London Laser Scans, An estimated five million Britons are living with age-related eye conditions, such as glaucoma. We spoke to the experts to discover the latest on prevention and treatment for four common problems.
GLAUCOMA
This is caused by fluid building up in the eye as the drainage tubes become blocked — typically because of age. This puts pressure on the optic nerve.
It starts with blind spots at the edge of your vision that you won't notice, progressing to tunnel vision and sight loss, which can take up to five or six years to become apparent, says Gus Gazzard, a consultant ophthalmic surgeon at Moorfields Eye Hospital, London.
Up to half a million Britons have a degree of sight loss due to glaucoma. 'Most cases are picked up by opticians, but there's a high rate of under-diagnosis.' It's easy to miss when it is caused not by pressure in the eye, but as a result of problems with blood flow.
Risk factors: Family history, ethnic group (Afro-Caribbean, Indian and Chinese people are more at risk) and increasing age are the biggest risk factors. Regular sight tests will detect it early and treatments can prevent further damage.
Treatments: Traditionally, it is treated with eye drops (one to four times a day) that reduce fluid production or increase its flow out from the eye.
But they can be unpleasant to use and potential side-effects include sleep problems and impotence.
A new ten-minute procedure, selective laser trabeculoplasty, effectively causes a minor injury to the eye, drawing white blood cells to the area. These clear the blockage as they repair the damage. This is offered on the NHS. Moorfields is running a trial comparing it against eyedrops.
Between 10 to 20 per cent of patients need surgery. With the standard operation, trabeculectomy, a channel is made in the white of the eye so fluid can drain out. Lasers can also open up the blocked drainage tubes. There is a risk of scarring preventing fluid flow.
With the latest surgery, a device called a trabectome destroys blocked tubes with an electrical impulse. The procedure, which has a small risk of bleeding, is available only at Moorfields, Musgrove Park Hospital, Taunton and the Royal Hallamshire Hospital, Sheffield.
This is characterised by central loss of vision and you lose the ability to see fine details in faces. It's also difficult watching TV or reading, as objects may seem distorted.
This is caused by damage to the macula, the spot at the centre of the retina (the light-sensitive cells at the back of the eye).
There are two types: dry and wet. Dry is slower to develop, much more common, harder to treat and caused by a build-up of waste products forming deposits (drusen) that dislodge the macula. In wet AMD, which accounts for a tenth of cases, tiny blood vessels grow under the retina, leaking blood and fluid. The dry form can sometimes lead to wet AMD.
Risk factors: Smoking increases the incidence of AMD by three times — possibly because the retina is damaged by free radical molecules from cigarette smoke. UV light and poor diet are also implicated. Age is a major risk factor.
Treatments: For dry AMD, there's little patients can do except take specific high-dose vitamins to reduce progression of the condition and to prevent wet AMD.
A new drug, Lampalizumab, is being trialled. Given as an eye injection, it targets inflammation and so reduces damage to retinal tissue. Early studies suggest it reduced the progression of dry AMD by up to 44 per cent.
Another new option at some private clinics is the iolAMD lens. This ten-minute procedure involves replacing the patient's lens with two artificial lenses, one in front of the other.
This works like a telescope, magnifying an image and diverting it to a healthier part of the retina, which takes over the role of the macula to improve vision.
It costs £9,750 per eye and is available at the The London Eye Hospital. Studies on the results are due to be published.
For wet AMD, injections into the eye seal leaking blood vessels to stop the problem worsening and sometimes improving vision. Patients need four to eight injections a year for life.
The drugs Lucentis, Avastin and a newer product, Eylea, inhibit proteins called Vascular Endothelial Growth Factor (VEGF), which causes abnormal blood vessels to grow. Injections must be given within weeks of symptoms appearing to be effective (Eylea may be more effective so you need fewer jabs)
.
Two drugs being trialled, Fovista and DARPin, 'potentially may be more potent,' says Simon Kelly, an ophthalmic surgeon at the Royal Bolton Hospital.
A new technique, Oraya's IRAY, uses low voltage X-ray beams to stop abnormal blood vessels growing and reduce inflammation and scarring. A trial at King's College Hospital London found it reduces the number of injections needed. Not available on the NHS, it costs from £4,000 privately.
