Good Sight Guide 2010

A
WHAT DOCTORS DONT TELL YOU

P U B L I C AT I O N
The WDDTY Good Sight Guide
A comprehensive guide to keeping your eyes healthy
Copyright 2010 WDDTY Publishing Ltd First published in various editions of What Doctors Dont Tell You. Editor and co-Publisher: Lynne McTaggart; Publisher: Bryan Hubbard No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including recording, photocopy, computerised or electronic storage or retrieval system, without permission granted in writing from the publisher. While every care is taken in preparing this material, the publisher cannot accept any responsibility for any damage or harm caused by any treatment, advice or information contained in this publication. You should consult a qualified practitioner before undertaking any treatment.
Contents
5 INTRODUCTION 7 1 CHILDRENS EYE PROBLEMS Common ailments Eye testing Alternatives to glasses How to cure squint 17 2 MYOPIA AND FARSIGHTEDNESS Radial keratotomy Laser surgery Contact lenses Educational eye strain Prevention Alternative treatment 37 3 CATARACTS How they develop Risks from surgery Types of cataract The UV connection Prevention Nutritional cures The Evans treatment 51 4 GLAUCOMA What does it do? Are you at risk? Tests Dangers of drug treatments Surgical approaches Drug-free approach Exercise Acupuncture 65 5 AGE-RELATED MACULAR DEGENERATION (AMD) Possible causes The link with fats and minerals The dangers of aspirin and other NSAIDs Solutions from nature 77 6 COMMON COMPLAINTS Dry eyes Floaters Blepharitis Herbs for the eyes 87 7 THE BATES METHOD Exercise your eyes back into shape Techniques Other vision programmes Recommended reading
Introduction
erhaps more than any other part of the body, doctors act as though eyes have a life of their own, disconnected from the rest of our bodies. The medical profession tends to view eye problems as purely mechanicala retina that somehow got detached, a globe that became misshapen or stubbornly refuses to stay straight or see correctly, a bad toss of the dice that has somehow, without our having anything to do with it, just happened. Consequently, the prevailing medical approach is to surgically or chemically get those errant lenses or muscles back into linean approach that attempts to correct vision by treating the symptoms, not the underlying cause. In most cases, the underlying cause isnt understood and certainly never connected to our diet or any drugs we may be taking. What Doctors Dont Tell You has amassed an increasing amount of evidence showing the pitfalls of the orthodox approach to vision problems. This guide will show you why vision loss is not inevitable with age. Growing old no longer means going blind. It also reveals how popular procedures for common problems such as strabismus (squint) and myopia (nearsightedness) are ineffective and to be avoided at all costs. Dont assume that your vision will deteriorate with age, and dont assume that there isnt anything you can do about it. The worse thing you can do is become accustomed to having poor eyesight. There are steps you can take now to prevent vision loss, and choices you can make about treatment. A positive approach and perception is the first step to seeing through the fog of orthodox medicine for vision. Our thanks go to the late British ophthalmologist Stanley Evans, whose nutritional approach to many eye problems, as well as his analyses of eye surgery, is covered throughout this booklet, and to Dr Harald Gaier, WDDTYs resident naturopath for his advice on herbs for the eyes. The
advice from Peter Mansfield (The Bates Method) and Dr Robert-Michael Kaplan (Seeing Without Glasses) is much in evidence within this booklet, as is, of course, that of the late W.H. Bates, MD.
Lynne McTaggart
Childrens Eye Problems
he eye suffers more unnecessary medical intervention than virtually any other part of the bodyand this includes the wearing of glasses. Far too many children wear spectacles for conditions that could be treated by other means, such as nutrition and eye exercises; some ophthalmologists, particularly those who follow the Bates Method, estimate that up to 80 per cent of spectacle wearers have been prescribed them unnecessarily. Another test, carried out in the US, revealed that seven out of 10 children wearing glasses need not do so, either because the spectacles were inappropriately prescribed or because the eye deficiency was too slight to benefit from wearing eyeglasses. In addition, there is the overtreatment of minor eye illnesses, such as conjunctivitis or pink eye, which are often caused by an allergic reaction to food, the environment, chemicals and so on.
Common eye ailments
Cross-eyes or wall-eyes. These occur in very small babies, usually within the first three months of life, when the eyes seem to operate independently of each other and before they begin to work in coordination. Sometimes the condition persists so that one eye wanders; this is called alternating strabismus and will usually self-correct before the child is age five. Medical options include surgerybut such a decision should not be taken lightly, and certainly not before the child has had a chance to grow out of the condition. A more serious condition is known as amblyopia, when one eye sits in the corner. Usually, the child cannot see out of the lazy eye, and some intervention may be necessary to help it along. This can vary from patching over the good eye, thereby forcing the lazy one to start work7
ing, to eye exercises, eyeglasses or, in extreme cases only, surgery. Be sure, however, that you are dealing with amblyopia and not strabismus, as even specialists have been known to confuse the two. Styes are infections of the sebaceous glands lying along the edge of the eyelid caused by staphylococcal bacteria. The first stage of a stye feels like a piece of grit in the eye, followed by painful irritation and redness. Finally, a pimple-like lesion forms at the edge of the eyelid. This will go away on its own, although it can be helped along with the application of hot compresses every 1015 minutes. Boric acid and Epsom salts can also be used, though hot water often works just as well. Eventually, a stye will either burst or get smaller and smaller; the latter kind is known as an internal stye. Conjunctivitis, also known as pink eye, refers to inflammation of the conjunctiva, the eyes protective outer covering. In this common condition, the eye becomes red, sore, feels gritty and may have a discharge. Conjunctivitis can be due to an infection or allergy, a chemical or drug, or exposure to ultraviolet radiation, therapeutic lamps or even the reflected glare from snow. Allergic conjunctivitis is often triggered by hayfever, the dander of animals, mascara, contact lens-cleaning solutions or, very occasionally, food. Infective conjunctivitis can arise from an infection picked up in an inadequately chlorinated swimming pool, or it may appear at the same time as a cold or other infection such as measles. It is usually spread by hand-to-mouth contact (often in children), or by the viruses associated with colds, sore throats or an illness such as measles. Conventional medicine usually treats infective conjunctivitis with eyedrops or an ointment containing an antibiotic drug. Chloramphenicol (Chloromycetin, Sno Phenicol) is a commonly prescribed broadspectrum antibacterial, and the drug of choice for most GPs for any superficial eye infectionbacterial or otherwise. It is applied topically as an ointment or as eyedrops. Nevertheless, manufacturers of the drug have disclosed that, on rare occasions, it can cause aplastic anaemia. Although the incidence of this happening is supposedly rare, the disease is very serious indeed (there
1 Childrens Eye Problems
is a significant reduction in red blood cell-producing marrow elements). In spite of this, GPs could be said to be somewhat cavalier about prescribing the drug for simple infective conjunctivitis, especially as many cases are caused by viruses that will not respond to it. Simpler and safer treatments abound in alternative medicine.
First aid

For babies, the traditional folk-medicine approach is to bathe the eyes in milk, preferably breastmilk if available (the second choice is goats milk) Mixing one drop of the herb Euphrasia officinalis (eyebright) as an extract with an eggcupful of cooled boiled water and applying it with an eye bath or a dropper will usually help adults. When treating children, dilute the extract and apply it with cottonwool Dr Alfred Vogel, in his book The Nature Doctor (Main Stream Publishing, 1996) suggests applying the white of an egg to your eye (assuming you are not allergic to eggs) Take beta-carotene (4 mg per 30 cm of height) in divided doses throughout the day (J Nutr Environ Med, 1995; 5: 23542) For rh i n o v i rus (nose) infection involving the conjunctiva, take zinc gluconate lozenges (containing 23 mg of elemental zinc) every two hours while awake (J Antimicrob Chemother, 1997; 40: 48393).
Homeopathy

Rhus tox 6CH twice dailyif your eyes are sensitive to light and there is pustular inflammation Staphysagria 3CH twice dailyfor recurrent styes and if a pronounced heat is felt in the eyeballs Arsenicum alb 12CH twice dailyfor acrid tearful discharge and oedema around the eyes Aconite 6CH twice dailyfor grittiness and profuse watering of the eyes, vertigo, and when the eyelids are swollen, hard and very red Mercurius 12CH twice dailyif you can see black floaters after exposure to ultraviolet light, and when there is a profuse, burning discharge with thick, swollen lids (Boericke W. Pocket Manual of Homeopathic Materia Medica, 9th edn. Boericke & Tafel, 1927).
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Western herbalism
Apply warm compresses using extract of Euphrasia rostkoviana (another species of the eyebright plant) or Arctium lappa (burdock as a herb, not the root), or use Calendula officinalis (marigold) as an eye lotion. Take immune-boosting herbs such as garlic or Echinacea (Planta Med, 1973; 23: 324). Remember: never use straight herbal tinctures in the eye. Make sure you consult a qualified health professional if conjunctivitis lasts for more than 48 hours, whenever there is a thick discharge, if vision is affected or if light hurts the eyes.
Eye-testing
Medicines intervention starts pretty early, usually with the eye test. The first eye test is far from unnecessary, although nothing much of use can be gleaned before the age of four, as the eye is still developing. Indeed, some argue that no eye test should take place before the child is five years of age, when true seeingwhen the eye and brain coordinateis first established. But having measured the quality of your childs vision, the practice of annual tests after that is generally a waste of everyones time. A sensible interval between eye tests is about four or five years. A child who took an eye test at the age of four need not have another until age nine. The only exception to this admittedly general rule would be if your child has complained of blurred vision or difficulty seeing in the meantime. But even in such cases, it is better to first suspect an infection or allergic reaction than a sudden overall deterioration of the eye. If your child has taken a bad eye test, and the ophthalmologist or optometrist suggests spectacles to correct vision, its advisable to have your child take another test perhaps a month or so later, before immediately succumbing to a spectacle-wearing existence for your child. Everyone, specialists included, seems to view the eye as an unvarying, static organ whereas, of course, it is very much alive, with its own off days like any other part of the body. Some days, our joints are a little stiff or perhaps we have a headache, but nobody would dream of making us wear a splint or a head bandage for the rest of our lives. This is because
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we know that tomorrow, or soon after that, these minor symptoms will disappear. Similarly, many things can affect our visionstress, allergic reactions, illness, smoke and so onso if your child is unlucky enough to have an eye test on an off day, he could be condemned to eyeglasses for the rest of his life. Your child will not suffer any damage for waiting a little while longer before wearing spectacles; conversely, his eyes could be permanently damaged by wearing glasses that were not necessary. Perfect eyesight, by the way, is popularly known as 20/20 vision. It is so called because it is measured as a ratio of that which can be seen against that which should be seen. So someone who can see at 20 feet everything he should see at that distance is said to have 20/20 vision. Someone with 20/60 vision would see at 20 feet what he should be able to see at 60 feet. Although a childs eyes are physically developed by the age of six months to see with 20/20 vision, the interaction of the eye with the brain is still being established, which means that 20/20 vision cannot be measured much before the age of five. So, a child of two will have about 20/70 vision, at three, 20/30 or 20/40 vision and, at four, 20/25.
Alternatives to spectacles
The most common reasons why people wear eyeglasses are because they have myopia (short- or nearsightedness), hyperopia (farsightedness) or astigmatism. The conventional wisdom has it that visual problems have a purely physical cause and are linked to the shape of the eyeball. A US study (JAMA, 1994; 271: 13236) found that the eyes of children whose parents are myopic are not spherical, but more elongated than those of children with non-myopic parents. Given that the children of myopic parents are more likely to develop myopia (Clin Vis Sci, 1993; 8: 33744; Acta Ophthalmol, 1968; 98 [suppl]: 1172; Hum Hered, 1985; 35: 2329), these findings offer hope that measuring axial length may provide a way to assess whether a child is in the process of becoming myopic. Nearsightedness is due to the fact that the distance between the cornea and the retina is too great, forcing the eye to focus in front of the retina. If
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the distance between cornea and retina is too short, the eye has to focus behind the retina, causing farsightedness. Astigmatism is when the cornea or the lens is bumpy or irregular. Farsightedness can improve after the age of 21, as all ophthalmologists agree, and myopia will also stabilise at around that age. But several schools of thought have had considerable success in treating these common conditions without spectacles.
The Bates Method

The first of these is the Bates Method (also see Chapter 7, page 87), named after a New York oculist, William Bates, who died in 1931. Bates champion was the writer Aldous Huxley, whose book The Art of Seeing introduced Bates methods to many thousands of people. The Bates system considers seeing to be dynamic and also, in part, to be a function of memory. People who have difficulty seeing, Bates observed, will stare or squint, which tenses the eye muscles. The healthy eye, in comparison, is relaxed and constantly moving, continually picking up bit-sized portions of the image in front of it, thus building and rebuilding the entire picture. The person with poor sight, in contrast, tries to gulp in the whole picture without moving the eye and, of course, fails. Spectacles, Bates argues, trap the eye in the state it happened to be in when it was tested. The analogy drawn by Huxley is like putting a broken leg in a permanent cast; without use, the leg will wither and always be dependent on the cast. We know, of course, that exercising the leg will make it strong again. This, in simple terms, is exactly what the Bates method tries to do for the eyes.
Nutrition
Another school of thought maintains that nutrition can help cure or improve most eye ailments. While many nutritionists will argue that a healthy diet can cure some ailments such as conjunctivitis, others go further and maintain that even permanent eye disorders can be successfully treated with good nutrition. The late Stanley Evans, a vision expert, based his research on the
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successful treatment of myopia, cataracts, glaucoma and other eye disorders with nutrition. He made many of his discoveries while working with malnourished people in Nigeria. Some cases of myopia, for example, were successfully treated by Mr Evans and his followers with the use of glucose and various vitamins. The precise nutritional diet depends, however, on the individual, and so general guidelines would be useless, although vitamins A and C play an important role. High doses of vitamin A can be toxic, and so it is advisable to take it as beta-carotene instead (see Chapter 3 on cataracts, page 37).
Autogenic training
As this involves visualisation and self-hypnosis, it may not suit all children. However, the remarkable success of one doctor, who restored his own vision despite having his iris destroyed, is inspirational, and throws more light on what we call seeing. Dr Kai Kermani had an incurable condition which leads to blindness. One of his eyes was already blind, and the other was almost so when he took up autogenic training, which he combined with reflexology, spiritual healing and massage. Miraculously, the discipline had almost restored the sight to both his eyes when he suffered a severe injury to one eye which tore his eyeball, destroying the iris. Nevertheless, within months, his eyesight returned when he resumed the autogenic training.
The dangers of surgery for strabismus

The last 50 years have shown that most cases of strabismus, or squint (when eyes are not properly aligned), can be cured with nutritional therapy. However, many cases of squinting are still treated surgically and, in every such case, serious damage is done to the eyes binocular function. Over the past 30 years, Stanley Evans witnessed many cases of strabismus that were cured within a few weeks with his own brand of nutritional therapy. Compare this to the years it takes to cure the condition through traditional methods, such as wearing a patch over the normal eye. The success rate of these traditional methods is very low, which is why the majority of cases are referred for surgery.
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When one eye deviates from its normal position, the usual surgical method to straighten the eye is to cut one or more of the muscles attached to the eye responsible for moving the eye in the direction of the deviation, and suturing it further back onto the surface of the eyeball so as to weaken its pull. Alternatively, the muscle or muscles responsible for moving the eye in the opposite direction may be cut and sutured further forward on the surface of the eyeball so as to increase the pull and, thus, overcome the deviation. Frequently, both of these procedures are done, and it is very common for the good eye as well as the deviating eye to be operated on. The operation thus destroys the normal function of all the horizontally acting muscles. Not only is the delicate relationship between the photoreceptors in the retinas and the individual muscle fibres of all four eye muscles disrupted, but the flexibility of all four muscles is seriously impaired. The result is that normal eye movements are restricted in both horizontal directions. Furthermore, it is very rare for a patient to undergo a single operation. Even when compound surgical procedures are adopted, these frequently have to be repeated because the operation, by its very nature, has such a high potential for inaccuracy. Indeed, the first operation may reduce the deviation or cause one in the opposite direction, so that another operation has to be done to correct the error of the first one, or repeated several times until the eye appears straight. In performing such an operation, the surgeon is confronted with a most delicate task, and it is not possible to accurately forecast the result. Often, the first operation is not expected to completely correct the deviation; the surgeon will deliberately operate in stages, rather than attempt to do it all at once. This has to do with the scale of the surgery. The eyeball is a globe less than one inch in diameter. Changing the position of a muscle insertion by only one millimetre will change the position of the eye by approximately five degrees of arc. Most operations are performed to correct deviations this slight. Even when the most accurate apparatus possible is used with the highest level of skill and experience, the kind of accuracy
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called for is often too high to guarantee success. In addition to this, the healing process can completely upset even the most superior surgery. The fact that the eyes may appear straight after the operation, or series of operations, does not mean that the two eyes are working together correctly and giving normal binocular vision. Every time an eye muscle is cut and sutured in a different position, the delicate circuit connections feeding the group of muscle fibres that have been cut no longer remain in contact with the cells of the nuclei in the brainstem, with the photoreceptors in the retinas, or with the brain cells in the visual or motor cortex. This means that the delicate mechanism designed for providing eye balance and movement is irreparably disrupted. Over the past half-century, Mr Evans was consulted by a large number of patients who had been operated on for squint, and who had subsequently experienced very serious trouble because they were unable to move their eyes correctly or change fixation with comfort. Many patients experienced double-vision whenever they attempted to move their eyes from the straight-ahead position. In every case of squint, the patient or parent should never consent to surgery without first attempting a thorough trial of nutritional and exercise therapy. Such therapy never harms the eye functions but invariably improves them, whereas surgery always permanently destroys at least part of the delicate visual mechanism, and frequently causes far more trouble than leaving the strabismus alone. Often the parent is too anxious to straighten a squint in a child when he is young in the mistaken belief that nothing can be done later. Many cases of strabismus have been cured by the nutritional approach even after many years whereas, with surgery, the normal binocular vision is very unlikely ever to be restored.
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Myopia and Farsightedness
aser eye operationor photorefractive keratectomy (PRK)to correct myopia (shortsightedness) is the new darling in the operating room. It was first introduced in the US in 1987 and in the UK two years later to replace surgical correction that entailed making several cuts into the eye. However, if youre considering surgery to correct eyesight, you may want to think again. Research is uncovering the dangers behind the two most frequently performed correctional proceduresradial keratotomy and laser surgery. And 50 years of study has uncovered methods using nutrition and exercise that can help your sight.
A close-up look at radial keratotomy

