Windows to the World
To hear about a beautiful place, a gorgeous flower or a mou thwatering meal is inviting for sure. But to see it—to experience it all with your eyes, that’s magical. Our eyesight makes every experience more personal and memorable, so it’s an important thing to monitor and protect. To keep us seeing clearly, doctors discuss the latest techniques in cataract surgery, improved contact lenses, and the effect modern technology has (or doesn’t!) on children’s vision.
Cataract surgery, which dates back to the 15th century B C, may be one of the oldest medical procedures, but only in recent decades has it become an efficient method to restore and often improve vision.
“If we live long enough, most of us will develop cataracts to the point that we need surgery,” says Dr. Sean Breit, an ophthalmologist who specializes in cataracts at Eye Care Associates of St. Louis. “The lens continues growing with age, and eventually, its cells get crushed and become cloudy. A cataract is the clouding in the lens. The average age for cataract surgery is 70, but I have seen people in their 30s all the way up to their 90s.”’
“There was a procedure called couching,” explains Dr. Jay Pepose, an ophthalmic surgeon at Pepose Vision Institute. “ Doctors would push the lens into the eye. Rather than going blind, patients could at least see light.”
Couching remained the standard care until 1753, when French ophthalmologist Jacques Daviel was credited with the first removal of a cataract through an incision in the cornea. That remained the latest advancement until WWII. “A Royal Air Force pilot got shards of his Plexiglas windshield embedded in his eyes,” Pepose says. “English ophthalmologist Harold Ridley realized there was no inflammation around the Plexiglas when he removed it, which gave him the idea for lens implants. By the 1970s, implants became a routine standard of care.”
The incisions required for stiff plastic lens implants, however, were extremely large. “ Doctors had to suture the incision, so cataract surgery was a five-day, inpatient procedure. Patients had to stay in the hospital with sandbags around their head so they didn’t move,” Pepose says.
In the past four decades, Pepose notes there has been a tremendous evolution. Ultrasonic liquefaction allows clouded lenses to be removed through a tiny incision and replaced with implants made of a soft material. “ The incision is so small, it selfseals,” he says.
Breit agrees that the surgery continues to get more efficient. “The average surgery is 10 to 12 minutes, and healing time is one to four days,” he notes. “Complication rates continue to decrease. Major complications are in the 1 to 2 percent range, and many of those can be treated. Serious complications are pretty rare.”
Implant technology improves before our eyes. “In the last five years, the use of specialized implants has become more common,” Breit says. “We can customize the prescription for each patient to treat far-sightedness, near-sightedness, astigmatism (an imperfection in the cornea’s curavture) and presbyopia, the loss of near-focusing.” While cataract surgery and basic implants are covered by medical insurance, specialized implants cost $2,000 to $4,000 out-of-pocket per eye, he says.
Pepose says implants can suit the patient’s activities. “If somebody has an astigmatism but loves wearing glasses, we probably aren’t going to correct the astigmatism,” he explains. “ There are bifocal lens implants that allow you to see near and far in the same eye, and within the last year, they have created an extended depth-of-focus lens with an an infinite number of focal points.”
Pepose says in about five to 10 years, electronic implants will be an option. “They will change shape and focus like natural lenses,” he says. “But even with the current technology, satisfaction is very high.
Contact lenses play a major role in the daily habits of many Americans. The Vision Council reports that nearly three out every four adults uses a form of vision correction. Of those 188.7 million people, about 40.5 million wear contacts.
Appearance and simplicity are reasons people choose contact lenses over other forms of eye correction, but more notable advancements are improving the treatment of refractive errors, says Dr. Sean Edelstein, a SLUCare ophthalmologist and assistant professor at the Saint Louis University Eye Institute. “Most people with healthy eyes can use contact lenses to correct near-sightedness, farsightedness and astigmatism. They also can correct presbyopia.”
At some point in life, reading glasses will be a wardrobe staple. The Vision Council says 30.9 million Americans use them. But, Edelstein says, the presbyopic era of life can be remedied with contact lenses that still permit or enhance sharp vision at other distances.
“There is an option called monovision,” he says. “One eye is corrected for distance, and the non-dominant eye is corrected for reading. Another option is multifocal contact lenses that can correct for distance or close viewing. Your brain adjusts to the different focal points and sees the different ranges. It can take some getting used to.”