CATARACTS
Cataracts are cloudy patches that form on the lens, commonly caused by ageing. Symptoms include cloudy or blurred vision or small patches of vision loss occurring gradually. At first, you might think your glasses are dirty. You may also need extra light to see smaller print.
Risk factors: Getting older, smoking, excess drinking, diabetes and family history.
Treatments: The only treatment is to have the cataract removed — more than 350,000 operations are performed every year.
Not everyone needs surgery as their cataract is not affecting their vision.
Traditionally, surgery has involved removing the cloudy lens through a 2-3mm incision in the eyeball using a metal blade and replacing it with a clear plastic one.
'Such small incisions do not require stitches, there is minimal disruption of the eye and visual recovery is quick,' says Vincenzo Maurino, a consultant ophthalmic surgeon at Moorfields. Most patients can resume their normal life in a few days.
First, the lens is softened and broken up using high frequency ultrasound and the fragments are flushed out. The latest advance is where the surgeon operates the laser via a robot. This is said to be more accurate, but there is not yet scientific evidence that it's superior.
The replacement lens can be used to correct short or long-sightedness or astigmatism. Patients should discuss their needs with the surgeon.
'Most prefer good distance vision without glasses after the op, but they will need reading glasses for close work,' says Mr Maurino.
You can also get multifocal lens implants that work in a similar way to varifocal glasses. It's available privately, from £6,950 per eye.
DIABETIC RETINOPATHY
This complication of diabetes is caused by high blood sugar levels damaging blood vessels, leading to fragile new blood vessels growing on the retina and leaking.
'Often you won't notice until the disease is advanced,' says Daniel Hardiman-McCartney, clinical adviser to the College of Optometrists.
Then you may experience shapes floating in your vision, blurred vision or sudden vision loss. Untreated it can cause blindness.
Risk factors: Uncontrolled high blood sugar is a major risk factor, as is high blood pressure.
Treatments: 'Everyone who is diagnosed with diabetes should have a free retinal scan and an annual check-up,' says Mr Hardiman-McCartney.
A third of people with type 2 diabetes have signs of retinal damage when they're diagnosed.
In the past, laser treatment was used to heal leaking blood vessels, but increasingly Lucentis and Eylea monthly injections are used to tackle blood vessel growth.
Should YOU have laser eye surgery?
Most people have some form of eye problem, from short sight, long sight to age-related issues such as cataracts and everyday complaints such as conjunctivitis and dry eye.
Here, in the third part of our unique How To Beat series, experts reveal the latest thinking in treating sight problems and how best to protect your eyes.
Short sight (myopia), where distant vision is blurred and near vision is clear, means the eyeball is too long from front to back, so light rays are focused just in front of the retina.
The normal length of an eyeball is 24mm. If it is just 1mm longer, you will be short-sighted.
Daniel Hardiman-McCartney, clinical adviser to the College of Optometrists, says that though the eyes stop growing between the ages of seven and 13, your sight can worsen as the cornea, the clear window at the front of the eye, changes over the years (it becomes stiffer and thinner, and the curvature can alter).
More children are developing myopia, probably as a result of using screens and spending more time indoors. It is thought playing outside is protective, perhaps because of higher levels of light and the fact the eyes don't have to focus on near objects.
Long-sightedness (hyperopia), when distant objects appear clear and close vision is blurry, occurs because the eyeballs are too short or the cornea is too curved, so the light rays focus beyond the retina.
It tends to become more noticeable with age — this is because your near vision is already poor, so when age-related problems with reading kick in, the blurriness is more noticeable.
A third kind of refractive error, astigmatism, occurs when the lens or cornea is not perfectly spherical, causing blurred or distorted vision. It can accompany short or long sight
All three problems can be helped with glasses or contact lenses, but more people are opting for laser eye surgery. The laser reshapes the cornea so light is focused on to the retina.
An estimated 100,000 laser eye procedures are carried out each year. It is not available on the NHS without special medical circumstances, so 98 per cent are done in the private sector.
