    When Nice approved Lucentis and Eylea for treatment on the NHS in 2013, it ‘all changed, changed utterly’, says Kelly, quoting Yeats. Now the problem is keeping up with demand. Eye surgeons including Kelly are training nurses to deliver the injections, but because the drugs’ licences state injections should only be undertaken by an ophthalmologist, these 20,000-plus treatments are in a legal grey area. Kelly is campaigning to get the licences changed. ‘Hospitals are fully aware this is happening, and the Royal College of Ophthalmologists now support trained nurses in the public domain.’

    Smoking is, as ever, a no-no. It doubles the risk of wet AMD — the link is as strong as that between smoking and lung cancer.

    Glaucoma can also go unnoticed, because the peripheral vision is affected first. A build-up of pressure in the eye means that the optic nerve at the back gets pinned, leading to a restricted field of vision and possibly further damage. Under 40? You probably needn’t worry; but over that age, the condition affects one in 50 of the population — and the risk goes up tenfold if you have immediate family history of the problem. In that case, take advantage of free NHS screening. If it’s caught early enough, the condition can be managed with eye drops that lessen the pressure in the eyeball, or an operation.

    Diabetes — types I and II — increase the risk of glaucoma and wet AMD. That’s why it’s important, again, for sufferers to attend the free eye screening tests laid on by the NHS. ‘The system is superb,’ says Kelly, ‘but despite this, many people — often the socio-economically deprived — don’t attend them.’


    The other thing that is worth protecting eyes against is sheer human stupidity. I speak to Raja Das-Bhaumik as he comes out of an emergency operation repairing trauma to an eyelid. ‘If in any doubt about an activity where your eyes might be in danger, wear protective goggles,’ he says, with the experience of someone who deals with a proportion of the 300-350 patients with eye trauma who end up in Moorfields A&E daily. Luckily enough health and safety seems to have caught on in workplaces, but home — and away — seem to be a different matter. ‘It’s depressing how many avoidable injuries we have to deal with on a Monday morning,’ says Kelly. ‘Some cases are because of alcohol and violence, others because of a hazardous sport [squash and paintballing as well as skiing and horseriding]. DIY is another big factor.’ Shards of metal in the eye sound wincingly grim.

    On a more day-to-day level, sunglasses that filter UV light are also important — Das-Bhaumik points out the rise of basal cell carcinomas, or skin cancer, which occur particularly in the corner of the eye — ‘possibly because light reflections in the parabola of the eyesocket are concentrated there’. Dawn Richards also notes that contact lenses wearers should be careful with their hygiene: ‘Ultimately you’re introducing a foreign body — and potentially an infection — every time you put your lenses in.’

    Also — as obvious as it might sound — don’t give children laser pointers to play with. ‘The power of these has gone up but the cost has come down,’ notes Kelly, who has seen first-hand the burns and retinal damage caused by hand-held lasers manufactured in Hong Kong and China and not subject to UK law.

    In terms of senses, our eyes are ‘the most advanced organs we have’, says Das-Bhaumik, and so for young and old alike, loss of vision is a major handicap. When younger people lose sight, it can be because of disruption of the blood flow to the eye, or disruption to the brain. Anyone affected by blindness suffers loss of independence, so the condition goes hand in hand with depression and sometimes suicide. Visual hallucinations can occur, where sufferers ‘see’ animals or monsters in their bedrooms — a frightening experience, but because they think they’re going mad, they don’t want to discuss it. It is a recognised condition, however, that affects up to 60 per cent of people who have serious sight loss. Called Charles Bonnet syndrome, sufferers also may ‘see’ patterns or other fantasy pictures stored in the brain, as that confused and confusing organ attempts to come to terms with a deterioration of one of its major inputs.

    Because eyes are small and delicate organ, every aspect of ophthalmology has been hugely helped by technological advancements. ‘Now, I rarely use a scalpel,’ says Das-Bhaumik, going on to describe instruments such as radio-frequency needles which cut and coagulate skin, minimising bleeding and making surgery safer. Stem cell research being carried out now will lead in the near future to treatments that ‘rejuvenate and repair the cornea, retina and skin around the eye’, says Das-Bhaumik. ‘It’s an area which will revolutionise medicine, and because there are so many different tissues in the eye, particularly ophthalmology.’

    While the eye is a complex organ, it is also instantly examinable. ‘There are new and exciting ways of imaging the eye that simply weren’t available ten years ago,’ says Das-Bhaumik. A 3D scan will show all the layers of the retina, allowing treatments to be finely targeted. Eyes are also bellwethers for the rest of our bodies: any systemic disease — diabetes, hypertension, some cancers and brain tumours — will manifest in our sight organs. So keeping an eye on your eye health can, in the end, work exponentially in your favour.