Myopia is caused when the eye is a flattened sphere that is too long from front to back. As a result, the lens will focus images in front of the retina instead of on it. The standard treatment to correct this is eyeglasses or contact lenses. However, patients can also opt for an elective procedure called radial keratotomy (RK). During RK, several hairlike incisions are made in the cornea like the spokes of a wheel, avoiding the centre of the lens. During the healing process, the scars contract, causing the cornea to flatten and become less powerful. When RK was first introduced some 30 years ago, it quickly became all the rage. However, subsequent research shed some doubt on the efficacy of the procedure. According to an article in the medical journal The Lancet (October 29, 1994), a 10-year follow-up study found that RK is unpredictable as regards both the short- and long-term changes in eye refraction. The Prospective Evaluation of Radial Keratotomy study found that the operation could
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lead to a continuing hyperopic shift (a shift to farsightedness) during the 10 years following the operation. Radial keratotomy also increases the risk of infection and ulceration long after the procedure is done. In some serious cases, a therapeutic corneal transplantation has been necessary (American Journal of Ophthalmology, July 1994 and June 1995).
Laser eye surgery: a shortsighted solution

Laser eye surgery was supposed to be the great saviour for all glasseswearers, and was sciences answer to most of the common sight problems. But, already, the hype and hope are giving way to growing concerns over the safety and effectiveness of the various techniques, and patients are proving to be somewhat elusive just as the surgery is being offered on every high street in the UK. In the US, a growing number of consumers are questioning the procedure, and its popularity is apparently waning. At its peak in 2000, 1.42 million Americans underwent the surgery, but figures for the following two years saw a significant drop to 1.31 million in 2001 and 1.15 million in 2002. Profits and share prices of the medical chains performing the operation tumbled as a result (International Herald Tribune, 31 January 2003). In the UK, around 100,000 people undergo the procedure each year. Nevertheless, patients concerns are well placed. Researchers at the New Jersey Medical School discovered that as many as one in five of the patients in their study of 1306 patients needed to undergo retreatment to repair or enhance the first one (Ophthalmology, 2003; 110: 74854). One of the major concerns of ophthalmologists is the sudden loss of contrast sensitivitythe ability to distinguish objects in poor lightafter surgery. This problem surfaced in 1996 when researchers at Tbingen University in Germany reported that three-quarters of the patients who had undergone photorefractive keratectomy (PRK) surgery for myopia over the previous 10 years had such poor contrast sensitivity that they had failed federal German night-vision standards (ASCRS [American Society of Cataract and Refractive Surgery] Symposium, June 1996). The London Centre for Refractive Surgery has reported similar problems. After hearing of the German findings, the centre recalled all patients
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2 Myopia and Farsightedness
treated with an Excimer laser and found that 56 per cent (36 of 54 patients) also had greatly reduced contrast sensitivity (Lancet, 2003; 361: 12256). This loss of sensitivity appears to be permanent and untreatable, says Dr William Jory, consultant ophthalmologist at the London Centre for Refractive Surgery. These findings have been supported by a further German study (ESCRS [European Society of Cataract and Redfractive Surgeons], Brussels, 2000) and one from Canada (Can J Ophthalmol, 2000; 35: 192203). The Canadian federal government in Ottawa has since advised all provincial governments to test patients night vision after surgery before a drivers licence is issued. Advocates of laser eye surgery argue that many of these safety issues relate to the PRK technique, which has since been superseded by LASEK (laser subepithelial keratomileusis), a modification of PRK, and by LASIK (laser in situ keratomileusis), now probably the most popular form of laser eye surgery (Semin Ophthalmol, 2003; 18: 210). With PRK, the surgeon applies the laser beam directly to the cornea (the transparent tissue covering the front of the eye), and shaves and reshapes it. LASIK uses a special knife to lift a flap of tissue from the surface of the cornea to reveal the corneal bed (stroma). The laser works on this tissue, then the flap is replaced. The LASEK technique detaches the outermost layer (epithelium) of the cornea, and reshapes the corneal surface with the laser. The epithelium is then returned to its normal position. There has been a range of concerns about the PRK technique, but one that is rarely aired is the possibility of postoperative infection. One study reviewed the records of 12 PRK patients who developed infectious keratitis, which can result in corneal ulceration. The researchers recommended that just-in-case antibiotics be given to all PRK patients before surgery (Ophthalmology, 2003; 110: 7437). Contrast sensitivity is also a major concern for PRK patients. Researchers at Moorfields Eye Hospital in London reported that 30 per cent of its PRK patients suffered a loss of contrast sensitivity within two years of surgery (Refractive Surgery Symposium, London 2001)and the same symposium heard that half of all LASIK patients suffered a similar loss, one year after the operation. The LASIK technique can cause the cornea to weaken in up to 40 per
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cent of all cases (Lancet, 2003; 361: 12256) and, sometimes, the weakened cornea resumes its original shapeso the myopia returns. One study reported on a variety of complications following LASIK surgery. Of the 24 cases, 13 of the complications occurred during the procedure, and the rest afterwards. The technique, the researchers concluded, could result in serious complications that can lead to visual loss (Eur J Ophthalmol, 2003; 13: 13945). Patients may also have to go through a second, corrective operation. In one study of 1306 LASIK patients, over 10 per cent had to undergo a second operation, a likelihood that increases with age, the degree of initial correction and the extent of astigmatism (Ophthalmology, 2003; 110: 74854). As with PRK, postoperative infection is also a concern for the LASIK patient. One study found that keratitis could occur up to 450 days after surgery, and was serious enough to threaten vision (Ophthalmology, 2003; 110: 50310). The US Food and Drug Administration (FDA) is equally unsure of the LASIK technique. According to its website (www.fda.gov), LASIK is an option for risk takers. LASEK is a newer technique, so there are fewer studies into its efficacy and safety. However, one study from Japan urges caution. After studying the progress of 42 LASEK patients, the researchers reported postoperative complications such as pain, delayed recovery of visual sharpness and corneal haze (Nippon Ganka Gakkai Zasshi, 2003; 107: 24956). Compared with PRK, LASEK may result in less discomfort in the early postoperative period, faster visual recovery and less haze, but these claims, made by LASEK proponents, need to be vindicated in long-term trials, say researchers at the University of Washington (Semin Ophthalmol, 2003; 18: 210). In general, complications that can develop after any of these three procedures have included: Eye infections (Ophthalmology, 2003; 110: 7437; J Cataract Refract Surg, 2002; 28: 7224; J Cataract Refract Surg, 2001; 27: 4713) Dry eye with compromised tear function (Am J Ophthalmol, 2001; 132: 17) Strabismus (cross-eyes) (Yonsei Med J, 2000; 41: 4046) Detached retina (Am J Ophthalmol, 1999; 128: 58894) Macular damage (Am J Ophthalmol, 2001; 131: 6667)
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Vision disturbance due to optic nerve damage (Am

66871)
J Ophthalmol, 2000; 129:
Irregular astigmatism (a misshapen cornea, causing blurred or distorted vision) caused by surgical complications (Rev Optom, May 1999) Impaired night vision and loss of contrast sensitivity, making it hard to see objects against a similarly coloured background (Med Post, 8 June 2000) Long-term weakening and thinning of the cornea, leading to a risk of further myopia (Ophthalmology, 2001; 108: 66672). Corneal weakening and corneal distortion are serious complications, according to Dr Jory. They cause myopia that, in some cases, becomes progressively worse. No one knows the rate of risk or the timescale, he says. With more and more walk-in laser-surgery centres opening up, the emphasis is on the benefits; very few mention the possible risks either in their advertisements or during the face-to-face consultations before the operation. The Advertising Standards Authority, the UKs advertising watchdog, has upheld complaints against misleading advertising for LASIK surgery which had been produced by Boots, Maxivision and Optimax, some of the leading players in this lucrative field. Such a misleading approach was a major concern of the patients, according to a poll conducted by HealthWhich? earlier this year. Some complications that doctors deemed minor can seriously affect peoples lives and jobs. One patient complained she could no longer drive and now fails to recognise people who are just 10 feet away. But because she can still read an eye chart, her problem is not considered significant, the poll said. Some patients whose lives have been ruined by eye surgery have taken on the task of providing a health warning to potential patients, and also to provide help to those already affected. The Surgical Eyes Foundation (www.surgicaleyes.org) is a US-based support group for people with longer-term complications from refractive surgery. Their aim is to restore quality of life to the thousands who suffer from complications of . . . refractive surgeries. Others are much more militant. In the UK, the Medical Defence Union,
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the biggest insurer of British doctors, said claims against surgeons performing laser eye operations are soaringbecause the expectations of the patients dont match their results. The MDU says doctors needed to warn patients of the possibility of an imperfect result and other complications before obtaining the appropriate consent for the procedure (The Guardian, 26 May 2003). Unrealistic expectations, or perhaps expectations that have been put in the patients mind by advertisements or during the preoperative discussions, could be at the heart of the issue. Even if you are among those who suffer no reactions or complications after surgery, you are still likely to need to wear glasses for some tasks, eye surgeon David Gartry told the BBC News (26 May 2003). Quality of treatment can vary enormously from one clinic to another. Yet, this information is rarely, if ever, made available to patients choosing where to have their treatment. Extraordinarily, any currently registered doctor can offer laser eye surgery without the need for any special, formal qualifications. In the main, surgeons receive just two or three days of training at bestand then go on to develop and perfect their skills on you, the patient. Britains Royal College of Ophthalmologists recommends that refractive surgeons should be fully trained ophthalmologists and should have undergone additional specialist training; they suggest that prospective patients should ask about this when enquiring about surgery.
Laser eye surgery: whats involved

Lasers have been used in eye surgery for some time, but they have only been in widespread use since the beginning of the 1990s. Before that time, the eye surgeon needed supreme skill and confidence with a scalpel. When lasers are used to treat myopia, the shape of the cornea is finely sculpted to allow the eye to focus better. The central part of the cornea is flattened, which brings the focal point of the eye closer to the retina, allowing distance vision to be improved. The surgery removes microscopic amounts of tissue from the outer surface with a cool, computer-controlled ultraviolet beam of light. The beam is so precise that it can cut notches in a strand of human hair
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without breaking it. Each pulse can remove 39 millionths of an inch of tissue in 12 billionths of a second. All eye surgery is carried out under local anaesthetic, given as eyedrops. It is an outpatient procedure that takes just a few minutes to perform. Patients are typically able to return to their daily routines within one to three daysif all goes according to plan. Before the procedure begins, the patients eye is measured to determine the degree of visual problem, and a map of the eyes surface is constructed. The required corneal change is calculated based on this information, and is then entered into the lasers computer. Patients who elect for LASIK surgery rarely feel pain during the procedure. The doctor will have you lie down, then make sure the eye is directly under the laser. (One eye is operated on at a time.) A kind of retainer is placed over your eye to keep your eyelids open. This has a suction ring that keeps your eye pressurised, which is important in LASIK for allowing the surgeon to cut the corneal flap. The surgeon uses an ink marker to indicate where the flap should be. The cut is then made with the microkeratome. During the procedure, you wont see the flap being cut as it is very thin. The surgeon uses a computer to adjust the laser to your particular prescription. You will be asked to look at a target light for a short time while he/she watches your eye through a microscope and the laser sends pulses of light to your cornea. With some lasers, it is critical that your eye remains fixated on the target light to obtain the best results. Other lasers are equipped with a special tracking device that follows your eye even if it moves. The laser light-pulses will then painlessly remove tissue. Youll hear a steady clicking sound when the laser is in operation. Youre also likely to smell a mildly acrid odour from the tissue being removed. The higher your prescription, the more time the operation takes. The surgeon has full control of the laser and can turn it off at any time. When the procedure is finished, you will rest for a little while. If youre having both eyes done on the same day, the surgeon will probably do the other eye after a short period of time. Some people choose to have their second eye done a week later.
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The doctor may prescribe medication for any postoperative pain, but many people feel no more than mild discomfort after LASIK, whereas painkillers are often prescribed after a PRK procedure. After the procedure, you will be advised to take proper rest. What occurs after the surgery can affect your vision just as much as the operation itself. You may be able to go to work the next day, but many doctors advise a couple of days of rest instead. They also recommend no strenuous exercise for up to a week afterwards, as this can traumatise the eye and affect healing. Avoid rubbing your eye as there is a chance of dislodging the corneal flap. Laser eye surgery is costly and, at present, not normally available on the UKs National Health Service or under most health-insurance schemes in the US. A straw poll of clinics revealed variable pricesmost charging upwards of 1200 per eye, or more in the small number of centres offering the more advanced wavefront technology (see below). In the US, the Los Angeles Times reports a typical price of between $1500 and $2000 per eye. Potential patients need to check whether the prices include aftercare, and any necessary repair or retreatment in case of disappointing results.
The next wave

If at first you dont succeed, then wavefront could be the new technology in laser eye surgery to stifle the critics. One company promotes the treatment by saying in its press release that it takes most of the guesswork out of predicting the results of surgery. The technology is a byproduct of astronomy, which uses it to unscramble starlight from space. A fine beam of light is shone into each eye and reflected back by the retina. The returning reflection is assessed over many different points on the pupil, and surgeons are now able to spot very slight imperfections and aberrations more accurately than before. This allows the subsequent treatment with the laser to be tailor-made for each patient in a more precise way, or so its advocates claim. One overview of US trends in eye surgery reported their findings that the
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new forms of laser surgery were minimally employed but appear poised to be the wave of the future (J Refract Surg, 2003, 1: 35763). Science magazine (14 March 2003) describes new developments in eye examination that peer into the eye, rather than assessing the information that comes back from it. Adaptive optics again uses space-honed technology on the human eye to examine single cells deep in the eye. The worlds first and only scanning laser ophthalmoscope can look at the retina at different depths, and each layer of the retina tells its own story, says Science. This has enormous potential for a range of eye diseases and conditions. Presbyopiadiminished elasticity of the lens due to ageingcan sometimes be treated with laser surgery using a treatment known as monovision. The laser is used to deliberately make one eye slightly shortsightedthe resulting imbalance aims to improve vision for close objects. Its usual to advise a prospective patient to first try contact lenses or spectacles to see if this imbalance in the eyes works, as the surgery is not reversible. So, does this new technology offer a safer way forward? Its just too early to say. Watchful waiting has to be the best approach at the moment.
A suitable case for treatment?

Not everyone can, or should, have laser eye surgery. Any reputable doctor or clinic will check your expectations and your medical situation very carefully before agreeing to surgery. And, of course, you will undergo a detailed eye examination. It also makes sense for you to ask questions, shop around, do your own searches on the Internet and perhaps, if you can, think about waiting a while before deciding on which form of treatment, if any, you want. You might also wish to consider getting one eye done at a time to allow time to check for any after- e ffects before deciding to have both eyes treated. The website www.surgicaleyes.com has a list of evidence-based contra-indications to laser eye surgery. Some of the most common include: uncontrolled diabetes pregnancy vascular disease, such as lupus or rheumatoid arthritis, and autoimmune diseases
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inability to wear contact lenses, particularly rigid gas permeables (if you devel op any complications of eye surgery, these lenses may be the only ones you can wear to correct your vision) cataracts tendency to dry eyes (exacerbated after surgery).
Contact lenses
A common concern with contact lensesparticularly extended-wear lensesis the risk of infection. All contact-lens wearers are at some such risk, as all types of contact lenses reduce the amount of oxygen that reaches your corneathe clear membrane over-lying the pupil and irisand less oxygen can promote infection. However, studies show that the incidence of eye infections is higher among people who sleep in their lenses. In the 1980s, when extended-wear lenses first came out, a four- to 15fold increase in the risk of infection was seen when lenses were worn overnight, rather than just during the day (Br J Opthalmol, 2000; 84; 327-8). Users of extended-wear lenses who wore them overnight had a 10- to 15times greater risk of ulcerative keratitis (inflammation and ulceration of the cornea) compared with those who didn't sleep in their lenses (N Engl J Med, 1989; 321: 773-8). Ulcerative keratitis is considered the most serious adverse effect of contact lenses as it can lead to scarring and blindness. As a result of these findings, the US Food and Drug Administration (FDA) recommended that lenses approved for extended wear should be worn for no more than one week. And many worried eyecare physicians discouraged patients from sleeping in their lenses. Recently, howeverthanks to highly permeable silicone hydrogel, or SiHyextended-wear lenses have made a comeback. Lenses made from SiHy allow more oxygen to reach the eye than conventional soft lenses, making overnight wear safer than before. In fact, they deliver so much oxygen to the cornea that some brands of SiHy lenses are approved for 30 days of continuous wear. CIBA Vision's Night and Day are among the 30-day lenses now on the market. In more than 6000 people who wore these lenses for up to 30 nights consecutively, the incidence of bacterial or fungal infection of the eye was low, around 18/10,000 users. Also, the rate of microbial infection
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resulting in loss of visual acuity was only about 3.6/10,000 wearers (Ophthalmology, 2005; 112: 2172-9).
However, these rates are still higher than with daily-wear lenses, and SiHy lenses on a daily-wear basis have fewer adverse events than when wearing them continuously (Eye Contact Lens, 2007; 33: 288-92). One study concluded that extended wear with even these newer [SiHy lenses] is still a risk factor in the development of microbial keratitis [corneal inflammation] (Br J Ophthalmol, 2002; 86: 355-7).
Contact lens safety tips