Contacts correct some visual errors better than glasses. “Someone who is extremely near-sighted would have to wear glasses with very thick lenses,” Edelstein points out. “Those can cause distortion in the image, and the actual image size is very small. With contacts, the image is normal. And, when there is a large difference in prescriptions for each eye, it can be uncomfortable with glasses because people see a different image size in each eye. That can be greatly improved by wearing contact lenses.”
Some unusual conditions also can be treated best with contacts, Edelstein says. “Patients with keratoconus, a condition where the cornea bulges outward, will get their best vision wearing a hard contact lens that treats the irregularity of the corneal surface.”
Diligence is a key in maintaining healthy contacts. “Someone who looks after their contact lenses and cleans them well will have a very low risk of problems,” Edelstein says. “We are referred a lot of patients who have developed infections from misuse or over-wear. If you top off your cleaning solution with tap water, you can get infections.” He notes that patients also can contract parasitic infections from contaminated water in swimming pools, hot tubs or lakes. “People who sleep in extended wear contact lenses and keep them in continually for 30 days or more significantly increase their risk of infection,” he says. Those with the least complications? Those who use daily disposable lenses and don’t have to clean them.
If you want to purchase contacts in a different color or with a decorative effect, Edelstein warns to be careful. “There is a lot of concern about them being obtained illegally,” he says. “Cosmetic or decorative lenses still need to be sold by an authorized dealer and fitted by an eye care professional.”
With the American Academy of Pediatrics recommending strict limits on screen time, it’s easy to assume it’s not the best for children’s eyes—or their development. But Dr. Lawrence Tychsen, a pediatric ophthalmologist at St. Louis Children’s Hospital and a professor at Washington University School of Medicine, notes that’s an unsupported conjecture. “Some video game companies have product warnings stating the device should not be used by children under a certain age, yet there is no physiologic, scientific basis for that assertion,” he says.
Could screen time be particularly harmful to children under the age of 2 who are undergoing the most important neurological development phase of life? “You are not born with the vision you have when you’re an adult,” says Dr. Francisco J. Garcia-Ferrer, an ophthalmologist at Mercy Clinic Eye Care Specialists in Creve Coeur. “Babies don’t even see in color very much. Their brains are still developing the visual pathways between the eye and the brain. As far as what ophthalmology literature states, the limited studies that have been done show no direct damage to the eyes from a screen.” She notes the issue is more about the developmental processes in children.
a closer look
Tychsen and his staff at St. Louis Children’s Hospital have looked for evidence of an anecdotally plausible connection between screen time and visual development. “We look at a number of qualitative measures of children viewing not just screens but virtual reality, which you think would increase the risk even more,” he says. “We have looked at all the important parameters—depth perception, balance, visual acuity, eye tracking, the coordination of the eyes—and have not found any deleterious effect on the visual system or the brain.”
But, he continues, “When it comes to children, there obviously are some caveats. The first is simply moral: Is the child watching something proper for his age? Second, screen time is passive, and children’s brain development requires active problemsolving and physical motion.”
the big picture
“The issue about screen time is more about the developmental processes in children,” Garcia-Ferrer agrees. “The American Academy of Pediatrics recommends parents be pretty strict. You want to limit screen time so children can participate in physical activities and social interactions.”
Tychsen adds, “If children are passively engaged with a screen for prolonged periods, that is an intellectual or neurological development concern.”
screen-time recommendations by the american academy of pediatrics
- Avoid digital media use (except video-chatting) in children younger than 18 to 24 months.
- For children ages 18 to 24 months, choose high-quality programming and use media together with your child.
- For children 2 to 5 years old, limit screen use to one hour per day of high-quality programming, co-view with your children, and help them apply what they learn to the world around them.
- Avoid fast-paced programs and apps with distracting or violent content.
- Turn off TVs and other devices when not in use.
- Avoid using media as the only way to calm your child. Although there are times when media is useful as a soothing strategy, it can also limit a child’s ability to develop emotion regulation.
- Monitor children’s media content. Test apps before the child uses them, and play them together.
- Keep bedrooms, mealtimes and parent-child playtimes screen-free for children and parents.
- No screens one hour before bedtime, and remove devices from bedrooms before bed.