HOW IT IS DONE
Laser eye surgery was first performed in the UK in 1989 by Professor David Gartry, a consultant ophthalmic surgeon at Moorfields Hospital. As he explains: ‘The technology was rough and ready 25 years ago but it’s infinitely better now - the basic principles are the same, it’s just more refined.
With the original PRK (photorefractive keratectomy) technique the surgeon manually scraped away the surface layer of the cornea (the epithelium) and the laser reshaped the exposed cornea. ‘But recovery was often slow and painful,’ says Professor Gartry, who has performed over 20,000 laser eye procedures.
'The technology was rough and ready 25 years ago, and is infinitely better now,' he says.
With the original PRK (photo-refractive keratectomy) technique, the surgeon scraped away the surface layer of the cornea (the epithelium) and the laser then reshaped the exposed cornea.
'But recovery was often slow and painful,' says Professor Gartry, who has performed more than 20,000 laser eye procedures.
Nowadays, 90 per cent of laser surgery is done using LASIK (Laser-Assisted In-Situ Keratomileusis) surgery where laser energy is used to create a hinged flap in the cornea, giving us access to reshape the cornea with a laser.
'It is much less painful and recovery is much quicker. You can have both eyes done on a Saturday and be back at work on Monday.'
Professor Gartry uses LASIK in conjunction with wavefront technology, a scanning technique that takes into account aberrations in the cornea to make the procedure more accurate.
'It is important that patients are offered a wavefront scan as it's the most accurate assessment of their prescription,' says Professor Gartry. 'It's the best technology we have to get a perfect result. These days most companies will offer it.'
TWO BETTER THAN ONE
Another option is IntraLASIK, a sophistication of LASIK where two more precise lasers are used. A femtosecond laser (also used in cataract surgery) is used to make the incision for the flap.
This procedure is safer and more accurate than older techniques, says Professor Gartry.
A second laser (an excimer laser) is used to reshape the cornea. 'This combination has produced results that are more predictable for all refractive errors, especially astigmatism,' he says.
This operation is not suitable for people who play contact sports, such as rugby, or have a job where they might be poked in the eye, such as in the military or police, as the flap in the cornea could become dislodged.
This is caused by fluid building up in the eye as the drainage tubes become blocked — typically because of age. This puts pressure on the optic nerve.
It starts with blind spots at the edge of your vision that you won't notice, progressing to tunnel vision and sight loss, which can take up to five or six years to become apparent, says Gus Gazzard, a consultant ophthalmic surgeon at Moorfields Eye Hospital, London.
Up to half a million Britons have a degree of sight loss due to glaucoma. 'Most cases are picked up by opticians, but there's a high rate of under-diagnosis.' It's easy to miss when it is caused not by pressure in the eye, but as a result of problems with blood flow.
Risk factors: Family history, ethnic group (Afro-Caribbean, Indian and Chinese people are more at risk) and increasing age are the biggest risk factors. Regular sight tests will detect it early and treatments can prevent further damage.
Treatments: Traditionally, it is treated with eye drops (one to four times a day) that reduce fluid production or increase its flow out from the eye.
But they can be unpleasant to use and potential side-effects include sleep problems and impotence.
A new ten-minute procedure, selective laser trabeculoplasty, effectively causes a minor injury to the eye, drawing white blood cells to the area. These clear the blockage as they repair the damage. This is offered on the NHS. Moorfields is running a trial comparing it against eyedrops.
Between 10 to 20 per cent of patients need surgery. With the standard operation, trabeculectomy, a channel is made in the white of the eye so fluid can drain out. Lasers can also open up the blocked drainage tubes. There is a risk of scarring preventing fluid flow.
With the latest surgery, a device called a trabectome destroys blocked tubes with an electrical impulse. The procedure, which has a small risk of bleeding, is available only at Moorfields, Musgrove Park Hospital, Taunton and the Royal Hallamshire Hospital, Sheffield.
This is characterised by central loss of vision and you lose the ability to see fine details in faces. It's also difficult watching TV or reading, as objects may seem distorted.
This is caused by damage to the macula, the spot at the centre of the retina (the light-sensitive cells at the back of the eye).