Don't clean your contact lenses with tap water, and don't swim in swimming pools when you're wearing them. These two simple rules will help reduce the risk of a special type of infection that can lead to blindness and which standard contact lens solutions cannot kill. Researchers have discovered that a high percentage of contact lenses are contaminated with pathogenic amoebae known as Acanthamoeba, a common protozoa found in soil and fresh water. The amoeba can cause infections, and can lead to an eye infection called amoebic keratitis, which can cause blindness. Around 85 per cent of all cases occur in people who wear contact lenses. The amoeba is found in chlorinated swimming pools and domestic tap water, and so contact lens wearers who either clean their lens in tap water, or who go swimming while wearing them, have a far greater risk of developing the infection. In one study of 153 contact lens cases from users in Tenerife, researchers discovered that 65.9 per cent were contaminated even though the wearers did not have any signs of infection. No strains were found in daily lenses, although some were found in monthly and bimonthly lenses. Those who wore the same lenses for more than two years had the greatest levels of infection (J Med Microbiol, 2008; 57: 1399-1404). Other pointers: Listen to your eyes: they should look well and feel comfortable, and vision should be clear If you have a problem, immediately remove your lenses and contact your eye care professional
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Never wear your lenses for longer than prescribed Always wash and rinse your hands thoroughly before handling them Wear good-fitting goggles if you go swimming with them Avoid wearing them overnight if you are unwell See your eyecare professional for regular checkups.
Taking a deeper look

Delaying the ageing process and preventing disease in the eye requires greater attention to nutrition, exercise and protection from harmful environmental influences. Practitioners are beginning to come around to the idea that visual disturbances are symptoms of the first stage of the progressive, but preventable, degeneration of the eye. For them, diseases such as cataracts and glaucoma are simply extreme forms of a common process. This theory gains some credence from the fact that people with myopia are known to be at a greater risk of developing eye diseases such as agerelated macular degeneration (AMD), glaucoma and cataracts. In one study, intraocular pressure (most commonly associated with glaucoma) was associated with the development of myopia. The progression of myopia in 49 children, aged 9 to 12 years, was studied over a period of two years. What they discovered was that the rate of myopia in those children with high intraocular pressure (IOP) was nearly double that of those with a lower IOP (Doc Ophthalmol, 1992; 102: 24955). Although almost every child can recall being told that carrots are good for your eyes, nutrition to improve eyesight is not a subject which has received much serious consideration in the medical journals. Vitamin A (found in, among other foods, carrots) is undoubtedly vital for healthy eyes. Carotene is metabolised in the intestinal mucosa into retinol, which is then transported to the liver, where the vitamin is stored in the form of retinyl palmitate. This is why, in diseases which affect the liver, reduced vision and even blindness are commonly seen. When diet is studied, it is usually in relation to serious conditions such as macular degeneration (J Am Optom Assoc, 1996; 67: 3049) and cataracts (Crit Rev Food Sci Nutr, 1995; 35: 11129), rather than refractive errors such as myopia. The damage which free radicals can do to the eye has also
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received some attention. Inflammation of the eye can occur when toxins such as free radicals build up in the body, including the eye (Nutrition, 1996; 12: 2747). However, preventative measures, such as taking antioxidants, have been extensively shown to help prevent visual deterioration (Ann Epidemiol, 1996; 6: 606; Ann NY Acad Sci, 1980; 570: 37282; Acta Ophthalmol, 1993; 71: 2148). One study did look specifically at the association between diet and myopia. The nutritional profiles of 24 children between seven and 10 years of age who developed myopia were compared with the nutritional data of 68 10-year-old subjects with perfect eyesight (Optom Vis Sci, 1996; 73: 63843). The results showed that those children who developed myopia had a generally lower intake of many essential nutrients compared with those whose vision remained good. In particular, there were statistically significant differences in total energy intake, protein, fat, vitamins B1, B2 and C, phosphorus, cholesterol and iron from the diet. This demonstrates the importance of the role of metabolism in eye health. If the blood pH (acid-to-alkaline balance) becomes acidic, muscle tone increases, turning the eyes inward, while an alkaline pH will interfere with normal muscle tone, leaving eyes posturing outward and generally fatigued. Blindness and cataracts are linked to diabetes, and reduced night vision is often linked to impaired liver function. Gastrointestinal disorders, such as Candida overgrowth and parasitic infestation, can also contribute to poor vision by interfering with the normal assimilation of essential proteins, vitamins and other nutrients.
Educational eye strain

The role of the environment is also important. Other reviews have concluded that the increasing prevalence of myopia among children and young people is related to the stressboth physiological and psychologicalplaced on them by the educational system. Long hours of close work force the eye to strain unnaturally when focusing on objects farther away (Tidsskr Nor Laegeforen, 1991; 73: 36357; Gig Sanit, 1996; 24: 1922). One Japanese study found that there was also a strong relationship between failing eyesight and the sitting posture adopted by young students during study. It concluded that myopia is strongly associated with a short view29
ing distance and increased neck flexion (Nippon Ganka Gakkai Zasshi, 1997; These data are, of course, also relevant for adults who work or study under similarly unfavourable conditions. What has received less research attention is the subject of electromagnetic fields (EMFs) and eye damage. Ann Silk is a retired optician and member of the Royal Society of Medicine who has made a special study of the effects of EMFs on eye function. Her findings were published in a twopart series in the Journal of Electromagnetic Hazard and Therapy (1998, 8: 1011; 1998; 9: 89). Ms Silk confirms through her research that EMFs can cause eye damage both directly and indirectly. For instance, low-level microwavessuch as those found in everyday communications equipmenthave been shown to cause direct damage to the retina, iris and macula. She also reports that dopamine loss, which can be triggered by external electrical fields, can lead to blurred vision. Dopamine is a hormone essential for the development and maintenance of the health of the eye. According to conventional wisdom, reduced night vision comes with age, or with wearing certain types of corrective lenses. However, according to Ms Silk, Reduced night vision, or night myopia, can have a nutritional cause, usually a zinc deficiency. But it can also be caused by sitting in a magnetic field all day. Research into indirect causes of eye damage has proved more challenging to obtain. But researchers in Tokyo have investigated the growth of both Escherichia coli and Bacillus subtilis bacterial species in a stronger-thannormal magnetic field. Their findings indicated that not only was bacterial growth gre a t e r, but also the bacterial cell death rate was inhibited. Research at the University of California at Los Angeles in the US has also shown that fungi proliferate in electromagnetic fields. The polymers used in the manufacture of contact lenses can also be affected by emissions from VDUs such as computer screens. Ongoing studies quoted by Ms Silk have shown that lenses can develop minute holes which can irritate and affect the health of the eye. Now is the time to sit back and watch as many of those who have had laser eye surgery within the last 10 years approach the point when longterm adverse effects may begin to reveal themselves.
101: 3939).
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Perhaps the point is to address the underlying causes of eye problems, such as nutrition, before leaping to cover up the symptoms.
Preventing myopia
Myopia may be linked to an increased intake of refined carbohydrates, according to a study carried out on huntergatherer societies and on recently Westernised huntergatherer groups (Acta Ophthalmol Scand, 2002; 80: 12535). The researchers speculate that, when huntergatherer societies change their lifestyles, and introduce grains and carbohydrates into their diet, they rapidly develop nearsightedness rates that equal or exceed those seen in Western societies. Children who develop myopia by the age of 10 have a diet that is lower in energy intake, protein, fat, vitamins B1, B2 and C, phosphorus, iron and cholesterol (Optom Vis Sci, 1996; 73: 63843). A further hypothesis linking diet to the development of myopia comes f rom ophthalmologist William Jory (bmj.com/cgi/eletters/324/7347/ 1195#22422). He bases his work on his own studies done in North West British Columbia on teenagers, contrasting both their high prevalence of myopia and greater height with their better-sighted, stockier parents. He suggests that this increase in long-bone measurement happened along with an increase in the axial length of the eye, causing myopia, and both were due to a sudden change of diet from high-protein meat and fish to a high-carbohydrate Western-style diet in a single generation. It was noteworthy, he says, that the further these tribes lived from a Western-style fast-food outlet, the lower the incidence of nearsightedness. Wearing rigid, gas-permeable contact lenses may slow the development of myopia. Several studies have indicated that children given this type of contact lens benefit from a slowing of the expected progression of shortsightedness. However, a major three-year trial, the CLAMP study, carried out by scientists at Ohio State University College of Optometry showed that, although myopia progressed more slowly, their results did not indicate that rigid gas-permeable lenses should be prescribed solely for myopia control (Arch Ophthalmol, 2004; 122: 17606). There are claims that eye exercisesand there are a number of different
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typescan improve nearsightedness, but there are no clinical trials showing any clear benefit. Perhaps the most famous of these is the Bates method, developed in the 1920s by American oculist William Bates and brought to the public by writer Aldous Huxley in his much-reprinted 1942 book on the Bates method, The Art of Seeing (Flamingo Modern Classics, 1994; see also Chapter 7, page 87). There is a growing interest in the impact of nutritional and lifestyle factors on eye health in general. The US Age-Related Eye Disease Study (AREDS) is an important ongoing study that may teach us a lot about ways of preventing and treating the progression of eyesight problems in older people. So far, significant benefits have been seen in the field of age-related macular degeneration (AMD), which leads to a progressive loss of sight. Nutrients included the antioxidant vitamins E, C and betacarotene, and zinc with copper. In the AMD trial groups, those at high risk of developing advanced AMD lowered their risk by about 25 per cent when treated with megadoses of antioxidants combined with minerals (Can J Ophthalmol, 2003; 38: 2732; Arch Ophthalmol, 2001; 119: 141736; Insight, 2002; 27: 57; see also Chapter 5, page 73).
Preventing farsightedness in the ageing eye

There are two types of farsightedness: hyperopia and presbyopia. Hyperopia, where the eye is shorter than usual, is a condition youre born with, but which gets worse over time. Presbyopia is where eye muscles become rigid and the eye lens is less able to focus. This is usually noticeable around age 40, when many people find they are unable to focus sharply on close objects. Medicine has no prevention or treatment for presbyopia other than various types of corrective lenses. As the condition progresses, many end up with two sets of glassesone for up-close work and one for seeing farther away. However, a technique called conductive keratoplasty (CK) uses radiowaves to create a constricting band of collagen around the eye to increase corneal curvature, bringing near-vision back into focus. Known as monovision, it is only done on one eye, so the other eye can focus on the distance. Optometry can do the same thing with different fixed lenses, but its a compromise, not a cure. There are various things you can do to slow the progression of presbyopia
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and perhaps even improve vision. Eat well. A diet that includes green leafy vegetables and grains will lower your likelihood of eye diseases such as AMD and cataracts. Adequate protein is also important as the eyes require all the essential amino acids. Take regular aerobic exercise, which encourages circulation and, thus, the transport of nutrients to your eyes. Avoid long hours focused on a computer screen. Take frequent breaks to allow your eyes to focus naturally on faraway objects, and work under adequate, but not glaring, light. Clean eyes twice a day with cool, clean water. Try Shiatsu or acupressure, and learn which acupoints can help to maintain good vision and eye health. Avoid environmental toxins, like pesticides, which can damage the eye (Invest Ophthalmol Vis Sci, 1981; 21: 70013). Likewise, take care when using shampoos and hair dyes, which can harm delicate eye tissues (Am J Optom Physiol Opt, 1982; 59: 10024). Manage chronic stress, linked to eye diseases like glaucoma, with biofeedback, meditation, yoga or tai chi. Avoid corrective lenses if you dont need them as they may worsen vision over time (Ophthalmic Physiol Opt, 2003; 23: 1320). Wear sunglasses as excessive exposure to heat and light can prematurely age the eye (Dev Ophthalmol, 2002; 35: 4059). Do eye exercises. Visit www.visionworksusa.com for free general eye exercises; or try the Bates method (Bates WH. Better Eye-sight Without Glasses, NY: Owl Books, 1981; www.seeing.org). Supplement with antioxidants (vitamins A, C and E) and 20 mg of lutein plus 1 mg of zeaxanthin daily, free-radical scavengers in the retina. Vinpocetine (periwinkle) 510 mg/day improves blood circulation to the eye.
Improving your sight
Increase antioxidants. Increasing your nutritional supplementation is important for good vision (Prog Food Nutri Sci, 1987; 10: 3955). Aim for excellent supplements that include vitamins A as well as B1, B2, B6 and B12, vitamin C (up to 3 g), high doses of vitamin D2, vitamin E and selenium, nicotinic acid, folic acid, para-aminobenzoic acid, calcium,
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choline and inositol, magnesium and potassium. Change your diet. The late ophthalmologist Stanley Evans recommended a high-protein diet with a minimum daily intake of 7080 g of goodquality protein in the form of milk, eggs and other high-protein foods (Evans SC. Help for Progressive Myopes. Teecoll Publications, 1990). While carrots are a useful source of beta-carotene, green vegetables may provide even more protection. In one study, a high intake of green vegetables reduced the risk of AMD (JAMA, 1994; 272: 141320). This has been confirmed by research which found that the foods richest in lutein and zeaxanthin, vital vision-saving substances, include kiwi, seedless grapes, celery, cucumber, pumpkin, spinach, butternut squash, courgettes, yellow squash, orange and green peppers, egg yolk, honeydew melon and corn (Br J Ophthalmol, 1998; 82: 90710). Avoid aspartame. While research is thin on the ground, some believe that a high consumption of aspartame-sweetened foods can contribute to eye problems. The sweeteners reported eyesight-related side-effects include decreased vision, blurring, bright flashes, tunnel-vision, black spots, double-vision, pain, dry eyes and even retinal detachment. (For more information, read Aspartame (NutraSweet): Is It Safe? [Philadelphia: Charles Press, 1990] or Sweetner Dearest: Bittersweet Vignettes About Aspartame (NutraSweet) [Florida: Sunshine Sentinel Press, 1992] by H.J. Roberts). Herbs. A single dose (200 mg) of Vaccinium myrtillus extract (VME), from bilberry or European blueberry, was shown to bring about measurable improvements (via electro retinography) in patients with myopia and glaucoma. Another study with VME at 400 mg/day with 20 mg/day of betacarotene found improved adaptation to light and night vision as well as enlargement of the visual field (Ann Oftalmol Clin Ocul, 1965; 91: 37186). Other studies show that VME combined with vitamin E can improve myopia (Klin Monatsbl Augenheilkd, 1977; 171: 6169). Pycnogenols (PCG), which contain vitamin C-like bioflavonoid nutrients, is made from the leaves of the hazelnut bush, the bract of the lime tree and the bark of the maritime pine tree or grape seed (Vitis vinifera). PCG at 150300 mg/day can significantly improve vision in the dark
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and after glare (J Fr Ophthalmol, 1988; 11: 45260; Bull Soc Ophthalmol Fr, 1988;
88: 1734, 1779).
In another small study, 85.7 per cent of myopic patients taking Vitis vinifera grape seed experienced significant improvementand 40 per cent showed remarkable improvementas determined by retinal measurements (Ann Aft Clin Ocul, 1988; 114: 8593). Rule out chemicals and other toxins. Heavy-metal poisoning may contribute to visual problems, as can household toxins and pollutants. The link between chemicals and eyesight was publicised in the medical press in the 1990s when the fashion for foam parties led to several eyesight problems (N Engl J Med, 1996; 334: 474). The foam used was alkaline and probably not far removed from the kind of chemicals and detergents used in the average home.
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Cataracts
he conventional wisdom among ophthalmologists tells us that, if you live long enough, you will get cataracts. Eye doctors believe that this clouding of the lens is an inevitable part of ageing, and that surgical removal of the lens is the only solution for regaining your sight. If your cataract is at such an advanced stage that it obstructs your vision and significantly impacts on your quality of life, cataract surgery may be the only solution. However, what many doctors dont tell you is that it is possible to prevent early developing cataracts from getting worse and, if caught soon enough, it can even be reversed.
What are cataracts?