There are two types: dry and wet. Dry is slower to develop, much more common, harder to treat and caused by a build-up of waste products forming deposits (drusen) that dislodge the macula. In wet AMD, which accounts for a tenth of cases, tiny blood vessels grow under the retina, leaking blood and fluid. The dry form can sometimes lead to wet AMD.
Risk factors: Smoking increases the incidence of AMD by three times — possibly because the retina is damaged by free radical molecules from cigarette smoke. UV light and poor diet are also implicated. Age is a major risk factor.
Treatments: For dry AMD, there's little patients can do except take specific high-dose vitamins to reduce progression of the condition and to prevent wet AMD.
A new drug, Lampalizumab, is being trialled. Given as an eye injection, it targets inflammation and so reduces damage to retinal tissue. Early studies suggest it reduced the progression of dry AMD by up to 44 per cent.
Another new option at some private clinics is the iolAMD lens. This ten-minute procedure involves replacing the patient's lens with two artificial lenses, one in front of the other.
This works like a telescope, magnifying an image and diverting it to a healthier part of the retina, which takes over the role of the macula to improve vision.
It costs £9,750 per eye and is available at the The London Eye Hospital. Studies on the results are due to be published.
For wet AMD, injections into the eye seal leaking blood vessels to stop the problem worsening and sometimes improving vision. Patients need four to eight injections a year for life.
The drugs Lucentis, Avastin and a newer product, Eylea, inhibit proteins called Vascular Endothelial Growth Factor (VEGF), which causes abnormal blood vessels to grow. Injections must be given within weeks of symptoms appearing to be effective (Eylea may be more effective so you need fewer jabs)
.
Two drugs being trialled, Fovista and DARPin, 'potentially may be more potent,' says Simon Kelly, an ophthalmic surgeon at the Royal Bolton Hospital.
A new technique, Oraya's IRAY, uses low voltage X-ray beams to stop abnormal blood vessels growing and reduce inflammation and scarring. A trial at King's College Hospital London found it reduces the number of injections needed. Not available on the NHS, it costs from £4,000 privately.
CATARACTS
Cataracts are cloudy patches that form on the lens, commonly caused by ageing. Symptoms include cloudy or blurred vision or small patches of vision loss occurring gradually. At first, you might think your glasses are dirty. You may also need extra light to see smaller print.
Risk factors: Getting older, smoking, excess drinking, diabetes and family history.
Treatments: The only treatment is to have the cataract removed — more than 350,000 operations are performed every year.
Not everyone needs surgery as their cataract is not affecting their vision.
Traditionally, surgery has involved removing the cloudy lens through a 2-3mm incision in the eyeball using a metal blade and replacing it with a clear plastic one.
'Such small incisions do not require stitches, there is minimal disruption of the eye and visual recovery is quick,' says Vincenzo Maurino, a consultant ophthalmic surgeon at Moorfields. Most patients can resume their normal life in a few days.
First, the lens is softened and broken up using high frequency ultrasound and the fragments are flushed out. The latest advance is where the surgeon operates the laser via a robot. This is said to be more accurate, but there is not yet scientific evidence that it's superior.
The replacement lens can be used to correct short or long-sightedness or astigmatism. Patients should discuss their needs with the surgeon.
'Most prefer good distance vision without glasses after the op, but they will need reading glasses for close work,' says Mr Maurino.
You can also get multifocal lens implants that work in a similar way to varifocal glasses. It's available privately, from £6,950 per eye.
DIABETIC RETINOPATHY
This complication of diabetes is caused by high blood sugar levels damaging blood vessels, leading to fragile new blood vessels growing on the retina and leaking.
'Often you won't notice until the disease is advanced,' says Daniel Hardiman-McCartney, clinical adviser to the College of Optometrists.
Then you may experience shapes floating in your vision, blurred vision or sudden vision loss. Untreated it can cause blindness.
Risk factors: Uncontrolled high blood sugar is a major risk factor, as is high blood pressure.
Treatments: 'Everyone who is diagnosed with diabetes should have a free retinal scan and an annual check-up,' says Mr Hardiman-McCartney.
A third of people with type 2 diabetes have signs of retinal damage when they're diagnosed.
In the past, laser treatment was used to heal leaking blood vessels, but increasingly Lucentis and Eylea monthly injections are used to tackle blood vessel growth.
Should YOU have laser eye surgery?
Most people have some form of eye problem, from short sight, long sight to age-related issues such as cataracts and everyday complaints such as conjunctivitis and dry eye.
Here, in the third part of our unique How To Beat series, experts reveal the latest thinking in treating sight problems and how best to protect your eyes.
Short sight (myopia), where distant vision is blurred and near vision is clear, means the eyeball is too long from front to back, so light rays are focused just in front of the retina.
The normal length of an eyeball is 24mm. If it is just 1mm longer, you will be short-sighted.
Daniel Hardiman-McCartney, clinical adviser to the College of Optometrists, says that though the eyes stop growing between the ages of seven and 13, your sight can worsen as the cornea, the clear window at the front of the eye, changes over the years (it becomes stiffer and thinner, and the curvature can alter).
More children are developing myopia, probably as a result of using screens and spending more time indoors. It is thought playing outside is protective, perhaps because of higher levels of light and the fact the eyes don't have to focus on near objects.
Long-sightedness (hyperopia), when distant objects appear clear and close vision is blurry, occurs because the eyeballs are too short or the cornea is too curved, so the light rays focus beyond the retina.
It tends to become more noticeable with age — this is because your near vision is already poor, so when age-related problems with reading kick in, the blurriness is more noticeable.
A third kind of refractive error, astigmatism, occurs when the lens or cornea is not perfectly spherical, causing blurred or distorted vision. It can accompany short or long sight
All three problems can be helped with glasses or contact lenses, but more people are opting for laser eye surgery. The laser reshapes the cornea so light is focused on to the retina.
An estimated 100,000 laser eye procedures are carried out each year. It is not available on the NHS without special medical circumstances, so 98 per cent are done in the private sector.
HOW IT IS DONE
Laser eye surgery was first performed in the UK in 1989 by Professor David Gartry, a consultant ophthalmic surgeon at Moorfields Hospital. As he explains: ‘The technology was rough and ready 25 years ago but it’s infinitely better now - the basic principles are the same, it’s just more refined.
With the original PRK (photorefractive keratectomy) technique the surgeon manually scraped away the surface layer of the cornea (the epithelium) and the laser reshaped the exposed cornea. ‘But recovery was often slow and painful,’ says Professor Gartry, who has performed over 20,000 laser eye procedures.
'The technology was rough and ready 25 years ago, and is infinitely better now,' he says.
With the original PRK (photo-refractive keratectomy) technique, the surgeon scraped away the surface layer of the cornea (the epithelium) and the laser then reshaped the exposed cornea.
'But recovery was often slow and painful,' says Professor Gartry, who has performed more than 20,000 laser eye procedures.
Nowadays, 90 per cent of laser surgery is done using LASIK (Laser-Assisted In-Situ Keratomileusis) surgery where laser energy is used to create a hinged flap in the cornea, giving us access to reshape the cornea with a laser.
'It is much less painful and recovery is much quicker. You can have both eyes done on a Saturday and be back at work on Monday.'
Professor Gartry uses LASIK in conjunction with wavefront technology, a scanning technique that takes into account aberrations in the cornea to make the procedure more accurate.
'It is important that patients are offered a wavefront scan as it's the most accurate assessment of their prescription,' says Professor Gartry. 'It's the best technology we have to get a perfect result. These days most companies will offer it.'
TWO BETTER THAN ONE
Another option is IntraLASIK, a sophistication of LASIK where two more precise lasers are used. A femtosecond laser (also used in cataract surgery) is used to make the incision for the flap.
This procedure is safer and more accurate than older techniques, says Professor Gartry.
A second laser (an excimer laser) is used to reshape the cornea. 'This combination has produced results that are more predictable for all refractive errors, especially astigmatism,' he says.
This operation is not suitable for people who play contact sports, such as rugby, or have a job where they might be poked in the eye, such as in the military or police, as the flap in the cornea could become dislodged.
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