Cataracts are described according to the site of the opacity. A nuclear cataract, commonly associated with ageing, affects the centre of the lens and causes a gradual loss in distance vision. A cortical cataract develops from the cortex, or outside, of the lens towards the centre. These have little initial effect on vision but, as they grow towards the centre of the lens, light may be seen surrounding objects, especially shiny ones. Posterior subcapsular cataracts typically start near the centre of the lens and tend to advance rapidly, causing major vision loss within months.
What doctors tell you

Up to some 15 years ago, cataract surgery involved making a small (1112 mm) cut into the lens to remove the cloudy nucleus. A clear artificial lens an intraocular lens (IOL)was then inserted and the incision sutured. This has now been replaced by phacoemulsification, in which a special probe uses high-frequency ultrasonic waves to break up the lens into fragments, which are simultaneously vacuumed away through the hollow
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probe. This technique involves a much smaller incision (23 mm) and no stitches are required. Healing is also much faster, with patients regaining clear vision after only a day or two. Given these technological advances, cataract surgery is now thought to have low complication rates and better outcomes. This has led to many patients being operated on earlier than before, as there is no longer any need to wait for the cataract to ripen as they would have done in the past.
What doctors dont tell you

Nevertheless, no matter how much the technology moves on, there is still room for error. Although the new-generation phaco systems can improve the outcome of cataract surgery, high levels of skill and concentration are required to use these tools. And surgeons, being only human, can still sometimes make mistakes. Phaco surgery is an unforgiving procedure because each step relies on the success of the previous one, says David Spalton, a consultant ophthalmologist at St Thomas Hospital in London. One badly performed incision at the start of the operation, for example, can make the whole procedure much more difficult and, indeed, jeopardise the whole operation, he continued (Optometry Today, 2001, Sept 7: 2833). Among the various complications that can arise during cataract surgery, one of the most serious is posterior capsular rupture (PCR), whereby the bag-like capsule that surrounds the lens is inadvertently torn. Although the incidence of PCR is considered to be a low 34 per cent, the consequences can be serious. Patients who sustain a capsular tear during surgery are more likely to go on to suffer further complications such as retinal detachment, significant macular oedema, increased pressure within the eye and difficulties in positioning (centring) the artifical lens (Ophthalmic Surg Lasers Imaging, 2004; 35: 21924). These problems, in turn, can lead to a marked reduction in eyesight. According to a study by a team of ophthalmologists at Londons Moorfields Eye Hospital, eyes that suffered PCR were nearly four times more likely to be below average in visual acuity (Br J Ophthalmol, 2001; 85: 2224). Another complication seen with phacoemulsificationespecially when older-generation machines are usedis burns wounds to the cornea. The
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3 Cataracts
high-frequency ultrasound beam has to be concentrated to break up the cataract, but the downside of this is that the energy generates a lot of heat and, if the surgeon is not careful, this heat can cause thermal injury to the cornea, resulting in visual distortions, or astigmatism. Another well-known postoperative complication is posterior capsular opacification (PCO), also known as a secondary cataract. This happens in approximately 20 per cent of patients within the first five years following cataract surgery. PCO is caused by cells accumulating on the backside of the lens capsule, which then becomes increasingly cloudy and begins to interfere with eyesight in the same way as the original cataract did. To get rid of this secondary cataract requires laser eye surgery, a procedure that, in itself, opens up a gateway to yet another set of problems.
Types of cataract
According to the late Stanley Evans, an ophthalmologist who cured many eye problems such as glaucoma and cataracts using a nutritional approach, of the number of different types of cataract, the one most commonly seen in the US is known as senile cataract. This usually begins after the age of 50, and is usually regarded as a normal consequence of ageing (comparable to having gray hair). Other forms of cataract are caused by metabolic disorders such as diabetes, or by outside influences such as toxins, trauma, radiation, prescription and over-the-counter medications, alcohol and tobacco. Some types of cataract are caused by orthodox methods of treating eye disorders. For example, pilocarpine drops, which are used for glaucoma, can cause cataracts. This has been known for many years. Also, a study in the British Medical Journal (July 2, 1994), reported a case of steroid-induced glaucoma and cataracts (with irreversible visual loss) following prolonged, unsupervised use of topical steroid eyedrops. The modern use of laser beams for different eye disorders is another hazard which can cause changes in the lens cells and precipitate cataract development, rendering the eye virtually useless. Congenital cataract is rare in developed countries, but common in the developing countries. It is present at birth, and is caused by either malnutrition and/or drugs, alcohol and smoking during pre g n a n c y.
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Nevertheless, the senile cataract of the developed countries is indistinguishable from the majority of cataracts caused by malnutrition and nutritional deficiency in developing countries. The exceptions demonstrate that, although age may be a factor in the onset of cataract, it is evidently not the root cause. Many people at 90 are free of these eye disorders.
Exposure to ultraviolet rays

Our daily exposure to ultraviolet (UV) radiation from the sun appears to be a cause of cataract. Studies conducted with animals have shown that prolonged exposure to UV light can damage the lens and retina of the eye (Shulman J. Cataracts: The Complete GuideFrom Diagnosis to Recovery for Patients and Families. Simon & Schuster, 1984). Other studies show that people with the greatest exposure to UV rays, those who live in sunny areas or who work outdoors, have a greatest risk of developing cataract (Executive Healths Good Health Report, May 1995). Excessive sunbathing, or exposure to UV rays reflected from surrounding objects such as road surfaces, buildings, sand and watereven when you are in the shadecan also increase the risk of cataract, even when wearing sunglasses. And as the ozone layer becomes more and more depleted, we are exposed to even more UV rays every day. The US Environmental Protection Agency (EPA) estimates there will be 4.5 million additional cases of cataract in people born in the US by 2031 (BMJ, November 23, 1991). Daily exposure to UV rays increases the amount of free radicals in the eyes and triples the amount of hydrogen peroxide in the aqueous humourthe fluid occupying the anterior chamber of the eye and the essential vehicle of nourishment to all of the eyes transparent components. If the quality of this fluid is impaired, less nutrients will reach the lens and the transparency of the optical structures will decrease. Our eyes are built with an antioxidant defence system to protect it against the free radicals caused by oxidation and UV exposure. According to researchers, the primary antioxidants used by the eyes are vitamin C, vitamin E, vitamin A and beta-carotene, glutathione and various minerals (Better Nutrition for Todays Living, August 1995; BMJ, 1992; 305: 13924; Archives of
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3 Cataracts
Ophthalmology, February 1991).
However, for some reason in some people, this defence mechanism is not doing its job.
How to prevent or delay cataracts

Several factors contribute to cataract formation, including physiological factors (such as age), medications (such as steroids and gout drugs), illnesses (such as diabetes, heart disease and hypothyroidism), and lifestyle and environmental factors (including smoking, obesity, UV and heavymetal exposure). Here are some tips to help you stave off cataracts for as long as possible: Stop smoking. Men who smoke over 20 cigarettes a day had the highest risk of developing cataracts, and even previously heavy smokers who had given up still ran a greater risk of cataracts (JAMA, 1992; 268: 98993). Its thought that the cadmium in cigarettes accumulates in the lens, and may enhance the accumulation of harmful lead and copper in the eye (Br J Ophthalmol, 1998; 82: 1868). Sport those sunglasses. Japanese researchers reviewing studies done in Japan as well as in Iceland, Australia and Singapore found that those who had the highest levels of sun exposure also had the greatest incidence of cataracts (Invest Ophthalmol Vis Sci, 2003; 44: 42104). Reduce/eliminate heavy-metal exposure. Long-term, low-level exposure to toxic metalsin particular, leadresults in its accumulation in the lens. Such a buildup increases the oxidative burden in the lens, leading to cataracts (JAMA, 2004; 292: 27504). Lose weight. Researchers at Harvard University discovered that people with a body mass index (BMI) of 30 or more increased their risk of cataract by at least a third compared with those who had a BMI of 23 or less (Int J Obes Relat Metab Disord, 2002; 26: 158895). Another study showed that its not just the weight that counts, but how the fat is distributed. Those whose fat is concentrated around the abdomen (central obesity) are more likely to develop cataracts (Am J Clin Nutr, 2000; 72: 1495502). Build up your antioxidants. The factors already mentioned underscore the importance of maintaining a good antioxidant status in your eyes. Cataract-busting nutrients include:
41
vitamin A and carotenes. Researchers looking at the 12-year food intake of over 77,000 nurses found that those who had more lutein and zeaxanthin in their diets had a 22 per cent lower risk of cataracts (Am J Clin Nutr, 1999; 70: 50916). Take 30,000180,000 IU/day of vitamin A depending on cataract severity vitamin C. A potent antioxidant, this vitamin also increases the levels and activity of glutathione (GSH), a polypeptide synthesised in the lens that is crucial for maintaining antioxidants in the eye. One studyalbeit in chicks and, thus, not necessarily applicable to humansfound that vitamin C slowed the decline of GSH levels (Exp Eye Res, 1985; 40: 44551). Take at least 2000 mg/day of vitamin C vitamin E. There is a link between low levels of vitamin E and an increased risk of cataracts. In patients with early-stage cataracts, 100 mg of vitamin E twice daily significantly decreased cataract size, and increased levels of GSH compared with a placebo (Ann Nutr Metab, 1999; 43: 2869). Take 100450 IU/day of vitamin E B vitamins. Folic acid is important for the production and maintenance of new cells. An Italian study found that those who consumed more folic acid were less than half as likely to develop cataracts compared with those who were deficient in this watersoluble form of vitamin B (Ann Epidemiol, 1996; 6: 416). Take 400 or 800 mcg/day of folic acid selenium. A deficiency of this trace mineral is seen in the eyes of people with cataracts, indicating a defective antioxidant system leading to lens changes (Acta Ophthalmol Scand, 1995; 73: 32932). Take 600 mcg/day of this mineral riboflavin. This B vitamin (B2) is essential for GSH function. One laboratory study found that adding flavin adenine dinucleotide (FAD), a riboflavin derivative, to surgically removed cataracts restored GSH activity (Curr Eye Res, 1987; 6: 124956). As B vitamins tend to work together, take B-complex supplements, which usually contain either 50 or 100 mg of riboflavin bilberry (Vaccinum myrtillus). Traditionally used for various eye conditions, this herb contains anthocyanosides, potent antioxidants that are particularly beneficial to the eye and blood vessels.
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3 Cataracts
In one Italian study, a four-month course of bilberry and vitamin E halted the progression of cataracts in 96 per cent of the study patients (Ann Ottalmol Clin Ocul, 1989; 115: 109). Take one to two 60-mg (standardised to 25 per cent anthocyanosides) bilberry capsules three times a day.
Nutritional help
Proper nutrition is the key to maintaining a healthy amount of antioxidants in the lens. The late Stanley Evans studied the connection between nutrition and vision for around half a century. He developed his nutritional approach to treating vision problems in Britain in the 1940s, and then spent 17 years in Nigeria on an extended research programme into the causes and prevention of blindness. He made the connection between many eye disorders and nutritional deficiency and, after studying which nutrients affected which parts of the eye, he developed a dietary therapy that has helped thousands of cataract patients. Mr Evans work in Africa demonstrated that cataract is essentially a nutritional disorder. In the developed countries, a persons nutritional status is reduced by changes in metabolism caused by ageing, which is still further compromised by exposure to UV rays and, in many cases, alcohol, careless eating habits, smoking and stress brought on by illness or prescription drugs. But if the patient improves his diet and maintains a good nutritional status, similar to the treatment used for vision problems in developing countries, Evans research confirms that cataract isnt likely to develop. He even found that, in many cases when cataract does develop, a proper diet and nutritional intake can arrest its growth. At the onset of cataract, the protein cells of the lens begin to change gradually. As this change progresses, the cells continue to become less clear until vision is lost. If nutritional status is raised before this cycle is complete, according to Evans, the visual acuity can often be restored. As long as the patient maintains this nutritional status, the cataract wont develop further and surgery can be avoided.
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It has been found that patients with cataract have lower levels of vitamin C, vitamin E and beta-carotene than those without cataract. This sparked a series of studies focusing on the effects of specific nutritional supplements for treating cataract. One study showed that supplementing with vitamins C and E helped to reduce the risk by 50 per cent (Am J Clin Nutr, January 1991). A team of Finnish researchers followed a group of men and women, aged 40 to 83, for 15 years. They found that those who had low serum concentrations of vitamins C and E and beta-carotene had an increased risk of developing cataract as they aged (BMJ, 1992; 305: 13924). Another study, published in The Archives of Ophthalmology (February 1991), found that older people who ate a good deal of fruits and vegetables, or took a daily vitamin supplement, were 37 per cent less likely to develop cataracts. Likewise, researchers at Harvard University found that women who ate a diet rich in fruits and vegetables (especially those rich in carotenes) had a 39-per-cent lower risk of developing severe cataracts than those with a low carotene intake (BMJ, August 8, 1992). A study that appeared in The American Journal of Public Health (1994; 84: 78892) found that supplementing with multivitamins can also reduce the risk of cataract.
Vitamins, minerals and enzymes

It is important to realise that the antioxidant vitamins, minerals and enzymes work synergistically. This means that the effectiveness of one of these three nutrients is always dependent on the presence and effectiveness of the other two. Dr Leslie H. Salov provides a good description of the relationships between the various antioxidants in the eyes in their book Hidden Secrets for Better Vision (Fischer Publishing Corp, 1995). As he explains, too much light can destroy vitamin C; however, the polypeptide glutathione helps to reactivate vitamin C. Similarly, riboflavin (vitamin B2) is a key factor in the production of glutathione reductase, an enzyme that activates glutathione. Vitamin E and selenium are also essential in the production of glutathione. A deficiency
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3 Cataracts
in any of these antioxidants will result in the failure of another.
Vitamin A and beta-carotene

Vitamin A is facilitated by the essential mineral zinc. The transparency of the cornea is dependent on adequate supplies of this vitamin. A deficiency can lead to difficulty in adjusting to changes in lighting, degeneration of the mucous membranes of the eye, drying of the cornea and, ultimately, degeneration of the delicate cells of the eyefirst seen as clouding of the lens, followed by ulceration and complete lens destruction. A deficiency in zinc, the symptoms of which resemble vitamin A deficiency (such as night-blindness), could lead to a deficiency of vitamin A. Other important nutrients that work in conjunction with vitamin A include vitamin C and the B-complex vitamins ( Health News & Review, Summer 1992). Beta-carotene is normally converted into vitamin A in the body. However, it also, in itself, acts as an antioxidant. Studies have shown that low levels of beta-carotene also increase a persons risk of developing cataract (Nutrition Research Newsletter, March 1993; JAMA, March 3, 1993).
Vitamin C
Not only is vitamin C essential as an antioxidant, but it is also vital to the crystalline lens and the normal growth of the lens fibres. It has been shown that low levels of vitamin C indicate an increased risk of developing cataract (American Journal of Clinical Nutrition, January 1991; Nutrition Research Newsletter, March 1993). An animal study by cataract authority Dr Shambhu D. Varma, of the Department of Ophthalmology at the University of Maryland Medical School, showed that rat lenses that had lost transparency as a result of exposure to free radicals were protected by the same free radicals when fortified with vitamin C (Lens Research 2, 198485). Canadian researchers found that subjects who did not supplement with vitamin C increased their risk fourfold (Nutrition Research Newsletter, March 1993).
Glutathione
Many researchers agree that glutathione is the primary defence mecha45
nism of the eye (Ophthalmic Res, 1986; 18: 23642). One researcher, Dr William B. Rathbun, of the University of Minnesota School of Medicine, has been studying glutathione for over 25 years. Dr Rathbun claims that glutathione, a peptide containing the amino-acid cysteine, is in short supply in most people. He believes that the best way to ensure proper amounts is to get enough vitamin C, vitamin E and selenium. Glutathione is normally found in high concentrations in the cornea and lens of the eye. As pointed out earlier, researchers believe that one reason for the development of cataracts is a riboflavin deficiency, as glutathione, found in short supply in cataract, is dependent on riboflavin (Better Nutrition for Todays Living, August 1995). According to Dr Eric R. Braverman in the book The Healing Nutrients Within (Keats Publishing, 1997), glutathione reductase was reduced by 25 per cent in the lens of animals with cataracts due to a riboflavin deficiency. Vitamin E is another nutrient that plays a significant role in the effectiveness of glutathione (Townsend Letter for Doctors, June 1995).
Early detection
The responsibility to notify the patient immediately as soon as a change in the lens is first discovered rests squarely on the practitioner, so that the patient has the opportunity to seek help from a nutritionist. The prejudice with which most eye doctors view nutritional therapy robs the patient of the opportunity of obtaining help, so that he is finally obliged to accept the surgeons knife as the only solution. When you are having your eyes examined, always ask your doctor whether cataract development has commenced or whether there are any signs that it might develop. If he doesnt answer your questions satisfactorily, be insistent. If a cataract has started to develop, instead of waiting for it to be ripe enough for surgery, seek ophthalmic nutritional therapy at once, since more help can be given in the early stages. The first thing to do is to stop smoking and abstain from alcohol. If you have been prescribed drugs for any condition, find out if they are likely to cause cataract. If so, ask your doctor to change the drug. Cortisone and other steroids are common culprits. A good doctor familiar with ophthalmic nutritional therapy should
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3 Cataracts
examine you for evidence of ocular suppression or abnormality. Your diet will also be analysed and corrected when necessary. Your eyes will also be photographed and tested for intraocular tension.
The Evans treatment for cataracts

Heres the nutritional regimen Mr Evans recommended for cataracts, based on his work in Africa. For any patient with cataract, supplements should include the following: Protein, in the form of milk and/or powdered milk or egg products, or other high-protein foods. The patients diet should also be assessed and adjusted to increase protein intake. A minimum intake in cases of eye disorder is 7080 g/day Dextrose or glucose, essential to maintain the transparency of the crystalline lens. Take at least 915 g/day Vitamin A, 30,000180,000 IU/day, according to the eye condition being treated Vitamin B1, 515 mg/day Vitamin B2, 412 mg/day Vitamin B6, 412 mg/day Vitamin B12, 0.10.5 mg/day Vitamin C, 4003800 mg/day Vitamin D2, 3003000 IU/day Vitamin E, 100450 IU/day Vitamin K, essential for normal circulatory function; a deficiency renders the patient susceptible to haemorrhage. Besides ensuring a much higher rate of success in eye surgery, this vitamin also assists in controlling any possible hemorrhage Nicotinic acid, 1545 mg three times daily Folic acid, 26 mg/day Para-aminobenzoic acid, 1030 mg/day Calcium pantothenate, 1030 mg/day Calcium lactate, 250750 mg/day Choline, 250750 mg/day Inositol, 250750 mg/day Magnesium, essential for normal muscle and nerve control, 35100 mg/day Potassium, 35100 mg/day
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Iron and other minerals shown to be necessary to the patient.
The success stories

Here are a few examples out of the hundreds of patients in Britain and Africa successfully treated with the late Mr Evans nutritional therapy. A 55-year-old woman had vision in the right eye that was 60 per cent of normal. She was only able to count fingers with the left eye. The ophthalmoscope revealed a central opacity in the right eye, while the left eye was totally clouded. After one month of nutritional therapy, the vision in the right eye had improved to 150 per cent of normal (still abnormal, but much improved), while vision in the left eye had improved to 15 per cent of normal. The media in the right eye was completely clear. Cataract had begun to develop in a 32-year-old man three weeks before being seen by Mr Evans. The vision in his right eye had fallen to 20 per cent of normal, while the sight in the left eye was 200 per cent of normal. The right eye was milky, as is so often the case with rapidly developing cataract. After four weeks of nutritional therapy, the vision in the right eye had improved to 100 per cent of normal. The ophthalmoscope revealed that the media in the right eye was reasonably clear. A little girl, aged nine, had cataracts that had developed three weeks before she was seen by Mr Evans. The child was very underfed. The parent had taken her to the chemist because the pupil of the right eye was white, for which the chemist gave her antibiotics. After using the antibiotics for three weeks, and finding that the whiteness was getting worse, the mother took the child to Mr Evans eye centre. The antibiotics no doubt further reduced an already low nutritional state. The sight in the right eye was so bad that the child could perceive only hand movements, while the left eye had perfect sight. The ophthalmoscope revealed a full-aperture, milky cataract in the right eye. After four weeks of nutrition therapy, the childs vision had improved to 16.7 per cent of normal. The refraction of the eye was also improved and brought the eyesight up to normal. This case demonstrates how nutritional deficiency is often the sole
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3 Cataracts
cause of cataract, even in children, and that, once a cataract has been sorted out nutritionally, there may also be a marked reduction of myopia. This also suggests that a basic flattening of the lens is the result of malnutrition. A 60-year-old man could only count fingers with his right eye, while his left eye had vision that 10 per cent of normal. A full-aperture cataract covered each eye. Two weeks of nutritional therapy raised the visual acuity in the right eye to 20 per cent of normal and to 30 per cent of normal in the left eye. An 80-year-old man with a full-aperture cataract in each eye and eyesight that was 10 per cent of normal came to Mr Evans for nutritional therapy. Within two weeks, the patients vision improved to 50 per cent of normal. According to Jane Heimlich in What Your Doctor Wont Tell You, two eye specialists in the United States have had similar results. The late Gary Price Todd, ophthalmologist and author of Nutrition, Health and Disease (Norfolk and Vi rginia Beach, VA: The Donning Company, 1985), stumbled on his nutritional approach. His story is similar to Evans. While doing research in Ethiopia, he discovered that eye disease was common in children, and blindness endemic in people over 40; he also made the connection with their obviously deficient diet. After experimenting with various supplements in his private practice in Waynesville, North Carolina, Todd came up with this approach. A hair analysis is done on the patient to determine whether there is heavy-metal poisoning (true in one-third of all patients) or any mineral deficiencies. If so, minerals are prescribed to cover any deficiencies, plus supplements that include beta-carotene (a form of vitamin A), vitamin E (400 IU) bioflavonoids, B-complex vitamins and the enzyme glutathione, considered by some researchers to prevent oxidation of the lens (a natural occurrence that accelerates with age). Todd claimed that 51 per cent of his patients no longer needed surgery and, according to a two-year study of 50 patients, 88 per cent had improved their eyesight with his treatment regime. Of 18 blind patients, 54 per cent had their sight restored. Sadly, he was also hounded by the American Academy of
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Ophthalmology and the North Carolina Board of Medical Examiners, which attempted (unsuccessfully) to revoke his medical licence. Dr Stuart Kemeny is an eye, ear, nose and throat specialist, with training in ophthalmology. Kemenys treatment regimen includes a multivitamin/ mineral supplement containing glutathione, ultraviolet light-absorbing glasses, eyedrops containing glutathione and phenoxazine carboxylic acid, plus an extra 400 IU of vitamin E two or three times a day (but only once a day if you have high blood pressure), 100 mcg of selenium twice a day, 500 mg of vitamin C with bioflavonoids two or three times a day, 100 mg of vitamin B (unless you have cancer) and 30,000 IU of vitamin A with zinc. His first clinical study in 1980 showed that 54 per cent of the patients had improved their vision and, two years later, 85 per cent of them had done so.
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Glaucoma
ust as we are advised to watch our blood pressure as we get older, the pressure within our eyes is equally at risk with advancing years. Changes in the ageing eye can lead to less-effective drainage of the clear fluid (aqueous humor) in the eye, resulting in a buildup of intraocular pressure (IOP). A dangerously elevated IOP, or ocular hypertension (OHT), is a major risk factor for glaucoma. The condition is the third-leading cause of blindness in the world. It can strike at any age, but the elderly are particularly susceptible. Current estimates of the incidence of glaucoma are a staggering 100150 million cases worldwide. With our ageing populationincreasing by 50 per cent in the US alone over the next 15 yearsthe numbers are expected to soar dramatically (Arch Ophthalmol, 2004; 122: 5328). Notorious for its lack of symptoms, glaucoma can cause progressive damage to the optic nerve without your realising it. The damage often involves loss of peripheral vision, which is not easily apparent. Its only when your field of vision has been seriously reduced (when patients complain of bumping into things a lot) that the sufferer is likely to finally head off to see a doctor.
What does it do?

Glaucoma causes damage when the eye pressure becomes elevated, due to an obstruction in the flow of the aqueous humor, eventually injuring the optic nerve. The aqueous humor normally maintains a pressure of 1020 mmHg to maintain the shape of the eyeball. If the flow is blocked, the pressure increases. Exactly how the fluid is blocked determines what type of glaucoma you have.
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Primary open-angle glaucoma (chronic glaucoma) is the most common. It is characterised by clogged drainage canals that stop the flow of the aqueous humor. Symptoms of this type of glaucoma usually go undetected because the gradual loss of peripheral vision is not readily apparent to the patient. Primary angle-closure glaucoma (acute glaucoma) is more rare than openangle glaucoma. It occurs when the drainage of the aqueous humor is blocked by the iris pushing against the cornea. This form usually appears suddenly, with symptoms such as a dull, severe, aching pain, blurred vision, nausea and vomiting, and the perception of a rainbow and halo around lights and bright objects. The terminology surrounding glaucoma is somewhat confusing. There are lots of different types and combinations, including: Low-pressure glaucoma, where eye-fluid pressure is normal, or below normal, but the patient experiences loss of side vision. This is now thought to be caused by constricted veins. Ocular hypertension, where the eye-fluid pressure is elevated, but no other signs of glaucoma are evident. Steroid-induced glaucoma, where steroids contribute by helping to impede the eyes drainage canals. Pigmentary glaucoma, where pigment flakes off from the back of the iris and clogs up the drainage canal. This variety of glaucoma was first reported in 1949 and may be induced by physical exercise (Ophthalmology, 1992; 99: 1096103). Pseudoexfoliative glaucoma, where particles flake off from the lens of the eye and are trapped in the drainage canal. This causes eye-fluid pressure to rise. Allergic glaucoma, where the release of histamine clogs up the drainage canal. Optic nerve disease (a secondary condition to toxins such as tobacco or aspartame), where the patient suffers from malnutrition, pernicious anaemia and malabsorption. Glaucoma secondary to inflammation, caused by viral infections or other inflammatory conditions; 28 per cent of patients with herpes eye infections have secondary glaucoma (Glaucoma, 1991; 13: 403).
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4 Glaucoma
Are you at risk?

While symptoms are rare, there are a number of risk factors that doctors consider to determine whether or not you should undergo regular screening tests for glaucoma. The most obvious of these risks is a raised intraocular pressure. If your pressure is above the norm, your doctor may want to consider performing additional tests to evaluate the health of the optic nerve. However, a high pressure reading does not always indicate glaucoma. Also, a normal pressure reading does not mean you dont have glaucoma or that youre not at risk. While there are over 20 types of glaucoma, the term is most often used to describe primary open-angle glaucoma (POAG), or chronic glaucoma, the most common form. Here, the aqueous humorthe nutrient fluid produced by the ciliary body (a small gland in the eye)doesnt drain properly from the eye and into the bloodstream. Pressure then builds up within the eye, resulting in damage to the optic nerve, which has the job of transmitting visual messages to the brain. However, although hypertension in the eyes blood vessels is a key risk factor for glaucoma, not all rises in eye pressure inevitably cause visual damage: in some people, the optic nerve is strong enough to withstand the increased pressure. Equally, those with particularly weak optic nerves can develop glaucoma even if their eye-pressure readings are normal. Who are those most at risk? Anyone can develop glaucoma, but the risk is significantly greater for those over 40, and the risk doubles for those who are aged 7580. It is suggested that age-related changes to various parts of the eye may be responsible for the loss of fluid regulation within the eye. Race is another important factor. In a study funded by the US National Eye Institute, researchers at Johns Hopkins University, in Baltimore, Maryland, found that glaucoma is three to four times more likely in people of Afro-Caribbean origin than in white Europeans, and strikes them at a younger age (Arch Ophthalmol, 2004; 122: 5328). Other high-risk groups include family members of those already diagnosed with the condition, and people who are extremely shortsighted, diabetic or suffering from high blood pressure.
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Glaucoma can also be due to drugs (Drug Saf, 2003; 26: 74967), including: corticosteroids (these mainly cause or worsen POAG) sulpha-based drugs antidepressants anticoagulants antihistamines/antacids (H1-/H2-receptor antagonists). Ironically, drugs such as adrenergic agonists and cholinergics, which are often used to treat glaucoma, can also sometimes bring the condition on. As prevention is always better than cure, those who belong to these high-risk groups should have their eyes regularly checkedthat means going to your opticians for that annual eye testand their eye pressure monitored.
Glaucoma tests
Once your risk has been determined, your doctor needs to decide what tests to perform. This is where the controversy begins. There are a variety of tests and instruments your doctor can use. But there is also a number of questions surrounding their use: Which tests are more accurate? Which are most cost-effective? Are mass screenings necessary and effective? What combination of tests should be used? There are three types of tests to choose from. They are rated according to sensitivity (the higher the sensitivity, the fewer false-negative results) and specificity (the higher the specificity, the fewer the false-positive results). Intraocular-pressure tests Tonometry measures the pressure of the fluid within the eye (intraocular pressure). At one time, tonometry was the only test doctors would conduct. Mass screenings were organised in an attempt to detect as many cases of glaucoma in the early stages as possible while, at the same time, heightening peoples awareness of the serious nature of glaucoma. However, it was soon found that tonometry alone did not have the greatest sensitivity (5070 per cent) nor specificity (only 1030 per cent) (Am J Ophthalmol, December 1995). Doctors then had to consider using tonometry in combination with other tests.
1.
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4 Glaucoma
Visual-field tests These tests measure the total area perceptible while looking straight ahead, including areas beside, below and above the centre line of vision. Most people with glaucoma gradually begin to lose their peripheral vision first. However, this usually goes undetected by the patient until their central line of vision is affected. Some doctors view visual-field tests as impractical because of the need for large, specialised equipment, trained personnel, and 1020 minutes of examination time (Am Fam Phys, December 1995). However, others agree that some form of this test is necessary to overcome the limitations of tonometry. It is also considered cost-effective and accurate (Am J Ophthalmol, December 1995). Optic-nerve tests Examination of the optic nerve using an ophthalmoscope is thought to be one of the most underused tests for glaucoma. The ophthalmoscope can determine changes in the nerve before problems with the visual field are detectable. This has been found to be the most sensitive and cost-effective test for glaucoma (Am Fam Phys, December 1995). Researchers agree that ophthalmoscopy should be mandatory, but not on its own. Routine tonometry and occasional visual-field testing is also suggested (BMJ, March 4, 1995). Tests are being assessed that can determine the retinal function of the eye. These include colour-vision analysis, blue-on-yellow-field-testing, contrast sensitivity, and dark adaptation (Am Fam Phys, December 1995). One study, sponsored by the US National Eye Institute, found no differences among patients treated with eyedrops and those left untreated. The report also claims that no study has used a long-enough follow-up period to establish that drug therapy prevents blindness. At best, the drugs will decrease the amount of optic-nerve damage. The US Preventive Services Task Force does not recommend mass screening for people under 65, and suggests that drugs should only be considered for patients with an intraocular pressure above 35 mmHg (HealthFacts, June 1995).
2.
3.
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Dangers of drug treatments

Drugs are big business in the glaucoma field. The way doctors prescribe eyedrops (sometimes combining two or more types) to glaucoma patients has helped to rake in big profits for the ophthalmic drugs industry. Worldwide sales of medicated eyedrops for glaucoma average USD$3billion each year, and account for almost half of the total ophthalmic pharmaceutical market. Given the predicted rise in glaucoma cases in tandem with the ageing population, that sound you can just about hear is the drug companies rubbing their hands in anticipation. But these seemingly innocuous dropswhich, in most cases, have to be taken for lifecause a laundry list of side-effects, and are often as dangerous to the body as drugs taken by mouth. Miotics such as pilocarpine work by constricting the pupil and stimulating the ciliary muscles to increase the drainage of fluid from the eye. Downside: Because miotics reduce the size of the pupil, a common complaint is blurred or dim vision. This could also artificially induce night-blindness. Also, as these eyedrops need to be administered four times a day, patients may find it difficult to keep track of their regular use as prescribed. Carbonic anhydrase inhibitors are available as eyedrops (Trusopt, Azopt) or in an oral form (Diamox). These agents inhibit the enzyme involved in producing the aqueous humor, thereby decreasing IOP. Downside: Chronic use of these drops can cause an allergic response, with redness and itching of the eye (conjunctiva) as well as scaling on the lower eyelids. When taken orally, the side-effects stretch considerably to include frequent urination, tingling in the fingers/toes, skin rash, gastrointestinal disorders, depression, fatigue, impotence, weight loss and lethargy. Alpha-adrenergic agents (Alphagan, Iopidine) reduce the production of eye fluid while increasing its outflow rate. Downside: The most common side-effects are burning or itching of the eye, browache, headache, a slight raising of the upper lids, dry eye/mouth/nose, light sensitivity, dizziness, mild sedation, fatigue and depression.
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4 Glaucoma
Beta-blockers have been the mainstay of glaucoma treatment following their launch in the late 1970s. They lower eye pressure by reducing aqueous production. Despite their eroding popularity due to the arrival of the newer prostaglandin analogues (see below), these agents are still commonly prescribed for ocular hypertension and glaucoma. Downside: Beta-blockers as eyedrops can cause the same systemic adverse effects as when taken orally. The most common side-effects involving the eye include superficial punctate keratitis (scattered pinpoints of corneal inflammation), corneal numbness and visual disturbances (J Am Optom Assoc, 1985; 56: 10812; Am J Ophthalmol, 1979; 88: 73943). Beta-blockers are either non-specific (targetting both beta-1 and -2 receptors) or specific (targetting either beta-1 or -2 receptors). Nonspecific drops such as timolol (Timoptic, Betimol), levobunolol (Betagen) and carteolol (Ocupress) are generally thought to be more effective in lowering intraocular pressure than specific beta-blockers such as betaxolol (Betoptic). However, the latter comes with fewer systemic side-effects. Beta-blocker eyedrops, as with all other ophthalmic drops, enter the body via tear ducts that connect with the nasal cavity. This enables the drug to bypass the liver and directly enter the bodys circulation. Consequently, a significant amount of drug is absorbeda typical dose (one drop of 0.5 per cent timolol solution in each eye) is as potent as a 10-mg oral dose for treating hypertension and angina (Ophthalmology, 1984; 91: 13613). Its well known that beta-blockers come with an extensive list of side-effectssome of which may be lethal. A review of nearly 550 reports of adverse reactions with timolol, sent to the National Registry for Drug-Induced Ocular Side Effects, found that half of these were linked to systemic reactions affecting the heart, lungs, central nervous system, digestion and skin (Ophthalmology, 1980; 87: 44750). Cardiovascular effects range from arrhythmias (heart-rate disturbances) to full-blown congestive heart failure (Clin Physiol Funct Imaging,
2002; 22: 2718; Acta Anaesthesiol Scand, 1996; 40: 37981; Am J Hosp Pharm, 1981; 38: 699701). Ironically, these drugs, which are supposed to help con-
trol high blood pressure, cause disturbances in blood-fat levels, which

57
could be a risk factor for heart disease. Several studies have shown how beta-blockers alter the ratio of low-density lipoprotein (LDL, the bad cholesterol) to high-density lipoprotein (HDL, the good cholesterol). A study of postmenopausal women with either eye hypertension or glaucoma found that those treated with timolol had significant decreases in HDL cholesterol, while total (and LDL) cholesterols were increased (J Glaucoma, 1999; 8: 38895). Respiratory problems are also a common complication of betablockers, particularly in those with a history of lung disease. One case report described a 67-year-old man with stable chronic obstructive lung disease going into respiratory arrest just 30 minutes after receiving his first dose of timolol (Chest, 1983; 84: 6401). Another report told of a 74-year-old long-term asthmatic who developed a severeand fatal attack of asthma several hours after taking timolol (Nihon Kyobu Shikkan Gakkai Zasshi, 1990; 28: 1569). Nevertheless, drug-induced respiratory side-effects such as breathlessness and increased exercise intolerance are often overlooked or written off by doctors as simply being normal signs of ageing among the elderly (who make up the majority of glaucoma sufferers). Central nervous system side-effects with beta-blockers include depression, psychosis, hallucinations, confusion, fatigue, insomnia and impotence (J Clin Psychopharmacol, 1987; 7: 2647; JAMA, 1986; 255: 378). Prostaglandin analogues such as latanoprost (Xalatan), bimatoprost (Lumigan) and travoprost (Travatan) have toppled beta-blockers off their dominant position in the glaucoma drugs market. They lower eye pressure by increasing the size of the holes in the drainage system, allowing more fluid to flow out of the eye. The popularity of prostaglandins for glaucoma therapy has been attributed to their superior eye-pressure-lowering effects (Br J Ophthalmol, 2004; 88: 13914) and their easy-to-comply-with, once-daily dosing. Downside: All three types of prostaglandins often cause bizarre changes in eye colour and eyelashes. The eyes may darken due to an increase in melanin (the eye-colour pigment) in the iris; there may be darkening of the skin on the eyelids and sometimes under the eyes; and the eyelashes may increase in length and thickness (a benefit).
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4 Glaucoma
Uveitis (inflammation of the nourishing membrane of the eye) is a more serious side-effect commonly seen with latanoprost (Ophthalmology, 1998; 105: 2638). Glaucoma patients with a history of uveitis were most likely to have a flare-up, and a small number of patients with no previous uveitis also developed the condition after using latanoprost eyedrops (Acta Ophthalmol Scand, 1999; 77: 66872). Latanoprost can also reactivate the herpes simplex virus and trigger bouts of herpes simplex-related keratitis (Arch Soc Esp Oftalmol, 2000; 75: 7758; Am J Ophthalmol, 1999; 127: 6024). In these cases, only stopping the latanoprost solved the problem. Prostaglandin eyedrops can also induce macular swelling, especially in people who have undergone cataract surgery (Am J Ophthalmol, 2002; 133: 4035), and they may also cause eye pressure to fall too low, resulting in eye damage due to detachment of the choroid (the thin vascular layer between the whites of the eye and the retina) (Am J Ophthalmol, 2001; 132: 9289). Prostaglandins have been hailed by the medical profession as the best tolerated eyedrops with the fewest systemic side-effects. Nevertheless, latanoprost can cause cardiovascular effects as well as headache and facial rash (J Ocul Pharmacol Ther, 2003; 19: 40515; BMJ, 2001; 323: 783). A case report from Germany described a young patient using a betablockerlatanoprost combination drug treatment to treat his aniridia and glaucoma having to endure heavy sweating over his entire body for up to two hours due to using the drops (Ophthalmologe, 1998; 95: 6334). A study comparing latanoprost with the alpha-adrenergic brimonidine found that nearly half the patients using latanoprost complained of hands and feet that became cold easily (Ophthalmology, 2002; 109: 30714).
Eyedrops in your lenses

In acknowledgement of these drug side-effects, the medical industry is now working on a new generation of treatments for glaucoma as well as for hard-to-treat retinal diseases. These novel ideas include contact lenses that incorporate nanotechnology to deliver drugs directly into the eye. Medicine understands that 95 per cent of the medication administered via eyedrops drains into the nasal cavity and enters the bloodstream
59
hence, the adverse systemic effects. The assumption is that, if a drug can be directed to only go where its needed, then most of the unwanted side-effects will disappear. While this appears to be a valid line of reasoning, there is still the issue of the delivered drugs themselves and their long-term risks. Eyedrops or high-tech contact lensesthey are both just time-bombs in different gift-wrapping.
Corticosteroids
According to the late Stanley Evans, serious damage has been done to the eye by the use of steroid and cortisone drops. In a number of cases, cortisone drops cause the pupil to be fully dilated and paralysed and, so, intolerant to light. The oversized pupil (often in just one eye) is also disfigured. And in some cases, even after the drug had caused the damage, it was still being prescribed. In yet other cases, steroid and cortisone drops have been used to treat eye infections, causing serious corneal ulceration; besides impairment of vision, this also caused disfigurement. The side-effects of these eye drugs have been well documented. In 1975, T.F. Schlaegel reported to the American Academy of Ophthalmology that the use of corticosteroids can cause serious eye disturbances, some of which have caused blindness, including optic-nerve changes, swelling of the optic-nerve head, changes in the crystalline lens and myopia. There have also been reports in various medical journals concerning patients treated with steroids for arthritis developing cataract, and patients using steroids to relieve the discomfort of contact lenses subsequently developing cataract or glaucoma. Other reported side-effects include extensive and irreversible retinal damage, corneal perforation necessitating corneal transplants, an increase in intraocular tension in glaucoma patients, swelling of the optic disc and other eye disturbances.
Surgical approaches to glaucoma treatment

Laser and surgical treatments are available for glaucoma, but these are often aggressive, invasive procedures and, despite advances in technology,
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4 Glaucoma
still second in lineafter drugsas a standard glaucoma treatment, or only reserved for cases where drug therapy has failed. The more commonly available surgical procedures include: argon laser trabeculoplasty (ALT). The most frequently performed laser procedure for open-angle glaucoma, this uses an argon laser to burn 50100 spots in the eyes drainage systemthe trabecular meshwork, the spongy tissue at the front of the eyeto improve eye-fluid flow. The effectiveness of ALT varies but, in general, it controls eye pressure best within the first year of treatment. After that, it becomes less and less effective so that most patients need to either go back to drugs or undergo further laser treatment (Am J Ophthalmol, 1995; 120: 71831). selective laser trabeculoplasty (SLT). This is considered to be gentler than ALT as, instead of creating thermal burns, it targets the melanin pigment in cells of the trabecular meshwork, triggering a cellular reaction that improves fluid drainage. It works as well as ALT, lowering eye pressure in nearly 90 per cent of eyes. And, as SLT is less aggressive, it is more suitable for repeat treatments (Arch Ophthalmol, 2003; 121: 95760). trabeculectomy, or filtrating microsurgery. This is the usual non-laser surgery for glaucoma. It involves removing a piece of tissue from between the sclera (the whites of the eyes) and the trabecular meshwork, thus creating an alternative route for the aqueous fluid to escape. The fluid is then channelled into a reservoir, or bleb, under the eyelid, from where it is eventually absorbed into blood vessels. This has a high success rate (nearly 95 per cent two years after treatment), but still relies on the use of antimetabolites (in the form of eyedrops) to ensure that the bleb doesnt heal and close up. non-penetrating filtrating surgery. This procedure is less invasive than a trabeculectomy as the surgeon only works on the outermost layer of the eye. However, it is trickier to perform, and has a success rate of only 60 per cent (Chin Med J [Engl], 2004; 117: 100610).
Drug-free treatment
A large number of glaucoma cases are the result of nutritional deficien61
cies. For example, it is often due to a weakened antioxidant defense system (Am J Ophthalmol, 2004; 137: 629). One study of patients with advanced-stage glaucoma found significantly reduced amounts of glutathione, an essential component of the cellular antioxidant system, in eye fluid (Vestn Oftalmol, 1992; 108: 135). So, filling the following nutritional gaps in your diet could help to prevent or even treat the condition. Vitamin A and other carotenoids. In countries where malnutrition is widespread, vitamin-A deficiency is linked to blindness. The vitamin is essential for a healthy retina and for strengthening the mucous membranes that surround the eyes. Beta-carotene, a carotenoid that goes to make vitamin A, is also a powerful antioxidant. A Romanian animal study suggests that two other carotenoids, lutein and zeaxanthin, are also important for treating glaucoma, and can reduce damage to retinal nerve cells and the optic nerve (Oftalmologia, 2003; 59: 705). Suggested daily dose: 25,000 IU Vitamin C. In 30 patients with open-angle glaucoma (OAG), highdose vitamin C (an average of 10 g/day) lowered eye pressure in all caseswith no adverse effects (J Orthomol Med, 1995; 10: 165-8). Suggested daily dose: 3000 mg Vitamin E. This and other fat-soluble antioxidants are believed to prevent the eyes drainage system from deteriorating as well as inhibiting cell death (Br J Nutr, 2004; 91: 80929). Suggested daily dose: 500 mg B vitamins. Glaucoma patients are often highly deficient in vitamin B1 (thiamine) (Ann Ophthalmol, 1979; 11: 1095100). In one study, although vitamin B12 (cobalamin) did not lower eye pressure, it did halt visualfield loss for up to five years (Glaucoma, 1992; 14: 16770). Suggested daily dose: 50 mg (vitamins B1, B2 or B6); 50 mcg (vitamin B12) Alpha-lipoic acid (ALA). Supplementing with ALA increased glutathione (antioxidant containing the amino-acid cysteine, needed for cell energy and proper immune function) in the red blood cells of glaucoma patients (Vestn Oftalmol, 1992; 108: 135). In one Russian study of 45 patients with early-stage glaucoma, one group was given 150 mg/ day of ALA for a month, another was given 75 mg/day for two months
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4 Glaucoma
and a third group used only medicated eyedrops. The most improvement in eyesight and in fluid release was seen in the patients taking the highest dose of ALA, despite the shorter treatment time (Vestn Oftalmol, 1995; 111: 68). Omega-3 fatty acids. Glaucoma patients have lower levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) compared with their healthy siblings (Prostaglandins Leukot Essent Fatty Acids, 2006; 74: 157-63), and researchat least in ratsshows that an increased intake of these omega-3 fats can significantly reduce eye pressure (Invest Ophthalmol Vis Sci, 2007; 48: 756-62). Magnesium, zinc and iron. Deficiencies in these minerals are associated with glaucoma (Vestn Oftalmol, 1994; 110: 246). In one study, 121.5 mg of magnesium improved the eyesight of glaucoma patients (Ophthalmologica, 1995; 209: 113). A number of herbal and plant extracts may also benefit glaucoma patients. These include: Ginkgo biloba. This herb can successfully treat glaucoma and even improve damage to the visual field (Ophthalmology, 2003; 110: 35962). It works by enhancing the general blood circulation (J Ocul Pharmacol Ther, 1999; 15: 23340), reducing glaucoma-inducing vasospasm (where blood flow is decreased by a sudden contraction of blood vessel walls) and thinning the blood. Ginkgo also reduces cell toxicity and cell death (Med Hypoth, 2000; 54: 22135). Coleus forskohlii. Forskolin, the active ingredient in this plant, is involved in the production of cyclic adenosine monophosphate (cAMP), which decreases eye-fluid flow, thereby decreasing eye pressure. A number of studies have shown that eyedrops containing forskolin can significantly lower eye pressure for at least five hours. Indeed, in one, it decreased the aqueous flow rate by 34 per cent in healthy human volunteers (Lancet, 1983; i: 95860; Exp Eye Res, 1984; 39: 7459). Salvia miltiorrhiza (danshen). Often used in traditional Chinese medicine, this plants beneficial effects on the microcirculation of retinal nerve cells and the optic nerve have been demonstrated in animals with ocular hypertension (Chin Med J [Engl], 1993; 106: 9227; Zhonghua Yan
63
Ke Za Zhi, 1991; 27: 1748).
In humans, daily injections of a solution (2 g/mL) of this plant, either alone or in combination with other Chinese herbs, led to long-term vision improvements in patients with mid-tolate-stage glaucoma (Chin Med J [Engl]), 1983; 96: 445-7).
Evidence that exercise may help

Regular aerobic exercise has been associated with a reduction in intraocular tension and may represent an alternative treatment to drug therapy. Researchers monitored the intraocular pressure in nine sedentary patients before and after a three-month programme of aerobic exercise. They found that the intraocular pressure decreased at the end of the programme and returned to the elevated pressure within three weeks without conditioning (JAMA, October 23, 1991). So, take plenty of daily exerciseat least 30 minutes of brisk walking each day.
Acupuncture: a last resort

Acupuncture has been used successfully for the treatment of incurable eye disorders (Acupunct Electro Ther Res Int J, 1983; 8: 171255). It has been shown that enkephalins (molecules produced naturally by the central nervous system to numb pain) reduces eye-fluid pressure (Ophthalmol Res, 1993; 25: 105). Various reports suggest that acupuncture may be beneficial (J Trad Chin Med, 1989; 9: 1712), and may be helpful in cases where conventional medicines fail to stop the progressive loss of vision (J Trad Chin Med, 1992; 12: 1426). But acupuncturists are quick to point out that deep nerve stimulus with needles is: . . . not a substitute for conventional methods of treatment. But when every kind of routine treatment has been enhausted, acupuncture may offer some hope to patients (Res Int J, 1985; 10: 7993).
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Age-Related Macular Degeneration
ailing eyesight has become so closely associated with old age that the condition has become known as AMD, or 'age-related macular degeneration'. Around 15 million Americans and four million Britons s u ffer from the pro b l e m w h e re the sharpness of our central vision deterioratesand health experts now fear that AMD will take on epidemic proportions once the babyboomers reach their 60s and 70s. AMD comes in two forms'wet' and 'dry'. The dry type is by far the m o re common. This type occurs when photoreceptors in the central part of the eye, or 'macula', deteriorate and die. In contrast, the wet variety is caused by abnormal blood-vessel growth, which can lead to blood and p rotein leakages, irreversible and rapid vision loss, and even blindness. Also, the dry form can worsen and become wet. Because medicine has associated AMD with the ageing process, it hasn't looked much beyond that for other causes of the condition. This view has also influenced its treatment. Medicine contends that it has nothing to offer the sufferer who has dry AMD, and has only recently begun to o ffer regular injections of anti-angiogenic drugs designed to re v e r s e blood-vessel growth in those with the wet form. However, it's a controversialand painfultreatment, and only one of the drugsLucentis (ranibizumab)is approved in the US for wet AMD treatment. However, doctors are now starting to recommend something called 'photodynamic therapy' (PDT), using the light-activated drug Visudyne (verteporfin), for some forms of wet AMD. The drug is injected into the patient's arm and, after a short wait, a laser beam is shone into the patient's eyes to activate the drug, which is supposed to seal up abnormal blood vessels and destroy any that are leaking. However, PDT has p roved to be less effective than Lucentis injections in a study of 423
65
AMD patients over a two-year period (Ophthalmology, 2009; 116: 57-65.e5).
Possible causes of AMD

While macular degeneration primarily affects older people, there's little evidence to suggest that ageing is, on its own, the major cause of such failing eyesight. AMD affects 10 per cent of people aged up to 74 years and, despite its name, increases to only around a third of those between 75 and 85 years of age (www.agingeye.net/maculardegen/maculardegeninformation.php). Medicine believes that one of its causes could be exposure over the years to direct sunlight and, especially, to blue-spectrum light. Doctors often advise older people to wear sunglasses in direct sunlight to lessen their risk of developing AMD. This advice, however, may have been based on a series of animal studies that did not properly replicate the human experience. In a series of laboratory tests, researchers shone intense ultraviolet light into animals' eyes, which were held open mechanically. Aside from the fact that these studies amounted to extreme animal cruelty, the tests also failed to take account of the blinking reflex and the way that we humans have of avoiding looking directly at the sun. This idea has also been supported by a Cambridge, UK, study of 446 AMD suff e rers that found that direct sunlight is not a cause (Br J Ophthalmology, 2006; 90: 29-32), whereas other studies suggest that, in fact, sunlight is important for good health. Blue light, in particular, helps the body to release melatonin, which protects the heart and the eyes by keeping blood pressure levels low (J Clin Endocrinol Metab, 2003; 88: 4502-5). Another commonly held beliefthat alcohol can cause AMDmay also be mistaken. A major study involving 4439 people living in Beijing and in rural areas of China could find no connection between wine- and beerdrinking, and AMD (Ophthalamology, 2009; August 25, published online ahead of print). Instead, there's growing evidence to suggest that AMD is more likely to be the result of a mineral imbalance that is cumulative and so becomes more apparent as we get older. Low levels of zinc and copper are commonly found in people with AMD, as one study discovered when it analyzed the health profiles of 44 subjects with the condition. On average, the subjects' zinc and copper levels were 24-percent lower than those of the
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5 Age-Related Macular Degeneration
healthy controls. The researchers, from the Mayo Clinic in Rochester, Minnesota, also pointed out that, as shown by other studies where supplements were able to slow the progress of AMD, there appears to be a direct causal link between zinc and copper levels, and failing eyesight (Am J Ophthalmol, 2009; 147: 276-82.e1). On the other hand, iron tends to cluster in the retina, and may also play a role in a broad range of ocular diseases, including AMD (along with glaucoma, cataract and conditions causing intraocular haemorrh a g e ) because of iron-induced ocular oxidative damage (Prog Retin Eye Res, 2007; 26: 649-73). Too much lead can also cause AMD. One study of 25 AMD patients discovered that they all had retinal lead levels that were up to 75 per cent higher than those found in people with healthy eyes ( Am J Ophthalmol, 2009; September 4, published online ahead of print). What's more, new breakthrough research suggests that AMD could be an inflammatory disease brought about by a polymorphism (variation) in the complement factor H (CFH) gene. Researchers from the US National Eye Institute (NEI) and the National Cancer Institute (NCI) reckon that the gene variation could be responsible for half of all cases of AMD. Indeed, people who carry the polymorphism are nearly six times more likely to develop the condition (Science, 2005; 308: 385-9).
The role of fats

A group of researchers from Harvard Medical School and the Harvard School of Public Health set out to determine whether diet had any affect on the development of AMD. They selected 261 participants, aged 60 or older, with early or intermediate AMD and visual acuity of 20/200 in at least one eye. For four-and-a-half years, the researchers studied the participants dietary intake and compared it with the progression of their disease. Specifically, they looked at the amount and type of fat the participants were consuming in their daily diets (Arch Ophthalmol, 2003; 121: 172837). What they found was extraordinary. Those consuming high-fat diets were three times more likely to progress to advanced forms of AMD compared with those whose intake of fat was lowest.
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But the risks relating to the kinds of fats consumed confounded the usual expectations. Although intake of any animal fat was associated with a doubling of risk of the disease, higher levels of animal-fat intake did not increase the risk any further. In other words, you increase your risk of developing AMD by eating flesh foods, but your risk doesnt increase with the quantity of meat that you eat. The real risk for AMD was associated with vegetable-fat intake. Consuming high levels of these types of fats nearly quadrupled the risk of the disease progressing. These fats included the monounsaturated, polyunsaturated and trans unsaturated fats. And in this case, quantity did matter. The more of these you ate, the greater your risk. The researchers also made another connection that is most unusual in these types of studies. They noted a doubling of risk with intake of processed foods, which are usually laden with these types of processed vegetable fats. Other kinds of fats proved protective. Fish and nuts, both rich in omega3 fatty acids, slowed progression of the diseaseso long as your intake of the usual omega-6 fatty acids was also low. Other clues suggest that processed foods lie at the heart of AMD. A survey of more than 4000 people, carried out by re s e a rchers at Tufts University in Boston, MA, concluded that up to 20 per cent of all cases of AMD could have been avoided by a diet lower in processed foods such as white bread, cakes and biscuits (Am J Clin Nutr, 2007; 86: 180-8). Indeed, while the condition is the leading cause of blindness among the American, Canadian and English elderly, it is rare in the developing countries where, nevertheless, there is a high incidence of blindness from other eye diseases such as glaucoma and cataracts. These countries do not consume a highly processed diet.
Link with heart disease

AMD is also a cousin of coronary heart disease, and shares with it several common ancestors, such as atherosclerosis (Am J Epidemiol, 1995; 142: 4049), hypertension (Arch Ophthalmol, 2000, 118: 3518) and high cholesterol. AMD also afflicts nearly 40 per cent of those with diabetes (J Longev, 1998; 4: 246). Many other risk factors for heart problems are also risk factors for
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AMD. These include smoking (especially in women), age (3.8 per cent of Americans have either intermediate or advanced AMD by the time they reach age 5059 and, by the time they are 7079, this proportion will have increased to 14.4 per cent) and gender (women appear to be at a slightly greater risk than men). Increasingly, the evidence points to industrialised food-processing in the onset of heart disease and diabetes. More and more studies of heart patients are finding they have elevated levels of homocysteine, an amino acid derived from the normal breakdown of proteins in the body. Raised levels of this amino acid are an indication that something has gone awry. Crucial to this process is the presence of adequate levels of certain B vitamins. Other studies of heart patients have shown that they are deficient in these vitamins, and that adequate B-vitamin supplementation can reduce the incidence of heart attack and angina ( Res Commun Mol Path Pharm, 1995; 89: 20820). Links have also been made between the onset of diabetes and heart disease and deficiencies of chromium. Natural sugars and grains contain adequate concentrations of chromium to support the metabolism of high-carbohydrate foods. However, virtually all B vitamins and chromium are removed during the refining process of most of the sugars and processed foods that now make up the bulk of the typical Western diet. Diets high in processed carbohydrates are nearly always deficient in chromium.
Aspirin accelerates the damage

Another area that medicine has never explored is its own hand in the development of the AMD epidemic. Many of the drugs routinely prescribed for older people may well accelerate eye damage. Doctors push aspirin because it thins the blood, thereby reducing the risk of bloodclots. But, apart from poor effectiveness and the risk of gastrointestinal bleeding, research suggests that long-term aspirin use can accelerate macular degeneration and contribute to retinal haemorrhage. Over two decades ago, Dr J.D. Kingham wrote a letter to the prestigious New England Journal of Medicine (1988; 318: 11267) in which he noted that, in his clinic, many of the elderly patients who came to him with decreased central vision and macular haemorrhages had a history of recent ingestion
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of aspirin and other drugs known to affect platelet function or the bloodclotting process. NSAIDs (non-steroidal anti-inflammatory drugs) have been shown to increase the risk of cataractsitself a risk factor for the later development of AMDby as much as 44 per cent (Ophthalmology, 1998; 105: 17518). Many other common drugs, however, also contribute to a slow and steady degeneration in the eye, and hasten the onset of macular degeneration by making the eye more light-sensitive. These include certain antibiotics, psychotherapeutic medications and NSAIDs (Int J Toxicol, 2002; 21: 47390). Phenothiazine antipsychotics, antidopaminergics (for motion sickness) and calcium antagonists have also been associated with AMD ( Arch Ophthalmol, 2001; 119: 3549). However, some of these adverse effects of drugs are temporary. People taking sildenafil (Viagra), for example, often experience transient visual changes, described as blue tint, that usually lasts for four hours after taking the drug, according to the Viagra package insert. This greater affinity for blue light is linked to the way that sildenafil affects the rods and cones in the retina, the cells that process colour information. In a small study of men and women taking 200 mg of Viagra daily, 64 per cent of those who completed the study reported visual disturbances. The participants were given an electroretinogram, a test that looks at the behaviour of the rods and cones in the retina. While the test results were within normal limits, they also confirmed that taking the drug caused a slightly depressed function in the cone cells, which are responsible for detailed daytime colour vision (see below).
The hungry eye

Aspirin also apparently interferes with many of the nutrients that are specifically essential for eye health. To understand why this is important, it is necessary to know some basics about how the eye works. Four types of cells in the human retina capture light and process visual information. One type, the rod cells, regulates night vision. The other three types, called cone cells, control colour vision. This constant processing of visual information can cause a great deal of (normal) wear and tear in the cells of the eye.
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To continue to function optimally, our eyes require a constant supply of nutrients. High levels of antioxidants, such as vitamins C and E, betacarotene and lutein as well as zinc, selenium and copper, are all naturally present in the macula. Our eyes also require a great deal of oxygen. But where the oxygencontaining environment is especially rich and the metabolic rate is high, as it is in the macula, high levels of oxidative free radicals are also generated. So, in addition to providing nourishment, the antioxidants found in the eyes also protect against free-radical damage. Taking aspirin can increase the turnover of vitamin C in the body, leading to a possible deficiency (BMJ, 1975; I: 208). Similarly, taking 3 g/day of aspirin has been shown to decrease blood levels of zinc (Scand J Rheumatol, 1982; 11: 634). Aspirin also appeared to increase the loss of zinc through the urine in this study, and this effect was noted as early as three days after starting the aspirin regimen. Moreover, aspirin can enhance the blood-thinning effects of vitamin E in some individuals. In one double-blind study of smokers, those who took aspirin plus 50 IU/day of vitamin E had a statistically significant increase in the incidence of bleeding gums compared with those who took aspirin alone (Ann Med, 1998; 30: 5426). This increased risk of bleeding could have a theoretical impact on the eyes. Gastrointestinal (GI) bleeding is another common side-effect of taking aspirin. Often, this problem will go undetected for rather a long time. The long-term blood loss due to regular aspirin use can lead to iron-deficiency anaemia. Another potential problem area is foods containing salicylates, the main ingredient in aspirin. But aspirin may have another damaging effect. As well as depleting levels of important nutrients, aspirin can disrupt the normal circadian rhythms of the sleepwake cycle. The hormone melatonin is produced by the pineal gland at night. It helps us to sleep, but it also boosts immune function and, for those at risk of AMD, it helps to lower blood pressure (Hypertension, 2004; 43: 1927) and protects the retinal pigment from oxidative stress (Exp Eye Res, 2004; 78: 106975).
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NSAIDs (including aspirin) work, in part, by inhibiting prostaglandins, which produce pain and inflammation. They also contribute to the regulation of body temperature and the production of melatonin (J Pharm Pharmacol, 1987; 39: 8403). One double-blind study found that night-time body temperature did not drop to its usual levels after taking either aspirin or ibuprofen (Physiol Behav, 1996; 59: 1339). This was because taking these NSAIDs at night suppressed normal levels of melatonin. Earlier reports have confirmed that healthy individuals taking NSAIDs experience melatonin suppression and alterations in their normal sleep patterns (Sleep Res, 1992; 22: 165; Physiol Behav, 1994; 55: 10636). Such chronic disruption may allow blood pressure to rise, which may have negative effects on the eye, as well as expose the retina to greater levels of oxidative stress. Physicians themselves are suffering from a kind of blindness that prevents them from seeing the obvious role of diet and drugs in the development of AMD. The best a doctor might do for an AMD sufferer is to put down his prescription pad and say: Dont take two aspirin.
The AMD-free diet

Just as most of the risk factors for AMD parallel those of heart disease, most of the best alternative measures to keep the heart healthy can also maintain eye health. So, you can reduce your risk of AMD by making a few basic changes in your lifestyle: Consume an organic, unprocessed diet that is low in fat, and high in fruit and vegetables. Eat brightly coloured fruits and vegetables. People who consume red, orange and yellow fruits and vegetableswhich are high in betacarotene, another antioxidantare also at low risk of developing AMD (Am J Epidemiol, 1988; 128: 70010). Eat your greens, especially spinach. Deeply coloured foodssuch as spinach, collard greens and kaleare particularly rich in carotenoids, especially lutein and zeaxanthin. These nutrients have an affinity for that part of the retina where macular degeneration occurs. Once there, they can protect the retina from damage caused by sunlight (Methods
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Enzymol, 1992: 213: 3606).
One study found that people who ate spinach every day suffered only one-tenth as much from AMD as those who seldom ate it. For patients already with the condition, eating spinach prevented it from getting worse (JAMA, 1994; 272: 141320). Eat more fish. People who eat fish more than once a week have half the risk of developing AMD compared with those who eat fish less than once a month (Arch Ophthalmol, 2000; 118: 4014). Keep your weight down. Dont smoke. Drink a glass of red wine a day (Am J Ophthalmol, 1995; 120: 190-6) as, in one study, those who drank one glass a day reduced their risk of AMD by 20 per cent compared with those who either drank beer or spirits, or were teetotalers (Lancet, 1995; 351: 117). Take regular exercise, as this can help keep your blood pressure within normal ranges as effectively as many drugs. Avoid foods containing salicylates. Not so long ago, the American Heart Association audaciously credited the decline in heart attacks in the US since 1965 to the growing ingestion of artificial flavourings in processed foods (Sci News, 1993; 144: 19). These flavourings, used in everything from crisps to toothpaste, contain aspirin-like chemicals known as salicylates. The typical Western diet includes enough processed foods to provide the equivalent of more than one childrens aspirin daily (Health Alert, 1996; 13: 67). If you regularly consume such foods alongside a daily aspirin, you will be getting the equivalent of nearly two aspirin daily with no real benefit to your heart or eyes.
Solutions from nature

The best treatment is prevention. To make sure you dont develop AMD: Supplement, especially with antioxidants (Arch Ophthalmol, 1994; 112: 2227). A large multicentre clinical trial, sponsored by the US National Eye Institute, found that vitamins can reduce the risk of severe vision loss by 25 per cent in some cases of AMD (Arch Ophthalmol, 2001; 119: 141736). The specific daily amounts used by the study researchers were: vitamin C, 500 mg; vitamin E, 400 IU; beta-carotene, 15 mg (equivalent to 25,000 IU of vitamin A); zinc (as zinc oxide), 80 mg; and copper (as cupric oxide), 2 mg.
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Try herbs. Ginkgo biloba improves circulation and is an antioxidant aim to take 120 mg/day. Oligomeric proanthocyanidin complexes (OPCs) from grape seed/skin or bilberry extract are also powerful antioxidantsa useful dose is 200300 mg/day from grape seed/skin or 150 mg/day from bilberry. Drink green tea (unprocessed, preferably organic), which contains antioxidants that can slow or even halt the progression of AMD (VRP Nutr News, 1997; 11: 4, 10). If you already have AMD, you may be able to stop its progression if you start treatment in its early or intermediate stages. Follow the dietary suggestions mentioned above, and also (after checking with a nutritional practitioner, as these are very high doses) supplement with: high-dose antioxidants. Of seven studies, three showed improvement with nutritional supplements (Ophthal Physiol Opt, 2003; 23: 38399). lutein (10 mg/day). In the major Lutein Antioxidant Supplementation Trial (LAST), lutein with or without antioxidants was found to improve vision (Optometry, 2004; 75: 21630). zinc (45 mg/day) helped prevent vision loss in one study (Arch Ophthalmol, 1988; 106: 1928). Zinc has also been shown to work in concert with high-dose multi-vitamin/mineral supplements (Curr Opin Ophthalmol, 2003; 14: 15962). Ginkgo biloba. After four weeks, Ginkgo at doses of either 60 mg or 240 mg/day led to marked improvement of vision in AMD patients, although the higher dosage produced nearly twice the improvement of the lower one (Wien Med Wochenschr, 2002; 152: 4236).
Other possible treatments

If AMD is an inflammatory disease (see page 67), then high-dose antiinflammatory supplements could be an effective therapy. Vitamin B12 supplements have been successfully used to reduce the symptoms of other inflammatory conditions such as bursitis (Lininger SW Jr
et al., The Natural Pharmacy: Complete Home Reference to Natural Medicine. New York, NY: Three Rivers Press, 1999),
and vitamin C, at high doses, has been proven to have anti-inflammatory properties (Exp Eye Res, 1986; 42: 211-18). Vitamin E may be especially useful as it is able to suppress the symptoms of inflam74
mation in specific parts of the body (J Vitaminol, 1972; 18: 204-9). Copper and zinc are both strong anti-inflammatories, and AMD sufferers are usually deficient in both. Inflammation requires a higher copper intake to maintain levels of enzymes that are vital to the body's antiinflammatory processes, at least in animal studies (Agents Actions, 1985; 16: 504-13). In addition, findings in animal (rat) studies showed that zinc is an important healing agent during inflammation (Int J Tissue React, 1981; 3: 73-6). In clinical studies, zinc was able to help 70 per cent of men suffering from prostate problems (Bush IM et al., 'Zinc and the Prostate', presentation at the annual meeting of the American Medical Association, Chicago, 1974). Supplemental zinc, copper and manganese also reduced the risk of rheumatoid arthritis in more than 29,000 women aged 55-69 years and followed for 18 years (Am J Epidemiol, 2003; 157: 345-54). High-dose supplements of zinc and copper, and of vitamins A, C and Ethe usual antioxidants-prevented the progression of AMD in one study. The researchers, from the Age-Related Eye Disease Study Group in New Zealand, also found that most people are taking levels of vitamins that are too low to be effective. Yet, at the correct dosages, any combination of multivitamins and individual supplements can prevent AMD from worsening (N Z Med J, 2009; 122: 32-8).
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Common Complaints
Dry eyes
'Dry eye' is a catch-all term used to cover all disorders where the precorneal tear film of the eye is deficient. This thin layer of fluid covers the cornea and the corners (cul-de-sac) of the eye (where the tear ducts lie), and the conjunctiva, the thin mucous membrane that lines the inner surface of the eyelids. The job of this fluid is to nourish the cornea, remove any foreign entities like bacteria and lubricate the eyelids. This helps the eyes to blink which, in turn, helps to spread the tear film over the surface of the eye. When it isn't due to surgery, dry eye can also result from a problem with the meibomian glands, which secrete the fatty component of tears, or a simple deficiency of the tear film itself. People who don't blink often enough or whose eyes don't spread the tear film efficiently can also suffer from dry eye. It tends to mostly affect women after the menopause, but it can be seen in men or women of any age, and be linked to psoriasis, rheumatoid arthritis or psoriatic arthritis. Unfortunately, it is also a common adverse effect of laser eye surgery. To combat the problem, medicine has come up with 'ocular' lubricants artificial tears. These work by bulking up the volume of the tear film. However, they can only do this in contact with the eye surface. The first generation of these agents were made of cellulose ethers such as methylcellulose, known to be highly viscous. They were of variable effectiveness, so medicine moved on to polymers such as polyvinyl alcohol and polyvinylpyrrolidone. This generation of artificial tears work, but needs to be reapplied too often for comfort. Consequently, the pharmaceutical companies have now turned to
77
longer-acting gels containing polymers, such as polyacrylic acid. These swell up in water and retain moisture, and relieve the condition for longer than the earlier polymerswithout reapplication (Acta Ophthalmol Scand, 1997; 75: 457-61; Eur J Ophthalmol, 1998; 8: 81-9). But at what cost? These preparations use preservatives like benzalkonium chloride, toxic to the cornea, which keeps the eye moist. Thus, using artificial tears containing this preservative for any length of time is likely to make the problem worse and impair vision over the long term (Am J Ophthalmol, 1988; 105; 670-3). Although the newer preservatives sodium perboate and polyquaternium are thought to be less dangerous (Curr Eye Res, 1991; 10: 645-56), using any chemical in your eye for any length of time can create further problems. The conjunctiva, which comes in contact with the tear film, is highly permeablesome two to 30 times more permeable to drugs than the cornea (Pharmaceut Res, 1991; 8: 1039-43). In a sense, when you use artificial tears or any chemical eye solution, you are mainlining chemicals or plastic directly into your eye. And this is exacerbated by artificial-tear solutions. When patients treated with polyvinylpyrrolidone without preservative were compared with those using the same preparation with preservative, the preservative-treated group showed an increased permeability of their eye surface (Arch Ophthalmol, 1992; 99: 873-8). Another possible treatment is a lubricating lotion containing white paraffin, which melts on contact with a hot object like the eye. However, these tend to make blurred vision worse. Aside from the dangers, artificial tears are a poor substitute for the real thing. Tears are a complex mix of water, electrolytes and proteins, and contain both antibodies and enzymes to fight off bacteria and infection.
Natural ways to make your eyes wetter

Encourage your eyes to produce more lubrication by using: vitamin A, the premier vitamin for eye health. Suggested dosage: 10,000 IU/day, plus at least 400 IU/day of vitamin D. Also, increase your intake of vitamin A-rich foods like eggs and fish like salmon omega-3 fatty acids from either fish oils or flaxseed. Suggested dosage: 1000
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6 Common Complaints
mg three times a day glutathione and lutein, nutrients known to improve lubrication of the eye. Suggested dosage: 500 mg/day of glutathione; 6 mg/day (three cups of spinach a week) of lutein B-complex vitamins, particularly B2, which can help a wide variety of eye prob lems. Suggested dosage: 50 mg/day (B-complex) vitamin C. Suggested dosage: at least 3 g/day Cineraria eyedrops, a homeopathic remedy to help with the irrigation of the eye, available from Helios (+44 (0)1892 537 254; www.helios.co.uk) rose hydrosol (flower water), available from a reputable supplier of essential oils warmed oil, such as castor oil, rubbed externally on your eyelids last thing before going to bed warmed compresses which, placed over closed eyes for five minutes, can help to restore the tear film. Other strategies include: using a humidifier, especially in the winter making an effort to blink more often resting your eyes periodically during the day.
The painkiller connection

Although many elderly people complain of dry eyes and dry mouth, this phenomenon may not be a natural part of the ageing process, but a sideeffect of drugs, according to evidence. American researchers in Maryland studied 2481 patients, aged 6584, to assess the prevalence of dry eyes, dry mouth or both, and whether these were associated with rheumatic disease and other factors. More than a quarter of the study group reported these symptoms on their own, and a further 4.4 per cent experienced both. After adjusting for age, gender and race, there was no association found with rheumatoid arthritis, smoking, alcohol consumption or the presence of autoantibodies. However, various classes of drugs were associated with dry eyes and mouth in about a third of cases. These included painkillers and feverreducing drugs (such as aspirin) at the lowest end of the risk scale, and
79
antidepressants and antipsychotics at the highest end. Doctors are advised to consider the role of medications when elderly patients present with dry eyes and mouth (Arch Intern Med, 1999; 159: 135963).
Floaters
Floaters are little clumps of gel or cells floating through the thick transparent gel of the eyeball. They can appear as specks, strands, webs or other shapes, and may momentarily be confused with dust or tiny insects flying across the eye. Strictly speaking, what we are seeing are the shadows of these irregularities in the vitreous fluid that separates the lens and retina. This gel-like fluid maintains the eye's shape, aids the transmission of light to the retina, absorbs shock and holds the retina in place. Over the years, the vitreous fluid inevitably thickens, dries and shrinks, which is why floaters are more commonly seen in people over 40. If their onset is gradual, they are very likely harmless and require no treatment. However, if there is a sudden appearance of multiple floaters, this may be a sign of posterior vitreous detachment (PVD), the separation of vitreous fluid away from the retina. By age 70, PVD has usually already taken place gradually. However, floaters as well as PVD occur more oftenand earlierin shortsighted people, in diabetics and in those who have undergone cataract surgery, or laser surgery for the eye or skin, and as a result of trauma (Graefes Arch Clin Exp Ophthalmol, 2005; 26 July: 1-5; Am Fam Physician, 2004; 69: 1691-8; Dermatol Surg, 2002; 28: 1088-91). In addition, in about 25 per cent of cases, floaters indicate a sight-threatening condition such as tears or detachment of the retina, which is when any part of the retina gets pulled away from the back wall of the eye. If left untreated for several days, permanent vision loss or blindness will result. So, if floaters appear suddenly and are accompanied by light flashes or loss of peripheral vision, it may be prudent to visit an eyecare specialist immediately. Posterior uveitis (chronic eye inflammation brought about by infectious disease or an autoimmune disorder) can also be sight-threatening. But, unlike PVD, posterior uveitis is associated with a gradual blurring of vision. A surgical procedure called a 'vitrectomy' can remove floaters, but this should only be done if your vision is severely limited and any other possi80
6 Common Complaints
ble causesof which there are manyare ruled out. Indeed, the most common complication of vitrectomy is cataract, so you may well be trading a small problem for a more serious one (Br J Ophthalmol, 2001; 85: 546-8; Am J Ophthalmol, 1988; 105: 160-4). Floaters have also been linked to candidiasis, an overgrowth of the yeast-like fungus Candida albicans, and may simply be a symptom of this system-wide problem (Postgrad Med J, 2001; 77: 119-20). Candidiasis can be controlled by eliminating sugar and yeast from the diet, which is certainly a safer and simpler solution than surgery. According to traditional Chinese medicine (TCM), floaters are the result of a poor blood circulation that fails to nourish the optic nerve and surrounding muscles of the eye. In TCM terms, the cause of this weak circulation is congestion of the liver, kidneys and colon, so herbs that support these organs can improve vision, strengthen the retina and blood vessels, and keep the vitreous fluid free of debris. Although scientific studies are lacking, the anecdotal evidence points to the fruit of Lycium barbarum - or Chinese wolfberry (gou qi zi), a member of the nightshade family - as a popular TCM remedy that can nourish and support the liver and kidney, and treat a slew of eye problems (including floaters, excessive tearing and cloudy vision) while helping to prevent serious eye diseases. While there is no proven or universal cure for floaters, the nature of the condition suggests that lifestyle changes, and a programme of supplements and herbs to feed, stimulate and hydrate the vitreous fluid, may well improve the condition. For example, the anthocyanosides (flavonoid compounds) found in bilberry (Vaccinium myrtillus) have been shown to improve circulation in the blood vessels of the eye, maintain the integrity of capillaries, stabilise collagen, and correct the signs of retinal damage (Biochem Pharmacol, 1983; 32: 53-8; Angiologica, 1972; 9: 355-74; Minerva Med, 1977; 68: 3565-81). Ginkgo biloba, too, improves eye circulation by preventing clotting of blood platelets and causing blood vessels to dilate. Ginkgo works in synergy with bilberry, so taking this herbal combination is an excellent choice for improving overall eye health. In one German study, taking Ginkgo as a hard candy (160 mg/day for four weeks, then 120 mg/day) resulted in improved eyesight in patients with severe degenerative circulatory distur81
bances, visual-field defects and retinal problems (Klin Monatsbl Augenheilkd,

1980; 177: 577-83).
Finally, whereas most floaters are found in the vitreous fluid, it is important not to overlook another, simpler cause of the problem. You could be suffering from debris in the tear film. Many people, especially those prone to allergies, blepharitis (eyelid inflammation) or styes can accumulate makeup, mucus and other material within their tears. Floaters due to tearfilm debris move when you blink, whereas vitreous floaters respond more to eye movements than to blinking.
Blepharitis
Blepharitis, or inflammation of the eyelids, is a chronic condition that can lead to redness, dryness, burning, itching and irritation of the eyes. The most common causes are poor eyelid hygiene, bacterial infection and excess oil production by the meibomian glands in the eyelid. Wearing contact lenses and eye makeup can make blepharitis worse. Identifying the cause is key in any healing plan. Conventional treatment usually involves keeping the eyelids clean, applying warm compresses, using anti-dandruff shampoo and, when necessary, antibiotics or steroid eye drops. However, these measures tend to ease symptoms rather than cure. What's more, medicated eye drops can cause serious side-effects, such as increased pressure in the eye, and changes to the lens and cornea (Can J Ophthalmol, 2008; 43: 170-9).
Nutritional therapies
Essential fatty acids. Supplements of both omega-6 and omega-3 fatty acids may help against blepharitis. In 57 patients with meibomian gland dysfunction (a common form of blepharitis), warm compresses, eyelid massage and eyelid margin scrubbing, combined with a daily dose of omega-6 (28.5 mg of linoleic acid and 15 mg of gamma-linolenic acid), reduced symptoms better than either treatment alone (Cornea, 2007; 26: 260-4). Omega-3 supplements (two 1000-mg capsules three times a day) led to significant improvement in blepharitis sufferers after one year of treatment (Trans Am Ophthalmol Soc, 2008; 106: 336-56).
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6 Common Complaints
N-Acetylcysteine (NAC). This amino acid appears to help prevent dry eyes. In 40 patients with chronic blepharitis, the addition of oral NAC (100 mg three times daily) to their conventional therapy (topical antibiotics and steroids, and artificial tears) significantly increased tear quantity and improved tear quality, compared with the conventional therapy alone (Cornea, 2002; 21: 164-8). Vitamin A. The daily use of eye drops containing vitamin A (Viva-Drops; Vision Pharmaceuticals) led to the complete resolution of chronic blepharitis that had failed to respond to topical antibiotics and steroidsalbeit in a single case study (Altern Med Rev, 2008; 13: 191-204). Other nutrients. Deficiencies of vitamin B6, biotin, riboflavin and zinc have each been reported to result in blepharitis in humans and animals. Multivitamin and mineral supplements containing these nutrients are therefore recommended as supportive treatment in cases of blepharitis (Altern Med Rev, 2008; 13: 191-204).
Other solutions
Homeopathy. There is a range of homeopathic remedies for eye infection and inflammation, including Sulphur, Natrum Muriaticum, Hepar Sulphuris Calcareum and Mercurius Solubilis. However, it's best to let a qualified homeopath make a diagnosis, and choose the best remedy for your constitution and symptoms. Honey. Honeyespecially good-quality manuka honey, which has a wide range of antibacterial activitycan be used topically to treat bacterial eye infections (J Med Food, 2004; 7: 210-22). In 102 patients with eye infections, including blepharitis, improve-ment was seen in 85 per cent of cases (Bull Islam Med, 1982; 2: 422-5). Apply the honey to the eyelid (but not the eye) as you would an ointment. Herbs. Calendula (marigold), chamomile, eyebright and comfrey have traditionally been used for eye inflammation. For rapid relief of redness and swelling, try a compress of eyebright (15 g of dried herb in 500 mL (16 oz) of water, boiled for 10 minutes). Make sure that the preparation is sterile by making a fresh brew every time and throwing away the excess. Hygiene. Any treatment for blepharitis should always be combined with
83
a strict eyelid cleaning routine. Clear away oil and debris from around the eyelash follicles by applying warm compresses (using a cloth or cotton wool warmed with hot water) to the eyelids several times a day. Immediately after this, moisten a cottonbud with a solution of warm water and sodium bicarbonate (1 tsp in a cup of water will do), and use it to gently clean along the eyelashes. Avoid touching the eye itself and always use water that's been freshly boiled, then cooled.
Herbs for the eyes

People with eye problems consulting conventional ophthalmologists are generally told there is no solution other than drugs, surgery or glasses. However, herbal medicine has had great success in treating glaucoma, myopia, night blindness, macular degeneration, retinitis pigmentosa (a progressive loss of vision due to retinal degeneration) and even diabetic retinopathy. This has been highlighted in Botanical Influences on Illness: A Sourcebook of Clinical Research (Tarzana, CA: Third Line Press, 1994), a superb reference manual co-authored by WDDTY panellist Dr Melvyn R. Werbach and Dr Michael T. Murray. A single 200-mg dose of Vaccinium myrtillus (bilberry or European blueberry) extract (VME) brought about measurable improvements (as assessed by electroretinography) in patients with glaucoma and myopia ( Arch Med Int, 1985; 37: 2935). In other cases, VME measurably improved the eyesight of 80 per cent of treated patients (Ann Oftalm Clin Ocul, 1966; 92: 596605). Another study of patients given 400 mg/day of VME and 20 mg/day of beta-carotene demonstrated improved adaptation to light and night vision, and enlargement of the visual field (Ann Oftalm Clin Ocul, 1965; 91: 37186). Further trials confirm that VME, when used with vitamin E, can improve myopia (Klin Monatsbl Augenheilkd, 1977; 171: 6169). Finally, 31 patients with various types of retinopathy, including that caused by anticoagulant (blood-thinning) drugs or diabetes, were treated with VME. The results showed reduced permeability and haemorrhage (Klin Montsbl Augenheilkd, 1981; 178: 3869). Pycnogenols (PCG), which contain complexes of vitamin C-like bioflavonoid nutrients are made from the leaves of the hazelnut bush, the
84
6 Common Complaints
bract (the little leaves below the flower petals) of the lime tree, and the bark of the Landes pine tree or grapeseed skin (Vitis vinifera). At doses of 150300 mg/day, PCG has been shown to significantly improve visual performance in the dark and after glare (J Fr Ophtalmol, 1988; 88: 1734, 1779). In a well-controlled, double-blind study, an extract of Ginkgo biloba leaves (GBE) brought about significant improvement in chronic cerebroretinal ischaemia (lack of adequate blood supply to the eyes) in elderly patients (Klin Montsbl Augenheilkd, 1991; 199: 4328). GBE also led to significant long-term improvement in patients with senile macular degeneration (Presse Med, 1986; 15: 15568) and severe retinal circulatory disturbances or glaucoma (Klin Montsbl Augenheilkd, 1980; 177: 57783).
85
86
The Bates Method
magine being able to cure your vision problems without glasses or contact lenses, without drugs or without surgeryall you have to do is relax. Thats exactly what patients of Dr William Bates (18601931) were able to do. Dr Bates, author of Better Eyesight Without Glasses, was a pioneer in ophthalmology who was practising in New York at the turn of the century. He was the first to consider stress as the root cause of vision impairment, including myopia (nearsightedness) and hyperopia (farsightedness).
Exercise your eyes back into shape

Examining thousands of patients at the New York Eye and Ear Infirmary, Dr Bates research lead him to the conclusion that eyes could be exercised back into shape in the same way that other muscles in our bodies can be exercised. Dr Bates found that a persons level of vision fluctuates throughout the day, at various times shifting from nearsightedness to farsightedness and back. The degree of visual impairment would increase according to the amount of stress the individual was under at a given time of the day. For example, a cold, a loud noise or sleep would elicit a change in the vision of patients. Patients known to have 20/20 vision would even display some visual impairment when subjected to a stressful situation. Observations like these lead Dr Bates to the conclusion that a persons level of vision is not permanent. If it can change so often throughout the day, it can certainly be changed in the long term. As a result, Dr Bates created a series of exercises to relax and strengthen the muscles surrounding the eye. He believed that . . . perfect sight is a product of perfectly relaxed organs, unconsciously controlled, and that
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eyeglasses were useless tools that locked the eyes into a constant state of tension. Bates used his own techniques to cure himself of advanced farsightednessthe type we believe to be part of the normal process of ageing. Today, we understand that Dr Bates work provides a different theory of seeing, which looks upon human vision as holistica combination of mind, body and spirit. The Bates method is not simply an exercise programme, but a means of correcting bad habits such as straining to see, and developing a greater awareness of what we are looking at. The Bates method can work extremely well on young children or people whose problems are caught early, such as those in their 40s who are only just losing their ability to focus close up. However, it can help every type of visual disorder and is also effective as preventative medicine. The best way to embark on the Bates method is to work with a qualified Bates teacher, who will assess you and individually tailor exercises for you. Exercises used in the Bates method include: palming. Carefully cover your closed eyes with the palms of your hands (making sure your hands are warm) to block out all of the light, but without pressing against the surface of the eyeball. You should see absolute blackness. If you dont (in other words, if you see kaleidoscopic colours), you do not have perfect vision. To correct the problem, try focusing on a black object at a comfortable distance in front of you. Stay relaxed. Now close your eyes and see the same black object. If this doesnt work, try imagining a small black dot growing larger and larger until it envelopes the entire area behind your eyes, or a black fur or black hole. Relax with your palms over your eyes for several minutes. As your sight improves, the blackness will become deeper and darker. You should do this exercise several times a day. The improvement will be slow and gradual. lighting. Relax and sit in a chair in the sunshine or six feet from a 150-watt lightbulb. With your eyes closed, lift your face to the light and
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7 The Bates Method
slowly move your head from side to side for three to four minutes. Gradually increase the amount of time you spend in the light. This exercise will warm parts of the eye, relax the muscles, reduce redness and itchiness, and stimulate the retina. shifting. Shift your sight back and forth between any letter on a Snellen chart (the chart of letters everyone has probably seen at the doctor s office) and another letter that is several spaces along, but on the same line. Then, shift your sight back and forth between one of the larger letters at the top of the Snellen chart and one of the smaller letters at the bottom of the chart. Finally, shift your sight back and forth between an entire Snellen chart three to five feet away and one 10 to 20 feet away. lazy eights. Close your eyes and draw a number eight with your nose. Be sure to move your head slowly and evenly. Repeat this exercise a number of times, changing the size and direction of the eight. You can also try this exercise while drawing other simple objects like a wagon wheel. This will relax all of the muscles surrounding the eye, and increase the circulation in the head and neck. For further information on the Bates method, contact the Bates Association for Vision Education (BAVE). BAVE is a group of professionals dedicated to the teaching of vision improvement. All members of the Bates Association are fully qualified teachers of the Bates Method of Vision Education. To find out more about the method, and to find a teacher near you, visit the website: www.seeing.org/bave2/bave.htm. For teachers in the US, Canada and elsewhere around the world, visit the Association of Vision Educators website at: www.visioneducators. org/index.html.
Integrated Vision Therapy

Following on from the Bates idea of eye exercises, Dr Robert-Michael Kaplan has added other recommendations: Listen to relaxation tapes to assist in coordinating the left and right sides of the brain Eat a better diet Spend time in natural light without glasses Wear a one-eyed patch over your best (dominant) eye for, at most, four hours
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to help vision in the weaker eye Use glasses if youve been wearing contacts Get your eye doctor to prescribe vision-fitness glasses to correct your vision to 20/40, which will force your eyes to work a little harder. (Needless to say, never wear them when you are doing something potentially life-threatening like driving) Engage in regular aerobic exercise. Try to choose an activity that you can do without your glasses Set life goals to see your life clearly Copy an eye chart and place it on a wall five feet away (have a smaller one for close-up vision) and periodically measure how such factors as stress affect your perception. Dr Kaplan also recommends vision games, depending on your problem, such as zoomingshifting your focus quickly from near distance to far distance, which helps with age-related focus problems.
Recommended reading
W.H. Bates. The Bates Method for Better Eyesight Without Glasses. Grafton Books, 1979 Harry Benjamin. Better Sight Without Glasses. Thorsons, 1992 Peter Mansfield. The Bates Method: A Complete Guide To Improving Eyesight Naturally. Vermilion, 1995 Robert-Michael Kaplan. Seeing Without Glasses: I m p roving Your Vision Naturally. Beyond Words Publishing, 1994; The Power Behind Your Eyes: Improving Your Eyesight with Integrated Vision Therapy. Healing Arts Press, 1995 L. H. Salov, W.L. Fischer. Hidden Secrets for Better Vision. Fischer, 1995
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WHAT DOCTORS DONT TELL YOU

The WDDTY Good Sight Guide

A comprehensive guide to keeping your eyes healthy

The WDDTY Good Sight Guide

Childrens Eye Problems

Common eye ailments

The WDDTY Good Sight Guide

1 Childrens Eye Problems

The WDDTY Good Sight Guide

1 Childrens Eye Problems

The WDDTY Good Sight Guide

The Bates Method

1 Childrens Eye Problems

The dangers of surgery for strabismus

The WDDTY Good Sight Guide

1 Childrens Eye Problems

Myopia and Farsightedness

A close-up look at radial keratotomy

The WDDTY Good Sight Guide

Laser eye surgery: a shortsighted solution

2 Myopia and Farsightedness

The WDDTY Good Sight Guide

2 Myopia and Farsightedness

Vision disturbance due to optic nerve damage (Am

J Ophthalmol, 2000; 129:

The WDDTY Good Sight Guide

Laser eye surgery: whats involved

2 Myopia and Farsightedness

The WDDTY Good Sight Guide

The next wave

2 Myopia and Farsightedness

A suitable case for treatment?

The WDDTY Good Sight Guide

2 Myopia and Farsightedness

Contact lens safety tips

The WDDTY Good Sight Guide

Taking a deeper look

2 Myopia and Farsightedness

Educational eye strain

The WDDTY Good Sight Guide

2 Myopia and Farsightedness

The WDDTY Good Sight Guide

Preventing farsightedness in the ageing eye

2 Myopia and Farsightedness

Improving your sight

The WDDTY Good Sight Guide

2 Myopia and Farsightedness

What are cataracts?

What doctors tell you

The WDDTY Good Sight Guide

What doctors dont tell you

The WDDTY Good Sight Guide

Exposure to ultraviolet rays

Ophthalmology, February 1991).

How to prevent or delay cataracts

The WDDTY Good Sight Guide

The WDDTY Good Sight Guide

Vitamins, minerals and enzymes

in any of these antioxidants will result in the failure of another.

Vitamin A and beta-carotene

The WDDTY Good Sight Guide

The Evans treatment for cataracts